Colorectal cancer is a significant cause of cancer-related deaths and is a major contributor to the cancer burden worldwide. In 2020, there were estimated to be over 1.9 million new cases of colorectal cancer and around 935,000 deaths from the disease, representing almost one in ten cancer cases and cancer deaths globally [1]. Complete surgical resection is the mainstay of curative treatment for patients with localized or regionally advanced colon cancer. Therefore, the surgical strategy should ensure adequate oncological clearance, reduce perioperative morbidity, and maintain function and quality of life after surgery. Until recently, the standard surgical treatment for colon cancer was open colectomy. The introduction of laparoscopic techniques opened the door to minimizing surgical trauma and speeding up recovery, but early use led to concerns about the quality of resection, assessment of lymph nodes, recurrence, and long-term survival. In one of the earlier randomized trials by Lacy et al., recovery was quicker, oral intake was earlier, hospital stay was shorter, and morbidity was lower after laparoscopic-assisted colectomy. Importantly, the study did not show inferior oncological outcomes and showed good cancer-related outcomes with the laparoscopic approach [2]. Further multicenter randomized trials confirmed the oncological safety. The Clinical Outcomes of Surgical Therapy (COST) trial randomized 872 patients with colon cancer and showed comparable three-year recurrence rates (16% versus 18%) and three-year overall survival (86% versus 85%) between the two groups. Laparoscopic surgery was also linked to a shorter hospital stay and less postoperative pain medication [3]. The results of these studies led to the recognition of minimally invasive colectomy as an oncologically sound alternative to open surgery. This has been confirmed by longer-term randomized evidence. In the COLOR trial, three-year disease-free survival was 74.2% following laparoscopic surgery and 76.2% following open surgery, with similar resection margins, lymph-node retrieval, morbidity, and mortality [4]. Patients from the COLOR study also had broadly similar oncological results at 10 years, with 45.2% of patients in the laparoscopic group and 43.2% in the open surgery group being disease-free [5]. Another meta-analysis of randomized trials with over 3,000 patients also showed no difference in long-term overall survival between laparoscopic and open colectomy, including when analyzed by stage (I–III) [6]. While survival and recurrence are still the most important indicators of cancer surgery, they are not enough to capture the patient's postoperative experience. While minimally invasive surgery may have benefits in pain, mobility, bowel recovery, and return to normal activity, these benefits may not necessarily result in long-term differences in health-related quality of life. Weeks et al. reported that there were only minor differences between the two procedures in the quality-of-life arm of the COST trial, even though the laparoscopy group required less analgesia [7]. Likewise, Janson et al. reported on the EORTC QLQ-C30 and EQ-5D in patients who were randomized to laparoscopic or open colon resection and found that there were some early benefits in social and role functioning after laparoscopic surgery, but that the overall differences in quality of life were relatively small [8]. These observations underscore the need to evaluate quality of life in a longitudinal fashion and not to equate better perioperative recovery with better longer-term patient-reported outcomes. Although there is a wealth of international evidence, the relative benefits of laparoscopic and open colectomy in terms of perioperative recovery, oncological outcomes, and quality of life are still relevant in individual surgical settings where patient characteristics, disease stage, surgical expertise, and perioperative care can vary. These outcomes can be evaluated in the same randomized cohort to account for the early benefits of minimally invasive surgery in addition to oncological adequacy and patient-reported health outcomes. The present randomized controlled trial thus compared the outcomes of laparoscopic and open colectomy for nonmetastatic colon cancer, including perioperative and postoperative outcomes, oncological quality of resection, recurrence, disease-free and overall survival, and health-related quality of life. Quality of life was assessed over time with the EORTC QLQ-C30 and selected QLQ-CR29 domains, and the main oncological outcomes were disease-free and overall survival at 24 months.

Study design and participants This randomized controlled trial was conducted in the Department of Surgery, Veer Surendra Sai Institute of Medical Sciences and Research (VIMSAR), from August 2022 to August 2025. Patients were recruited between August 2022 and August 2023 and followed for approximately 24–36 months after surgery. Adults undergoing elective curative-intent resection for nonmetastatic colon cancer were eligible. Patients with metastatic disease were excluded. A total of 44 patients were randomized in a 1:1 ratio to laparoscopic colectomy or open colectomy, with 22 patients in each group. Analyses were performed according to the randomized treatment assignment on an intention-to-treat basis; patients requiring conversion from laparoscopic to open surgery remained in the laparoscopic group. Clinical and pathological assessment Baseline data included age, sex, body mass index, smoking status, diabetes, hypertension, ASA grade, ECOG performance status, hemoglobin, serum albumin, and carcinoembryonic antigen. Tumour characteristics included anatomical location, pathological T and N stage, overall pathological stage, histological type, tumour grade, tumour size, lymphovascular invasion, and perineural invasion. The operative procedure was selected according to tumour location and included right hemicolectomy, extended right hemicolectomy, transverse colectomy, left hemicolectomy, or sigmoid colectomy. Operative time, estimated blood loss, conversion, intraoperative complications, anastomosis, diverting stoma, resection-margin status, margin lengths, lymph-node yield, and number of positive lymph nodes were recorded. Postoperative and oncological outcomes Early postoperative outcomes included pain score at 24 hours, time to first flatus, bowel movement and oral intake, length of hospital stay, postoperative complications, Clavien-Dindo grade, anastomotic leak, surgical-site infection, ileus, respiratory complications, 30-day readmission, reoperation, and mortality. Adjuvant chemotherapy and its timing were recorded where applicable. Patients were followed for recurrence and survival until the last documented follow-up. Disease-free survival (DFS) was defined as the interval from surgery to first recurrence or death from any cause, with event-free patients censored at the last follow-up. Overall survival (OS) was defined as the interval from surgery to death from any cause, with surviving patients censored at their last follow-up. The principal survival endpoints were 24-month DFS and 24-month OS. Quality-of-life assessment Health-related quality of life was assessed using derived scale scores from the EORTC QLQ-C30 and selected EORTC QLQ-CR29 domains. QLQ-C30 Global Health Status was assessed at baseline and at 3, 6, 12, and 24 months. Scores were transformed to the conventional 0–100 scale according to EORTC scoring conventions. Higher Global Health and functional-domain scores indicate better status, whereas higher symptom-domain scores indicate greater symptom burden. Detailed domain-level analyses were considered exploratory. Statistical analysis Continuous variables were summarized as mean ± SD or median (IQR), as appropriate, and categorical variables as n (%). Between-group comparisons used Welch’s t test or the Mann–Whitney U test for continuous variables and the chi-square or Fisher exact test for categorical variables. Longitudinal QLQ-C30 Global Health scores were analyzed using a repeated-measures generalized estimating equation model including treatment group, time, and the treatment-by-time interaction. Between-group differences at individual follow-up points were reported with 95% confidence intervals. DFS and OS were estimated using the Kaplan–Meier method and compared using the log-rank test. Because the number of survival events was limited, multivariable Cox regression was not performed. No unnecessary subgroup analyses were undertaken, and exploratory quality-of-life domains were interpreted descriptively. All tests were two-sided, with p<0.05 considered statistically significant. Nonsignificant findings were not interpreted as evidence of equivalence. Ethical considerations The study was conducted in accordance with institutional ethical requirements and the principles of the Declaration of Helsinki. Written informed consent was obtained from all participants.

Study population and baseline characteristics Forty-four patients were analyzed according to randomized treatment assignment, with 22 (50.0%) in the laparoscopic group and 22 (50.0%) in the open group. Baseline demographic, clinical, and pathological characteristics were generally balanced between groups, including pathological stage and major adverse prognostic features (Table 1). Perioperative and oncological outcomes Laparoscopic colectomy had a longer operative time but lower blood loss, lower 24-hour pain scores, earlier return of gastrointestinal function and oral intake, and a shorter hospital stay. One laparoscopic procedure required conversion to open surgery. Postoperative complications occurred in 4 (18.2%) laparoscopic and 7 (31.8%) open procedures; the between-group difference was not statistically significant. Detailed perioperative and oncological outcomes are shown in Table 2. Quality of life EORTC QLQ-C30 Global Health scores changed significantly over time (Wald χ²=378.28, df=4, p<0.001). A treatment-by-time interaction was observed (Wald χ²=15.75, df=4, p=0.003), indicating different temporal trajectories between groups. At 24 months, the mean Global Health score was 75.5 ± 10.4 in the laparoscopic group and 80.5 ± 11.2 in the open group (mean difference −5.0, 95% CI −11.6 to 1.6; p=0.131) (Table 3 and Figure 1). Exploratory 24-month QLQ-C30 and QLQ-CR29 domain scores showed no consistent directional pattern across the two surgical groups and are summarized descriptively in Table 3A. Recurrence and survival Recurrence occurred in 1 (4.5%) patient in the laparoscopic group and 5 (22.7%) patients in the open group. At 24 months, disease-free survival was 21/22 (95.5%) and 20/22 (90.9%), respectively. The Kaplan–Meier disease-free survival comparison did not reach statistical significance (log-rank χ²=2.73, p=0.099) (Figure 2). One death occurred during follow-up, in the open group; 24-month overall survival was 22/22 (100.0%) in both groups. The overall-survival log-rank comparison was not statistically significant (χ²=0.69, p=0.405). Because survival events were sparse, Cox regression was not performed (Table 4). Table 1. Baseline demographic, clinical, and pathological characteristics Characteristic Laparoscopic (n=22) Open (n=22) Test statistic p value Age, years 60.5 ± 10.0 57.1 ± 9.8 t=1.11, df=42 0.272 Male sex 14 (63.6%) 16 (72.7%) χ²=0.42, df=1 0.517 BMI, kg/m² 24.0 ± 3.7 24.2 ± 3.0 t=-0.20, df=40 0.845 Preoperative hemoglobin, g/dL 12.4 ± 0.7 12.3 ± 0.9 t=0.64, df=41 0.528 Preoperative albumin, g/dL 4.0 ± 0.2 3.9 ± 0.2 t=1.35, df=40 0.185 Preoperative CEA, ng/mL 4.3 (3.0–8.3) 3.8 (2.8–7.8) U=258.5 0.707 Tumor size, cm 4.5 ± 1.2 4.4 ± 1.1 t=0.26, df=41 0.795 Diabetes 4 (18.2%) 3 (13.6%) Fisher exact 1.000 Hypertension 2 (9.1%) 3 (13.6%) Fisher exact 1.000 Lymphovascular invasion 4 (18.2%) 7 (31.8%) χ²=1.09, df=1 0.296 Perineural invasion 7 (31.8%) 2 (9.1%) Fisher exact 0.132 ASA grade I/II/III 4 (18.2%)/14 (63.6%)/4 (18.2%) 2 (9.1%)/15 (68.2%)/5 (22.7%) χ²=0.81, df=2 0.666 ECOG performance status 0/1/2 13 (59.1%)/7 (31.8%)/2 (9.1%) 10 (45.5%)/11 (50.0%)/1 (4.5%) χ²=1.61, df=2 0.446 Pathological stage I/II/III 5 (22.7%)/9 (40.9%)/8 (36.4%) 2 (9.1%)/13 (59.1%)/7 (31.8%) χ²=2.08, df=2 0.354 Tumor grade Well/Moderate/Poor 3 (13.6%)/17 (77.3%)/2 (9.1%) 3 (13.6%)/16 (72.7%)/3 (13.6%) χ²=0.23, df=2 0.891 Smoking Never/Former/Current 16 (72.7%)/4 (18.2%)/2 (9.1%) 14 (63.6%)/6 (27.3%)/2 (9.1%) χ²=0.53, df=2 0.766 Clinical stage I/II/III 4 (18.2%)/11 (50.0%)/7 (31.8%) 2 (9.1%)/14 (63.6%)/6 (27.3%) χ²=1.10, df=2 0.576 Histology Adenocarcinoma/Mucinous/Other 21 (95.5%)/1 (4.5%)/0 (0.0%) 19 (86.4%)/3 (13.6%)/0 (0.0%) χ²=1.10, df=1 0.294 Data are mean ± SD, median (IQR), or n (%) as appropriate. Welch's t test, Mann–Whitney U test, Pearson chi-square test, or Fisher exact test was used according to variable type and cell frequencies. Table 2. Operative, postoperative, and oncological outcomes Outcome Laparoscopic (n=22) Open (n=22) Test statistic p value Operative time, min 179.2 ± 22.9 158.2 ± 20.8 t=3.18, df=42 0.003 Estimated blood loss, mL 105.0 (87.5–127.5) 182.5 (140.0–227.5) U=62.5 <0.001 Pain score at 24 h (0–10) 4.4 ± 1.1 5.7 ± 1.0 t=-4.07, df=42 <0.001 Time to first flatus, days 2.2 ± 0.6 3.3 ± 0.6 t=-7.01, df=42 <0.001 Time to bowel movement, days 3.2 ± 0.7 4.4 ± 0.7 t=-5.62, df=42 <0.001 Time to oral intake, days 1.8 ± 0.5 2.8 ± 0.4 t=-7.11, df=41 <0.001 Hospital stay, days 5.5 (4.8–7.0) 7.4 (6.8–8.9) U=101.5 0.001 Lymph nodes retrieved 18.6 ± 4.9 16.0 ± 3.2 t=2.08, df=37 0.044 Conversion to open 1 (4.5%) Not applicable — — Any postoperative complication 4 (18.2%) 7 (31.8%) χ²=1.09, df=1 0.296 Anastomotic leak 1 (4.5%) 1 (4.5%) Fisher exact 1.000 Surgical site infection 0 (0.0%) 1 (4.5%) Fisher exact 1.000 Postoperative ileus 1 (4.5%) 2 (9.1%) Fisher exact 1.000 30-day readmission 0 (0.0%) 1 (4.5%) Fisher exact 1.000 30-day reoperation 0 (0.0%) 0 (0.0%) Fisher exact 1.000 R0 resection 22 (100.0%) 19 (86.4%) Fisher exact 0.233 Data are mean ± SD, median (IQR), or n (%). Converted patients remained in the laparoscopic randomized group for intention-to-treat analysis. Table 3. EORTC QLQ-C30 Global Health scores over time Time point Laparoscopic Open Mean difference (95% CI) Test statistic p value Baseline 63.2 ± 8.4 (n=22) 68.2 ± 9.0 (n=22) -5.0 (-10.3 to 0.3) t=-1.91, df=42 0.064 3 months 70.4 ± 8.9 (n=21) 68.8 ± 11.0 (n=22) 1.6 (-4.6 to 7.7) t=0.52, df=40 0.603 6 months 72.3 ± 10.2 (n=21) 75.3 ± 9.5 (n=22) -3.0 (-9.0 to 3.1) t=-1.00, df=40 0.325 12 months 75.8 ± 10.1 (n=22) 80.0 ± 10.5 (n=22) -4.2 (-10.4 to 2.1) t=-1.34, df=42 0.186 24 months 75.5 ± 10.4 (n=22) 80.5 ± 11.2 (n=22) -5.0 (-11.6 to 1.6) t=-1.54, df=42 0.131 Higher Global Health scores indicate better health status. Repeated-measures analysis: overall time effect Wald χ²=378.28, df=4, p<0.001; treatment × time interaction Wald χ²=15.75, df=4, p=0.003. Table 3A. Exploratory 24-month quality-of-life domains Domain Laparoscopic Open Scale interpretation QLQ-C30 physical functioning 79.2 ± 11.6 (n=21) 85.0 ± 12.9 (n=21) Higher = better functioning QLQ-C30 role functioning 77.0 ± 12.1 (n=22) 81.0 ± 14.5 (n=21) Higher = better functioning QLQ-C30 fatigue 28.7 ± 11.6 (n=21) 31.6 ± 9.3 (n=22) Higher = greater symptoms QLQ-C30 pain 20.0 ± 13.8 (n=22) 20.3 ± 9.7 (n=21) Higher = greater symptoms QLQ-CR29 body image 86.4 ± 10.6 (n=21) 81.7 ± 12.0 (n=22) Higher = better functioning QLQ-CR29 abdominal pain 23.5 ± 9.0 (n=20) 17.6 ± 12.7 (n=21) Higher = greater symptoms QLQ-CR29 stool frequency 20.0 ± 15.0 (n=22) 18.8 ± 15.7 (n=22) Higher = greater symptoms QLQ-CR29 flatulence 14.9 ± 10.8 (n=22) 13.8 ± 11.1 (n=20) Higher = greater symptoms QLQ-CR29 embarrassment 15.1 ± 10.8 (n=22) 11.5 ± 13.2 (n=22) Higher = greater symptoms EORTC QLQ-C30 and QLQ-CR29 domain scores use 0–100 scales. These domain-level results are descriptive and exploratory. Table 4. Recurrence and survival outcomes Outcome Laparoscopic (n=22) Open (n=22) Test statistic p value Follow-up duration, months 29.8 ± 3.7 30.4 ± 3.6 t=-0.56, df=42 0.581 Deaths 0 (0.0%) 1 (4.5%) Fisher exact 1.000 Recurrences 1 (4.5%) 5 (22.7%) Fisher exact 0.185 24-month overall survival 100.0% 100.0% Log-rank χ²=0.69, df=1 0.405 24-month disease-free survival 95.5% 90.9% Log-rank χ²=2.73, df=1 0.099 Survival comparisons used the log-rank test. With 1 overall-survival event and 6 disease-free-survival events, Cox regression was not performed. Points represent observed group means and error bars represent 95% confidence intervals. Higher scores indicate better global health status. Vertical tick marks indicate censoring. Log-rank χ²=2.73, df=1, p=0.099.

Laparoscopic colectomy demonstrated definite short-term benefits over open surgery in this randomized trial. Laparoscopy had less blood loss, less postoperative pain, earlier bowel function and oral intake, and a shorter hospital stay, though operative time was longer. Laparoscopy had a lower number of postoperative complications, but this was not statistically significant. The oncological parameters were generally acceptable in both groups, and quality of life improved over time, with no significant difference between the groups at 24 months. The laparoscopic arm had fewer recurrences, but the number of events was too small to draw definitive conclusions about survival. The results of this study are similar to the Australasian Laparoscopic Colon Cancer Study, where Hewett et al. found that laparoscopy resulted in quicker gastrointestinal recovery and reduced hospital stay, despite a longer operating time. Overall, the major postoperative outcomes and pathological measures were similar between approaches [9]. Braga et al. reported comparable perioperative advantages, including reduced 30-day morbidity, fewer wound infections, and shorter hospital stay following laparoscopic colorectal resection [10]. The approximate 2-day decrease in hospital stay, decrease in blood loss, and earlier recovery of the gastrointestinal system were similar in the present study, but the small number of patients did not allow significant differences to be demonstrated for uncommon complications. Kaiser et al. also demonstrated that the length of hospital stay, return to bowel function, and intravenous analgesic requirement were shorter after laparoscopic colectomy, with comparable lymph-node harvest and recurrence compared with open colectomy [11]. However, their relatively high conversion rate may reflect the effect of surgical experience and the level of laparoscopic adoption. Only one laparoscopic case in our cohort was converted, but this should not be interpreted as technical superiority, as case selection, instrumentation, and surgical skill vary between studies and eras. Oncological adequacy is always at the core of assessing minimally invasive colon cancer surgery. Similar lymph-node retrieval and comparable recurrence rates were reported after laparoscopic and open surgery for stage II–III left-sided colon cancer by Liang et al. [12]. Our results were also encouraging, as there was good retrieval of nodes in both groups, with a higher mean number of lymph nodes retrieved after laparoscopy. Recurrence occurred in 4.5% of laparoscopic patients compared with 22.7% of open patients; however, with only six recurrence events overall, this difference was not statistically significant. This finding should therefore be interpreted as exploratory and not as an indication of better cancer control. The JCOG0404 trial further underscores the importance of careful interpretation of survival results. Kitano et al. reported 91.8% 5-year overall survival after laparoscopic surgery and 90.4% after open surgery in patients who underwent D3 resection for stage II–III colon cancer, but the trial failed to meet its prespecified non-inferiority criterion [13]. This is important for the current study, as only one death and six disease-free survival events were noted. A lack of a statistically significant difference in overall or disease-free survival should not be interpreted as evidence of equivalence between surgical approaches. The quality-of-life results also need to be interpreted in context. In a randomized study of left-sided colonic resection, Braga et al. showed a short-term quality-of-life benefit with laparoscopy that did not persist at longer follow-up, and there was no difference in survival at 5 years [14]. Global health scores changed significantly over time in our study but were not significantly different between groups at 24 months. This indicates that the initial physiological advantages of minimally invasive surgery do not necessarily translate into a long-term global quality-of-life benefit. However, there may be some differences in specific domains of long-term patient-reported outcomes. Thong et al. reported that overall quality of life was similar for long-term colon cancer survivors who underwent laparoscopic and open colectomy, with body image being more positive after laparoscopy and treatment-related burden more common with open surgery [15]. In our exploratory analyses of the EORTC QLQ-C30 and QLQ-CR29, there was also no clear benefit in any specific domain. These results are descriptive because of the small sample size and multiple domain assessments. Our results corroborate those of Ohtani et al., who performed a meta-analysis of randomized trials and demonstrated that laparoscopic colectomy was associated with reduced blood loss, quicker recovery, shorter hospital stay, and fewer overall complications, but with similar long-term mortality and recurrence rates compared with open surgery [16]. The available evidence indicates that the most consistent advantages of laparoscopy are in perioperative recovery, while oncological results are more dependent on the quality of cancer resection than on the surgical approach. The strengths of this study are that treatment was randomized, intention-to-treat analysis was performed, both perioperative and oncological outcomes were evaluated, and quality of life was assessed longitudinally with validated EORTC questionnaires. The study was, however, limited by its single-center design, small sample size, and relatively short follow-up period of 24–36 months. Recurrence and mortality events were few, which reduced the power of survival comparisons and the ability to perform meaningful multivariable survival modelling. Therefore, nonsignificant differences should not be considered evidence of equivalence. Overall, laparoscopic colectomy was associated with reduced blood loss, less pain, earlier gastrointestinal recovery, and shorter hospital stay, while maintaining acceptable oncological and quality-of-life outcomes. Further studies with larger samples and longer follow-up are needed to determine whether differences in recurrence or survival emerge over time.

Laparoscopic colectomy was associated with better perioperative recovery, including lower blood loss, less postoperative pain, earlier return of bowel function, and shorter hospital stay, while oncological resection quality and 24-month quality-of-life outcomes were broadly comparable with open surgery. Recurrence and survival differences were not statistically significant, and the limited number of events precluded firm conclusions regarding long-term oncological superiority. Larger studies with longer follow-up are needed to clarify differences in disease recurrence and survival.

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