British Journal of Surgery 1998, 85, 735–741 Review Port-site metastases following laparoscopic surgery S. J. NEUHAUS, M. TEXLER*, P. J. HEWETT* and D. I. WATSON The University of Adelaide Department of Surgery, Royal Adelaide Hospital and *Queen Elizabeth Hospital, Adelaide, South Australia Correspondence to: Mr D. I. Watson, Department of Surgery, Level 6, Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia Background Application of laparoscopy to the resection of malignancy has been followed by a literature describing cases of metastatic involvement at laparoscopic port sites. These include patients who underwent surgery for early stage carcinoma and instances following laparoscopic procedures during which tumours were not dissected. Methods Recently published clinical and experimental studies, and case reports related to this problem are reviewed; their relevance is discussed. Results Experimental studies incorporating bench top and large animal models have confirmed that tumour cells may be redistributed to port sites during laparoscopic surgery either directly from contaminated instruments or indirectly via the insufflation gas. Small animal models suggest that the incidence of wound metastasis is increased following conventional laparoscopic surgery, and that it may be decreased by gasless laparoscopy or helium insufflation. This evidence suggests that the development of port-site metastases depends not only on the physical redistribution of tumour cells but also on the specific insufflation gas used, possibly because of influences on local metabolic or immune factors acting at the wound site. Conclusion Further research in this area is urgent. Until the issue is better understood, patients undergoing laparoscopic surgery for malignancy should be entered into clinical trials. Since the first report of metastasis to a laparoscopic port site by Döbrönte et al. 1 in 1978, it has become increasingly clear that the laparoscopic manipulation of both abdomi- nal and thoracic malignancies may be followed by metastasis to surgical access wounds. Whether this is more likely following laparoscopic than open surgery is contro- versial 2–4 . However individual case reports, as well as the results of recent experimental studies 5–9 , suggest that this problem is significant. A critical review of the issue is warranted, as laparoscopic techniques, while attractive in terms of cosmesis, shorter hospital stay and reduced postoperative pain 10 , cannot be justified if they result in an incidence of recurrent malignant disease in surgical access wounds which compromises long-term outcome. Wound seeding of a potentially curable malignancy is a disaster which may change a curable condition into an incurable one. Furthermore, recurrence after palliative laparoscopic resection may compromise quality of life. Consequently, many surgeons have expressed concern about the appro- priateness of the application of laparoscopic techniques to the surgical treatment of malignancy 2,3,9,11 . Evidence from clinical cases Since 1978, in excess of 100 reports of metastasis to laparoscopy wounds have appeared in the surgical and gynaecological literature 12 . These include instances of metastasis following diagnostic laparoscopy or laparo- scopic resection of carcinoma of the gallbladder 3,13,14 , ovary 1,15,16 , pancreas 4,17 , colon 18–20 , bladder 21,22 , stomach 23 and liver 24 . Of concern are reported instances of metastasis following laparoscopy when it has been documented that the primary tumour was not manipu- lated during the procedure 17,25 as well as metastasis follow- ing laparoscopic colectomy for Dukes A colonic lesions 20,26 , mucosal gallbladder cancer 6 and carcinoma in situ 3 ( Tables 1 and 2). It is also important to realize that this problem is not exclusive to laparoscopy; it has also been associated with thoracoscopic cancer resection 29,31,32 . Following the early case reports, Nduka et al. 2 published the first review of the problem in this Journal in 1994, describing a collected series of 20 cases, all adenocarci- nomas. Wibbenmeyer et al. 3 in 1995 reviewed a population undergoing laparoscopic cholecystectomy and reported a 1 per cent incidence of gallbladder cancer in the patient group studied. Laparoscopic cholecystectomy was associated with an increased risk of dissemination and Paper accepted 12 January 1998 Table 1 Case reports of port-site metastases developing following laparoscopic surgery without tumour manipulation Reference Year Procedure Tumour type Siriwardena and Samarji 4 1993 Laparoscopic cholecystectomy Pancreatic adenocarcinoma Watson 17 1995 Laparoscopic gastroenterostomy Pancreatic adenocarcinoma Nieveen et al. 27 1996 Diagnostic laparoscopy Pancreatic adenocarcinoma Jorgensen et al. 25 1995 Diagnostic laparoscopy Pancreatic adenocarcinoma Nieveen et al. 27 1996 Diagnostic laparoscopy Pancreatic adenocarcinoma Nieveen et al. 27 1996 Diagnostic laparoscopy Stomach adenocarcinoma Nieveen et al. 27 1996 Diagnostic laparoscopy Liver tumour © 1998 Blackwell Science Ltd 735