For a 46‑year‑old woman, ECOG 1, with a sigmoid colon cancer adherent to the anterior uterus and a 1.8 cm hypodense liver lesion who is not clinically obstructed, can we perform a staging laparoscopy and then proceed with a laparoscopic anterior resection together with total abdominal hysterectomy and bilateral salpingo‑oophorectomy?

Laparoscopic Staging and Combined Resection for Sigmoid Cancer with Uterine Involvement

Yes, you can perform staging laparoscopy followed by laparoscopic anterior resection with TAHBSO in this elective setting, as this approach allows for comprehensive staging, optimal oncologic resection, and addresses the locally advanced disease with uterine involvement in a single procedure.

Rationale for Combined Laparoscopic Approach

Staging Laparoscopy Feasibility

• Laparoscopic staging is feasible and safe for gynecologic malignancies, with 69% of patients achieving complete endoscopic staging in GOG studies, though 20% may require conversion to laparotomy for adhesions or metastatic disease 1.
• The staging laparoscopy will allow you to assess the 1.8 cm liver lesion directly, evaluate for peritoneal disease, and confirm resectability before proceeding with definitive resection 1.
• If unresectable disease or extensive peritoneal metastases are discovered during staging, you can abort and avoid unnecessary morbidity from a futile resection 1.

Laparoscopic Anterior Resection for Sigmoid Cancer

• Minimally invasive approaches (laparoscopy or robotic surgery) are acceptable for colorectal cancer resection when local technology and equipment are available, according to the Chinese Society of Clinical Oncology 2.
• However, laparoscopic surgery is NOT recommended for patients with obstruction 2—but your patient is explicitly NOT obstructed, making laparoscopy appropriate.
• Laparoscopic anterior resection demonstrates comparable oncologic outcomes to open surgery, with 3-year overall survival of 94.5% versus 97.1% and disease-free survival of 89.5% versus 87.4% 3.
• Adequate lymph node dissection can be achieved laparoscopically, with no difference in number of retrieved lymph nodes compared to open surgery 4.

Combined Resection with TAHBSO

Oncologic Justification

• When sigmoid cancer is adherent to the uterus, en bloc resection including the involved organs is necessary to achieve complete tumor removal and avoid tumor spillage 2.
• The standard surgical treatment should include complete resection with regional lymph node dissection 2.
• TAHBSO is appropriate for this 46-year-old woman as ovarian preservation is not indicated when performing cancer surgery, and the uterus is directly involved by tumor 2.

Technical Considerations

• Minimally invasive surgery can be extended to higher-risk tumors without detrimental effects on prognosis 2.
• The combined procedure allows for systematic exploration of the entire abdomen and pelvis, collection of peritoneal washings, assessment of pelvic and para-aortic lymph nodes, and complete staging 2.
• Laparoscopic lymphadenectomy (pelvic and para-aortic) can be performed as part of comprehensive staging 2.

Surgical Algorithm

Step 1: Diagnostic Laparoscopy

• Perform systematic exploration of entire abdomen and pelvis 2
• Obtain peritoneal washings for cytology 2
• Directly visualize and potentially biopsy the liver lesion to confirm or exclude metastatic disease 1
• Assess for peritoneal disease, omental involvement, and lymphadenopathy 2

Step 2: Decision Point

• If resectable disease confirmed: Proceed with definitive resection
• If unresectable metastases found: Abort, close, and proceed to systemic chemotherapy 2
• If extensive adhesions prevent safe laparoscopy: Convert to laparotomy 1

Step 3: Definitive Resection (if proceeding)

• Laparoscopic anterior resection with complete mesorectal excision and adequate proximal/distal margins 2
• En bloc TAHBSO including the adherent uterus and bilateral adnexa 2
• Pelvic lymph node dissection (minimum 12 lymph nodes) 2
• Consider para-aortic lymph node sampling if suspicious nodes identified 2
• Infracolic omentectomy should be considered given the liver lesion 2

Critical Caveats

Liver Lesion Management

• The 1.8 cm hypodense liver lesion requires definitive characterization—if this represents metastatic disease, the patient has Stage IV disease and surgery may not be the optimal initial approach 5.
• Consider preoperative biopsy or intraoperative frozen section of the liver lesion to guide decision-making 1.
• If confirmed metastatic, neoadjuvant chemotherapy followed by reassessment may be more appropriate than upfront surgery 2.

Conversion Threshold

• Maintain a low threshold for conversion to laparotomy if you encounter dense adhesions, unclear anatomy, or inability to achieve complete resection laparoscopically 1.
• The conversion rate in staging laparoscopy studies is approximately 20% 1.
• Bowel complications occur in 6% of laparoscopic staging procedures, so meticulous technique is essential 1.

Oncologic Principles

• Complete resection (R0) is paramount—do not compromise oncologic principles for minimally invasive approach 2.
• Ensure adequate lymph node harvest (≥12 nodes) as this impacts staging and adjuvant therapy decisions 2.
• Avoid tumor spillage or fragmentation during manipulation of the adherent sigmoid-uterine mass 2.

Expected Outcomes

• Hospital stay: 3 days with laparoscopy alone versus 6 days with laparotomy 1
• Operative time: May be longer with laparoscopy but with faster recovery 3
• Oncologic outcomes: Equivalent to open surgery when performed by experienced surgeons 3, 4