Stage 0: These cancers are in the inner lining of the colon; polypectomy or local excision through a colonoscope is often all that is needed. Colectomy may occasionally be needed if a tumor is too big to be removed by local excision.

Stage I: Several layers of the colon are penetrated from the cancer without spread outside the colon wall (or into nearby lymph nodes). Partial colectomy (i.e., surgery to remove the section of colon that has cancer and nearby lymph nodes) is the standard treatment without the need for additional therapy.

Stage II: Many of these cancers have grown through the wall of the colon and may extend into nearby tissue. They have not yet spread to the lymph nodes. Colectomy is usually the only treatment needed. However, adjuvant chemotherapy may be recommended if the cancer has a higher risk of returning because of certain factors: it looks very abnormal (is high grade) or has a dangerous histotype; shows MSI; has grown into nearby organs; the surgeon did not remove all the cancer and ≥12 lymph nodes; the cancer obstructs the colon or causes a perforation in the colon wall. Many research teams have studied the way to identify stage II because the risk of recurrence is greater. Petersen et al. [37] proposed a sub-classification of the prognostic index (PI) based on four elements subsequently considered by many other authors. Three of them have a score of 1: peritoneal involvement with or without ulceration; extramural or submucosal venous spread; or a involved or inflamed margin. The last element, perforation through the tumor, has a score of 2. Patients in stage II with a PI of ≥2 are to be considered at high risk and could be candidates for adjuvant therapy (see below). Even the pathological aspects of tumor necrosis as well as host systemic and local inflammatory responses are taken into account. Different criteria have been used to measure these variables, such as the Glasgow Prognostic Score [38] for systemic inflammatory responses, the Klintrup.Makinen criteria [39] for local inflammatory infiltrates and for the assessment of tumor necrosis. Richards et al. [40] confirmed by statistical means that tumor necrosis is a marker of a poor prognosis, independent of pathological stage, and that it is associated directly with an increase in the systemic inflammatory response and a decrease in local inflammatory cell infiltrates. This finding suggests that the impact of tumor necrosis on survival from CRC may be explained by close relationships with host inflammatory responses. Patients in stage II with extensive tumor necrosis are to be considered at high risk and could be candidates for adjuvant therapy.

Stage III: There is a spread to nearby lymph nodes, but cancer has not yet spread to other parts of the body. Partial colectomy followed by adjuvant chemotherapy is the standard treatment for this stage.

Stage IV: Distant organs and tissues such as the liver, lungs, peritoneum or ovaries can be affectted by colon cancer. If only a few small metastases are present in the liver or lungs and can be completely removed along with the colon cancer, surgery may prolong life and sometimes may even cure. Chemotherapy is typically given before and/or after surgery. Other options to destroy tumors in the liver include hepatic artery infusion, cryosurgery, radiofrequency ablation, or other non-surgical methods. If the cancer is too widespread to try to cure with surgery, colectomy or diverting colostomy may be needed in cases of bleeding or occlusion. Sometimes, such surgery can be avoided by inserting a stent into the colon during colonoscopy to keep the lumen patent. Most patients with stage-IV cancer will receive chemotherapy and/or targeted therapies to control the cancer.

Recurrent cancer means that the cancer has returned after treatment. If the cancer comes back locally, surgery (often with previous and/or after chemotherapy) can stop recurrence, prolong life, and eventually cure the patient. If the cancer comes back at a distant site (liver, lung, others), surgery may be an option in some cases. If needed, chemotherapy can be tried first to shrink the tumor(s), and may be followed by surgery. If the cancer is too widespread for a surgical approach, chemotherapy and/or targeted therapies may be used depending on which (if any) drugs were received before the cancer returned and how long ago the patient received them, as well as general health status. Radiotherapy may be an option to relieve symptoms in some cases.

Laparoscopic surgery for CRC has undergone slow (but tremendous overall) advancement since 1991, when first laparoscopic colonic resection for cancer was described. LC can today be considered the gold standard surgical treatment for colon cancer when indicated appropriately. Randomized clinical trials have shown that this method is safe and effective for malignant disease with oncologic outcomes equivalent to open surgery [43–45]. LC results in a shorter hospital stay as well as less morbidity and postoperative pain than open colorectal surgery.

Nevertheless significant socioeconomic disparities in the use of minimally invasive surgery (MIS) for colorectal disease remain. A recent revision of 211,862 colorectal resections carried out at high-volume hospitals in 2008 in the USA [46] demonstrated that only 16,637 (7.3%) colorectal resections were done using MIS. It was found that racial and socioeconomic factors influenced appreciably the access to MIS for CRC treatment. Laparoscopic surgery for colon cancer is the cornerstone of enhanced recovery programs thanks to its lower level of injury to potentially complex, immune-challenged hosts. The underlying philosophy of FT programs is to capitalize upon small differences to effectuate more important global benefits in overall patient recovery in the hope that the short-term advantages of enhanced-recovery colonic surgery may have important cumulative long-term benefits. Clearly, further investigation is warranted. Under the impact of an ever advancing technology, enhancing the ergonomics and extending the boundaries of MIS, the next few years are expected to be very promising for laparoscopic surgery of colon cancer with prospective randomized studies reaching full maturity and having the possibility to extend the follow-up to a more significant period of 10 years. The integration of enhanced-recovery regimens with laparoscopic methods should also provide greater uniformity of clinical outcomes throughout the world. Furthermore, the previously arduous learning curve will predominantly be addressed in the postgraduate training period. The comparisons of experiences will probably lead, in this decade, to an evermore important technical standardization of colectomies.

Single-incision laparoscopic surgery (SILS) represents the latest development in laparoscopic surgery and has been promoted to improve the cosmetic effect and incisional and/or parietal pain as well as to reduce port site-related complications. The initial increases in surgical costs associated with purchasing new equipment do not seem to be mitigated by a significant reduction in morbidity and duration of hospital stay [47]. SILS has several disadvantages compared with multiport laparoscopic surgery with regard to surgical instruments and methods. One of the biggest challenges associated with SILS is the optimal positioning of instruments. Therefore, SILS requires an experienced surgeon to overcome the difficulties of triangulation, pneumoperitoneum leaks, and instrument crowding. In fact, many cases require conversion to open or multiport laparoscopic procedures to get better retraction or aid in colonic mobilization. Some investigators recommend utilizing articulating instruments or variablelength tools, including a bariatric-length bowel grasper or an extra-long laparoscope to minimize external clashing. Most of the experiences in SILC have been in the setting of right hemicolectomy [48] (Fig. 3.1). This is because this procedure was proposed as an intracorporeal ileocolic anastomosis using an Endo stapler and closure of the orifice left from the stapler by the endostitch that requires limited wrist movements to avoid interference with the endoscope. It was also to avoid mesenteric traction occurring with extracorporeal sutures, which often involve enlarging the incision of the multiport device [49]. Further advantages can be gained from the use of particular access ports to allow the introduction of several trocars multiple times, for example using Gelport™, in which trocars can be kept apart for as long as possible to maintain instrument triangulation and to prevent clashing outside the abdomen. It has recently been suggested [50] that the implementation of robotic technology to SILC could help overcome some of the difficulties associated with conventional SILS.