LAPAROSCOPIC STAGING AND LAPAROSCOPIC ULTRASOUND

1. What do you mean by "staging"?

Pre-operative staging is an important step once a cancer is diagnosed. This is the process by which we determine how advanced a cancer is and whether it has spread to distant organs. It allows us to decide what are the best treatment options for a particular patient. Most cancers are divided into 4 stages (stage I being the earliest stage and stage IV the most advanced stage). In addition, each stage may have its own subdivision (eg stage IIa and Stage IIb). At the end of pre-operative staging we should be reasonably accurate in predicting what the actual stage is.

2. What are tests done in staging?

The tests needed depend on the cancer itself and the individual patient. We usually look at how likely the cancer may have spread to a particular organ and how likely that a test will pick this up. For example, a bone scan is very accurate in detecting cancer spread to the bones but this test is usually unnecessary as bone spread is uncommon for most cancers in someone without symptoms of bone pain. On the other hand, in a number of abdominal cancers, eg gastric cancers and pancreatic cancers, there is a high chance that it may already have spread to other abdominal organs - we call this peritoneal spread. The peritoneal deposits can be found on the lining of the abdominal wall or on the surface of the small bowel, large bowel or ovaries. They are often tiny (few mm in size) and cannot be seen on the CT scan. The best investigation to detect this is by Laparoscopic Staging and Laparoscopic Ultrasound.

4. What is Laparoscopic Staging and Laparoscopic Ultrasound?

During Laparoscopic Staging we insert a telescope directly into the abdominal cavity (through a 1cm incision) and perform a thorough examination of all the internal organs such as the bowel, ovaries and lining of the abdominal wall. A pair of fine calibre laparoscopic instruments is also inserted to manipulate the bowel in order to visualize every area clearly.

We will also wash the abdomen with saline and retrieve this washing to look for free floating cancer cells (a procedure called peritoneal lavage for cytology). Another 12 mm incision is made to insert a Laparoscopic Ultrasound probe. The ultrasound probe is placed into direct contact with the organs and allows to assess very accurately the size and invasion of the tumour, the spread to surrounding lymph nodes and whether there is spread to the liver.

5. How is Laparoscopic Staging and Laparoscopic Ultrasound done?

Laparoscopic Staging and Laparoscopic Ultrasound is done under a short general anaesthesia. The entire procedure takes only half an hour and can be done as Day Surgery. The patient goes home on the same day and recovery is quick. There is very little post-op pain.

This procedure gives us very accurate staging information and we will know at the end of the test what the best treatment for the patient is. In our experience, in those patients with gastric cancer where there are strong indications for doing this test, we will find additional information in 50% of these cases for us to change our original plan of treatment. Some of these patients would have otherwise ended up with an open exploratory operation only to find that the cancer is irresectable. Such "open and close" surgery is detrimental to the patient as they may take some time to heal from a long surgical incision. This will in turn delay further treatment options such as chemotherapy and radiotherapy.

In addition, in some patients where we find definite evidence of incurable spread during Laparoscopic Staging, we can immediately direct our treatment at the relief of problematic symptoms such as intestinal obstruction. Such symptoms often need surgery and we can do this straightaway without the need for a second operation. These procedures can also be performed using the minimally invasive approach (see Laparoscopic Bypass and Laparoscopic Palliation of Cancer).