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World J Clin Oncol. Aug 24, 2025; 16(8): 107757
Published online Aug 24, 2025. doi: 10.5306/wjco.v16.i8.107757
Minimally invasive surgery for colorectal cancer emergencies
Neng-Wei Wong, Salman Ahmed Abdul Jabbar, James Chi-Yong Ngu, Nan-Zun Teo, Department of Surgery, Changi General Hospital, Singapore 529889, Singapore
ORCID number: Neng-Wei Wong (0000-0003-0028-6128); James Chi-Yong Ngu (0000-0001-5233-457X); Nan-Zun Teo (0000-0002-5475-476X).
Author contributions: Wong NW, Ngu JCY, and Teo NZ conceptualized and designed the manuscript; Wong NW, Jabbar SAA, Ngu JCY, and Teo NZ critically revised and edited the manuscript; Wong NW prepared the draft; All authors have read and agreed to the final version of the manuscript.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Neng-Wei Wong, FRCS, Department of Surgery, Changi General Hospital, 2 Simei Street 3, Singapore 529889, Singapore. wong_neng_wei@singhealth.com.sg
Received: March 31, 2025
Revised: April 22, 2025
Accepted: June 18, 2025
Published online: August 24, 2025
Processing time: 144 Days and 23.6 Hours

Abstract

Colorectal cancer (CRC) is a leading cause of cancer-related morbidity and mortality globally, and its management in the emergency setting presents distinct challenges. In addition to its advantages in elective CRC surgery, studies have demonstrated that minimally invasive surgery (MIS) can provide benefits in CRC emergencies, such as reduced morbidity and a shorter length of hospitalization. However, the applicability of MIS in the emergency setting is limited by factors such as compromised patient physiology, resource constraints, and the need for technical expertise. As an alternative to emergency MIS, endoscopic interventions have also been increasingly supported by emerging evidence as a bridge to surgery. This article appraises contemporary guidelines and the evidence behind their recommendations for MIS surgery in CRC emergencies, whilst highlighting the challenges to implementation and the strategies to overcome them.

Key Words: Colorectal malignancy; Colorectal cancer emergency; Minimally invasive surgery; Laparoscopic; Robotic; Obstructed colorectal cancer; Perforated colorectal cancer; Bleeding colorectal cancer

Core Tip: The management of colorectal cancer in the emergency setting presents distinct challenges. Despite its merits, the applicability of minimally invasive surgery in the emergency setting is limited by factors such as compromised patient physiology, resource constraints, and the need for technical expertise. We discuss our approaches to various colorectal emergencies, critically evaluating available literature, examining the challenges and strategies to overcome them with the goal of increasing minimally invasive surgery penetrance in the management of these conditions.



INTRODUCTION

Colorectal cancer (CRC) is one of the most common malignancies worldwide[1]. The benefits of minimally invasive surgery (MIS), defined in this article as laparoscopic or robotic-assisted surgery, in the elective management of CRC are well established[2-4]. Recent studies have also shown a reduction in postoperative morbidity and mortality, in addition to a shorter length of stay (LOS) when an MIS approach is adopted for emergency colorectal surgery[5-7]. While major guidelines have shifted their recent recommendations to favor a MIS laparoscopic approach for emergency cases[8,9], the evidence has largely been retrospective, with criticisms pertaining to selection bias in an emergency setting (i.e. younger and fitter patients are more likely to undergo laparoscopic surgery compared to their elderly counterparts).

In addition, barriers remain in the adoption of MIS in the emergency setting, such as suboptimal patient physiology precluding safe pneumoperitoneum, protracted operating time, resource constraints, and the lack of trained staff outside of working hours. With approximately one-third of all CRCs presenting to hospitals as an emergency[1,10,11], either with obstruction, perforation, or bleeding, there is a need to examine the challenges and evaluate strategies to increase the adoption of MIS in the emergency management of CRC.

OBSTRUCTION IN CRC

The most common presentation of CRC in the emergency setting is large bowel obstruction (up to 80% of all cases)[1,11] and its management remains a challenge when considering multiple patient and disease factors coupled with the multitude of treatment options available. Key factors to consider in deciding on the best patient-tailored therapy include that of: (1) Management intent (curative vs palliative); (2) Site of tumor; (3) Hemodynamic stability of the patient and ability to tolerate pneumoperitoneum; (4) Patient’s age and physiology (i.e. American Society of Anesthesiologists [ASA] physical status and Eastern Cooperative Oncology Group performance status); and (5) Expertise of the clinician and/or institution in MIS or advanced endoscopic techniques.

The management options include self-expandable metallic stents (SEMS), proximal diversion or resectional surgery with or without anastomosis and covering stoma. The choice of approach should be individualized based on the aforementioned factors. This group of patients can be broadly classified into three groups: (1) Patients who should be palliated; (2) Patients who would benefit from decompression as a bridge to definitive surgery; and (3) Patients who require upfront resectional surgery.

Patients for palliation

Patients who should be considered for palliation are those who present with synchronous unresectable metastases, or those who have localized disease but are too frail to undertake surgery. In the setting of an obstructed colon cancer, a multidisciplinary team discussion that includes the medical oncologist should be held to discuss the patient’s tumor biology, suitability for potential conversion, and prognosis. This influences the decision for palliative SEMS or diverting stoma in view of the risk of bevacizumab-associated colonic perforation with SEMS. For those patients with a short life expectancy and those unlikely to receive chemotherapy, SEMS is the preferred choice as it is associated with shorter hospital LOS, lower ostomy rates and better quality of life[2]. For obstructed rectal cancer, where SEMS is contraindicated, a palliative diverting stoma should be the primary management strategy.

A laparoscopic approach should be undertaken when performing a diverting stoma[12]. Available evidence suggests that associated morbidity and mortality are lower than open surgical techniques, with faster patient recovery[12,13]. If patient physiology and technical factors permit, laparoscopic assisted stoma creation is the authors’ preferred choice, as it ensures accurate localization, orientation and mobilization of bowel for stoma creation.

For patients with right-sided colon cancer and deemed not suitable for stenting, palliative MIS resection with or without an anastomosis should be considered, especially in the context of a competent ileocecal valve, which precludes suitability for proximal diversion. Due to its retroperitoneal anatomy, performing an ascending colostomy in such a situation would be technically challenging. In the context of an incompetent ileocecal valve, a palliative ileostomy or surgical bypass are possible options. Best supportive care with management inputs from a palliative specialist is an alternative to the above options. Ultimately, treatment should be individualized with shared decision making with the patient.

Patients who would benefit from decompression first before subsequent MIS resectional surgery

Bridging to definitive surgery or bridge-to-surgery (BTS) aims to relieve the acute issue of obstruction either with a diverting stoma or SEMS[14] before definitive surgery. This approach averts high-risk emergency surgery and provides time for patient optimization and bowel decompression. Importantly, this also allows the adoption of MIS for elective definitive surgery and increases primary anastomosis (RPA) rates. Patients who benefit include those with localized disease and those with resectable metastases.

The role of SEMS as a BTS has evolved since initial concerns of poor long term oncological outcomes from micro perforations[15]. This is reflected in recent guidelines from the American Society of Colon and Rectal Surgeons and the European Society of Gastrointestinal Endoscopy, supporting the use of SEMS as a suitable alternative to upfront emergency surgery in left-sided malignant colonic obstruction[2,16] – a revision from prior recommendations, which advocated that its use be limited to high-risk patients or those for palliation[17]. A Systematic Review and Meta-Analysis conducted in 2020 of 3894 patients from 27 studies found that the use of SEMS as a BTS in curative cases resulted in improved short-term surgical outcomes with higher rates of RPA, decreased postoperative complications, lower 30-day mortality, decreased intensive care unit (ICU) days and hospital LOS with similar long term oncological (3-year and 5-year disease-free survival [DFS]) and survival outcomes[18]. This further substantiates the benefits of SEMS and addresses oncological concerns with its placement. The risk of bias for the randomized controlled trials (RCTs) were evaluated as per Cochrane Collaboration guidelines and selection of high quality non-RCTs were performed with a validated scoring system (methodological index for non-randomized studies instrument) as part of the quality assessment.

Evidence for the role of SEMs as a BTS in the management of right-sided colonic obstruction has also evolved to challenge the traditional dogma of upfront emergency resection. A recent meta-analysis of 5136 patients showed a reduction in postoperative complication and mortality, coupled with greater use of a laparoscopic approach when SEMS is used as a BTS[19]. The use of SEMS for the above indication is reflected in the American Society of Colon and Rectal Surgeons 2022 and European Society of Gastrointestinal Endoscopy 2020 guidelines.

Nevertheless, SEMS is not without its risk of complications including that of perforation, stent migration, technical failure and re-occlusion. Key factors affecting complication rates include the degree of occlusion, length and location of tumor, and operator experience[20]. Success with this procedure, requires appropriate patient selection, a clear understanding of the methods of SEMS deployment and should be performed in high volume centers with experienced endoscopists.

Given the evidence, SEMS appears to be the first choice as a BTS. This is especially in the setting of a patient at higher risk of postoperative complication after emergency surgery (> 70-year-old and/or ASA > II), as per European Society for Medical Oncology guidelines[21]. However, a diverting stoma remains an alternative BTS option in cases where technical expertise is not available; SEMS failure occurs; challenging anatomy precludes SEMS deployment (e.g., flexural areas, complete luminal obstruction); there is an obstructed rectal cancer, and in CRC patients with resectable metastases requiring neoadjuvant therapy. Tan et al[22] performed a systematic review and network meta-analysis which found that SEMS and decompressing stoma strategies as a BTS was associated with better 5-year overall survival and DFS rates than upfront emergency resection for left-sided obstructed CRC.

When performing a diverting stoma, the decision regarding its site should take into consideration the eventual plan for resection and whether a protective stoma is required. If no protective stoma is required during the definitive resection, the stoma should be sited within the planned resection zone to minimize the number of eventual anastomoses. However, if required, it may be sited to serve as a defunctioning stoma after definitive surgery (e.g., proximal loop transverse colostomy for obstructed rectal cancer planned for low anterior resection after neoadjuvant therapy).

For patients presenting with obstructing rectal cancer, SEMS is not an option for management due to its associated risk of chronic pain, tenesmus[23], and potential insufficient distal landing zone for safe SEMS placement. A diverting stoma is therefore the management of choice which allows time for adequate staging and initiation of neoadjuvant therapy before definitive surgery.

Patients who require upfront resectional surgery

Upfront resectional surgery should be reserved for patients with: (1) Threatened bowel; (2) Right sided lesions not amenable to stenting; (3) Stent related complications such as perforation; and (4) Those who decline staged surgery with BTS options. The planned resection margins should include an oncological resection of the obstructed tumor and any non-viable bowel. For left-sided obstructing colon cancer, a subtotal or total colectomy may be performed in situations if there is a long segment of non-viable bowel proximal to the primary malignancy. When the length of non-viable bowel is short and a significant distance away from the primary tumor, an alternative to a subtotal colectomy is to resect separately before deciding on suitability for anastomosis of each resected portion.

Where upfront surgery is considered in left-sided cancers, the decision to perform a Hartmann’s procedure vs resection with RPA with or without a diverting stoma should factor: (1) The patient’s surgical risk and hemodynamics; (2) Technical difficulty and morbidity of surgery; (3) Intra-operative findings – degree of contamination and tissue quality; and (4) Technical expertise of surgeon. Kube et al[24] retrospectively compared the different operative approaches for obstructed left colonic cancer and found no difference in morbidity or mortality between patients who underwent Hartmann’s procedure compared to resection with RPA and covering stoma. However, patients who underwent Hartmann’s procedure in their cohort, had more comorbidities and advanced lesions. They concluded that RPA with covering stoma should be undertaken when the patient’s risk profile is favorable. For advanced lesions and unfavorable patient risk profile, Hartmann’s procedure is preferred.

Where upfront surgery is considered in right-sided cancers with significantly dilated proximal bowel loops that precludes safe laparoscopy, initial bowel decompression at the intended proximal transection site can be performed extracorporeally before proceeding with laparoscopic right hemicolectomy.

A laparoscopic first approach should be attempted if suitable, taking into account the patient’s physiology, resectability of the cancer and available surgical expertise[25], and has been shown to be associated with better short term surgical outcomes, increased 3-year overall survival and DFS with similar 90-day mortality when compared to an open approach[26]. A multicenter RCT by Harji et al[27] also showed feasibility of a laparoscopic approach with benefits of lower morbidity and shorter LOS in this group of patients. As such, the recent Cesena guidelines by the World Society of Emergency Surgery[8] recommends the use of laparoscopy as the initial approach for stable patients with colorectal emergencies. Based on the afore-mentioned considerations, coupled with the primary consideration of patient’s physiology (hemodynamic stability), our management algorithm for obstructed CRC with the goal of achieving MIS surgery (be it primary or in a staged fashion) is summarized in Figure 1.

Figure 1
Figure 1 Suggested management algorithm for obstructed colorectal cancer. MIS: Minimally invasive surgery.
Technical challenges in MIS and suggested strategies for obstructed CRC

Challenges in performing MIS for emergency CRC can be broadly classified into patient factors, surgeon factors, institution/resource factors, and intra-operative factors. Of these, intra-operative technical challenge remains one of the commonly cited reasons for conversion to open surgery, even in the elective setting of colorectal surgery[28,29].

For stable patients who can tolerate pneumoperitoneum, surgeons are often faced with the technical challenge of a lack in working space secondary to distended bowel loops. This results in suboptimal exposure of the target anatomy and reduces the margin for error in performing safe laparoscopic dissection. Distended bowel loops further increase the risks of inadvertent injuries by being in the path of insertion of the laparoscopic instruments, making access to the target anatomy even more challenging. Failure to recognize key anatomical landmarks, poor access to the area of dissection can result in inadvertent injuries and conversions to open surgery. Strategies to achieve MIS surgery are therefore focused on dealing with these particular challenges, of which some strategies the authors propose are summarized in Table 1 and Figure 2.

Figure 2
Figure 2 Intraoperative findings during laparoscopic management of large bowel obstruction with ileocecal valve incompetence. A: Distended small bowel loops from large bowel obstruction with incompetent ileocecal valve upon exteriorization via periumbilical incision prior to decompression; B: Post decompression via controlled enterotomy at proximal transection site (distal ileum) on the same patient before returning small bowel into abdominal cavity and proceeding with minimally invasive surgery.
Table 1 Surgical strategies in dealing with obstructed colon cancer.
Challenges
Mitigation strategies
Limited working spaceConsider proximal decompression at site of intended proximal transection
e.g., in the case of right-sided cancer with significantly dilated small bowel loops from an incompetent ileocecal valve, an extended periumbilical incision can be made to first perform decompression via a controlled enterotomy extracorporeally at the site of the planned proximal transection (Figure 2), before proceeding with MIS surgery
Use gauzes to pack small bowel away and minimize accidental thermal injury to surrounding structures
Limited exposureAdjust patient’s positioning to displace distended bowel away and maximize exposure
(Consider the use of a surgical table with greater articulating range and patient secured to the table with a surgical bean-bag)
Limited access to target anatomyWork from different approaches (lateral/medial/inferior/supra-colic) and extrapolate from known planes
Perform dissection distal to obstruction where tissue planes are normal with collapsed bowel. Subsequently perform early distal bowel transection to gain better exposure, before working more proximally
PERFORATION IN CRC

Perforation is the second most common emergency presentation of CRC and can occur either at the tumor site (70% of cases) or proximal to it (30% of cases)[1]. Prompt recognition and timely surgical intervention for source control is essential to mitigate the high morbidity and mortality associated with septic shock, especially in uncontained perforations.

Key factors to consider in deciding on the best patient-tailored therapy include: (1) Management intent (curative/palliative); (2) Hemodynamic stability of the patient; (3) Degree of contamination and whether the perforation is contained; (4) Site of the perforation; (5) Patient’s age and physiology (ASA and Eastern Cooperative Oncology Group status); and (6) Expertise of the clinician/institution in MIS techniques. The adoption of MIS in this setting has generally been low and is largely due to technical challenges in surgery, impaired patient physiology from sepsis and resource constraints. In this section, we discuss our approach to the patient with perforated CRC, critically evaluate available literature and discuss the challenges and strategies to enable more patients with perforated CRC to reap the benefits of MIS.

Approach to patient with perforated CRC

Right-sided colon cancer: Patients with right-sided perforated colon cancer will require a right hemicolectomy to address the site of perforation for source control. In most situations, a primary ileocolic anastomosis is performed[30]. However, this decision should consider the degree of contamination, intraoperative bowel quality, and the patient’s preoperative and intraoperative physiology. It is important to keep in mind that an anastomotic leak would result in a delay to chemotherapy and risk of systemic dissemination of disease in addition to the risk of morbidity and mortality[31].

Damage control surgery aimed at reducing surgical operative time should be considered in patients who are unstable or with poor physiological reserves[1]. This entails resectional surgery and washout for the first surgery with temporary abdominal wall closure, resuscitating the patient in the ICU before a staged second surgery to reestablish GI continuity and close the abdominal wall.

Left-sided CRC: The site of perforation and location of tumor must be considered when deciding on the type of surgery for left-sided CRC. Surgical options include that of: (1) Resection without RPA such as the Hartmann’s procedure; (2) Resection with RPA without diverting stoma; and (3) RPA with diverting stoma and distal limb washout. Evidence on the choice of surgical approach are extrapolated from evidence relating to the management of perforated diverticulitis.

Breitenstein et al[32] found in their case-matched control study of 110 patients that RPA with diverting ileostomy was a superior treatment to Hartmann’s procedure in acute left-sided colon perforation in view of the higher rates of stoma reversals and that, in the absence of feculent peritonitis, an ileostomy appeared unnecessary. The quoted anastomotic leak rate was 13% in the RPA without stoma group.

Oberkofler et al[33] substantiated this in their multicenter RCT of 62 patients with Hinchey III or IV acute diverticulitis, favoring RPA with diverting ileostomy over Hartmann’s procedure in terms of stoma reversal outcomes by showing that ileostomy reversal was more likely to occur (90% vs 57%; P = 0.005) and associated with less severe complications than a colostomy reversal after Hartmann’s Procedure.

The multicenter, randomized superiority LADIES trial by Lambrichts et al[34] in 2019, which is the largest RCT on this topic to date, showed a significantly better 12-months stoma-free-survival for the RPA group (94.6% for RPA vs 71.7% for Hartmann’s procedure, hazard ratio = 2.79), with no difference in short term morbidity and mortality for the index procedures. They concluded that in hemodynamically stable, immunocompetent patients younger than 85 years, RPA with or without diverting stoma is preferred to Hartmann’s procedure as a treatment for perforated diverticulitis (Hinchey III or Hinchey IV disease). The 3-year follow-up data continued to show benefit for the RPA group with better 36-month stoma-free-survival rates, lower rates of parastomal hernias and lower rates of hospitalizations[35].

More recently, the prospective, international, multicenter, observational, “Goodbye Hartmann trial”[36] published in 2024 of 1215 patients recommended that RPA with or without diverting stoma be considered the surgical standard and Hartmann’s procedure to be left for exceptional cases. On logistic regression for factors influencing the decisions for either surgical option, they found RPA to be preferred in patients who were younger, had low ASA score (≤ 3), had absence of colonic ischemia, and performed by a surgeon with experience in at least 50 colorectal resections. The above factors reflect the reality of selection bias in emergency colorectal practice, where patients with higher surgical risks or emergency surgeries performed out of office hours in non-experienced hands, are more likely to undergo a Hartmann’s procedure.

Of note, the studies by Breitenstein et al[32], Oberkofler et al[33] and Lambrichts et al[34] all showed similar morbidity and overall complications in the index operation for both the RPA with or without diverting stoma and Hartmann’s procedure groups. The main benefit of RPA therefore relates to long term stoma-free-survival and reduced stoma related complications. For patients who are hemodynamically unstable with poor physiological reserves, the Hartmann’s procedure, which has a shorter operative time, is still very much relevant.

In terms of evidence on the utility of MIS in colorectal perforations, literature largely stems from the management of benign perforations such as acute diverticulitis or iatrogenic colorectal perforations. Retrospective cohorts with a mix of both benign and malignant etiologies have shown the benefit of the laparoscopic approach in reducing surgical site infections with no difference in overall morbidity and mortality[37,38].

Extrapolating from evidence on perforated diverticulitis regarding the use of a laparoscopic approach in performing a Hartmann’s procedure or resection with RPA from a database of > 4000 propensity score matched patients, Monzavi et al[39] found that laparoscopic resection with RPA was associated with longer operative times. However, when compared to an open approach, there were lower rates of wound complications, sepsis, morbidity and shorter LOS, without differences in anastomotic leak rates or mortality. The same study found that laparoscopic Hartmann’s procedure was associated with longer operative times than an open approach but lower rates of respiratory failure, without differences in morbidity, mortality or LOS. Although contemporary evidence suggests that MIS colorectal resections confer some short-term benefits, surgical decisions on approach should be individualized, taking into account patient factors, operative findings and the surgical expertise available.

Rectal cancer: The management of rectal cancer perforation depends on its site. Intraperitoneal perforations can cause significant peritonitis and are managed as per left-sided colonic perforations. For extraperitoneal mid to low rectal cancers where the lesion is challenging to resect, emergency proctectomy is associated with significant operative time, a higher risk of bleeding and injury to the nerves of the pelvic floor, bladder, and genitalia[40] and should generally be avoided. Instead, adequate drainage, proximal diverting stoma with distal limb washout should be considered in the emergency setting as a bridge to elective resectional surgery. If drainage is performed, the site of drainage (or percutaneous tract if performed under image guidance) should be incorporated into the eventual resection margin to reduce the risk of local recurrence. This temporizing measure allows time for appropriate clinical staging, optimization of the patient and discussion with a multidisciplinary team for neoadjuvant treatment if required. Also, if the planned oncological resection is likely to result in a sizeable defect, prior consultation with a reconstructive surgeon for appropriate defect coverage should be performed. Based on the above-mentioned considerations, our management algorithm for perforated CRC is summarized in Figure 3. Key priorities in the management includes the emphasis on sepsis control and the assessment of patient’s physiology before considering the various surgical approaches.

Figure 3
Figure 3 Suggested management algorithm for perforated colorectal cancer. MIS: Minimally invasive surgery.
Technical challenges in MIS and suggested strategies for perforated CRC

Challenges that pertain to perforated CRC include: (1) The lack of sufficient working space due to bowel distension secondary to paralytic ileus; (2) Challenging surgical anatomy due to less obvious anatomical planes, the presence of a bulky lesion, limited exposure to identify key structures, and active inflammation of tissues (especially in the presence of an inflammatory phlegmon); (3) Poor optics relating to plume generation from cautery over inflamed or edematous tissue; (4) Concerns on MIS ability for adequate lavage and decontamination; (5) Tissue quality (distended edematous bowel, inflamed friable tissues) which increases the risk of iatrogenic injury; and (6) Controlling further intraoperative spillage from the site of perforation. We share some suggested strategies to address these in Table 2.

Table 2 Surgical strategies for perforated colorectal cancer.
Challenges
Mitigation strategies
Limited working space, exposure and access to target anatomyAs per Table 1
Difficulty in identifying critical structures and less obvious anatomical planesExtrapolating from normal tissue planes and known anatomy – there may be a need to start dissection away from the target pathology to identify normal anatomical structures first, before working back towards the pathology by extrapolating from known tissue planes
Use of adjuncts such as use of lighted ureteric stents or indocyanine green can be helpful
Poor optics from surgical smoke and plume generationUse of intraoperative smoke evacuation systems, or continuous smoke evacuation and carbon dioxide recirculation devices (e.g., AirSeal iFS [CONMED Corp., Largo, FL United States]) to provide more stable pneumoperitoneum pressures and faster clearance of plume
Reduction of plume generation by keeping dissection planes dry with gauze and frequent suctioning
Concerns of adequate decontamination/Lavage in contaminated casesUse gravity to bring contaminated fluid to more accessible areas with systematic changes to patient positioning
Use of laparoscopic gauze as a wick when performing suctioning in regions that are harder to gain full exposure
Consider the use of laparoscopic suction/irrigation powered pump devices to improve surgical efficiency
Friable and inflamed tissueHeighten awareness on tactile and visual feedback when handling tissues to avoid excessive traction
Distributing force applied on tissues over a larger surface area by pushing tissues with an open grasper or using a gauze to aid in this. Avoid direct grasping or pulling of tissues as this can easily result in inadvertent injuries
Inflamed tissues are more susceptible to bleeding. Performing meticulous hemostasis at all times during the surgery to keep planes dry
Control of further intraoperative spillageProximal control with laparoscopic bulldog clamp to prevent continued downstream contamination
Pack defect with gauze
If tissue quality is suitable, perform primary closure of the site of perforation as a temporizing measure if added operative time is short
BLEEDING IN CRC

Bleeding is a common presentation of CRC but is usually slow in nature and self-limiting[41]. Its acute presentation in the emergency setting of CRC tends to be rare. In such situations, the treatment of choice would be that of endoscopic treatment[42] or angioembolization. Should emergent surgery be necessary, a MIS approach is recommended with an additional consideration to perform vascular control and ligation first to control further blood loss.

ROBOTICS IN EMERGENCY CRC SURGERY

Robotic-assisted surgery in elective MIS colorectal surgery is gaining traction with its ability to address the technical and ergonomic shortcomings of laparoscopic surgery. Evidence on its use in the emergency setting for colorectal surgery is still in its infancy and has been limited to early experiences from a few institutions[43-45]. Resource constraints, logistical challenges, and cost concerns pose significant barriers to its adoption in the emergency setting.

Despite this, there is growing acceptance[46] and interest in this topic, which has prompted the World Society of Emergency Surgery to publish a position paper in 2021 outlining guidance on specific situations in which robotic approaches may be preferred[47]. Robotic systems, with its capability of stable 3D stereoscopic vision, fully articulating wristed instruments, stable instruments with movement scaling and tremor filtration, are well suited to address some of the intraoperative challenges of emergency CRC surgery and may reduce the risk of conversions[47]. Its limitation when compared to laparoscopy is the inability to perform multi-quadrant surgery without the need to re-dock should contamination be extensive.

One of the early published studies on the use of robotic surgery in the management of emergency colorectal malignancy is a small series of four cases of malignant bowel obstructions and six benign colorectal conditions by Maertens et al[45], which found potential benefits of better radical lymph node dissection and reduced need for diverting stoma with robotic assisted surgery. Curfman et al[48] compared open, laparoscopic, and robotic approaches for the management of emergency colorectal resections in acute diverticulitis retrospectively. They found a reduction in ICU admission rates and anastomotic leak rates when robotic surgery was used compared to an open approach. When robotic surgery was compared with laparoscopic surgery, it was associated with reduced anastomotic leak rates and conversion rates to open surgery. However, robotic surgery was associated with longer intraoperative times.

Lunardi et al[46] analyzed temporal trends in MIS emergency surgery for common general surgical conditions as a secondary outcome in a recent retrospective cohort study using data from a claims registry of 89098 emergency colectomies of all surgical approaches (open, laparoscopic, robotic-assisted) between 2013 and 2021. The results demonstrated that, when compared to laparoscopic surgery, robotic-assisted surgery was associated with a significantly lower risk of conversion to open (odds ratio = 0.37) and shorter postoperative LOS (-0.48 days) after propensity score matching between the 2 MIS approaches (3375 patients in each group). The critique for this study is its relatively high conversion rate of 25.5% in the laparoscopic colectomy group which may indicate poor patient selection or insufficient surgical experience. However, this study showed a significant shift in current trends towards robotic-assisted surgery for emergency colectomies over the years (from 1.4% in 2013 to 8.8% in 2021, 0.9% increase per year, with a two-fold increase in numbers in the final 3 years of the study), providing us a projected trajectory of the future of emergency colorectal surgery. The ROEM prospective, multicenter international study[49] which recently published its trial protocol, aims to assess the safety, feasibility and cost-effectiveness of robotic-assisted benign emergency surgery and we await its future results. Patient selection remains key and, as robotic-assisted surgery becomes more prevalent, barriers to its implementation need to be addressed.

CONCLUSION

Evidence is maturing on the utility of MIS in the management of emergency CRC surgery. Despite longer operative times, MIS has been shown to be safe and feasible with improved short-term outcomes. Patient selection remains key to its successful adoption and important factors include that of overall management intent (curative/palliative), site of pathology and patient’s hemodynamic status.

MIS is technically challenging and should be performed by experienced surgeons who have mounted their learning curve for MIS elective colorectal resections as per National Comprehensive Cancer Network guidelines. The use of robotics in emergency colorectal surgery is evolving and shows promise with lower rates of conversion and shorter LOS by addressing certain limitations of laparoscopic surgery. Future prospective studies should be directed at addressing the utility of robotic emergency oncological surgery. With continued advancements and adoption of MIS techniques, the potential to improve patient outcomes in emergency CRC management is significant.

Footnotes

Provenance and peer review: Invited article; Externally peer reviewed.

Peer-review model: Single blind

Specialty type: Oncology

Country of origin: Singapore

Peer-review report’s classification

Scientific Quality: Grade C, Grade D

Novelty: Grade C, Grade C

Creativity or Innovation: Grade C, Grade D

Scientific Significance: Grade B, Grade C

P-Reviewer: Li XB S-Editor: Bai Y L-Editor: Filipodia P-Editor: Zhao YQ

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