Mentorship for participants in a laparoscopic colectomy course

Adoption rates of laparoscopic techniques for colorectal resections among Brazilian surgeons: limiting factors affecting incorporation into daily practice

Routine adoption of laparoscopy in clinical practice and Medical Residency has not been widely evaluated in Brazil so far.

Aim To take an overview on the adoption and limitations concerning the use of laparoscopic techniques among Brazilian colorectal surgeons.

Methods A questionnaire was sent to 1870 SBCP filiated members, containing personal and professional data such as sex, age, length and local of practice, SBCP filliation, number of procedures, treatment of cancer and laparoscopy limitations.

Results 418 members (22.4%) sent their response (80% men and 20% women). 110 members (26.3%) affirmed they don’t perform any laparoscopic procedure, while 308 (73.7%) have already adopted laparoscopy as a routine. An average number of 7.6 laparoscopic colorectal procedures were declared to be performed per month (1 to 40 procedures). Laparoscopic adoption rates were favourably influenced by young age members (46% vs. 28%) and affiliation to University hospitals (p = 0.01). Conversely, surgeons from private clinic showed a greater tendency of no adoption. Among the 308 responders, 106 (34.4%) have already surpassed more than 100 laparoscopic cases, and 167 (54.2%) reported an experience of more than 50 operated patients. The group of surgeons not using minimally invasive techniques incriminated lack of training (73.6%) and laparoscopic instruments availability (27.3%) as the main reasons for no adoption.

Conclusions Adoption rate of laparoscopic techniques to treat colorectal diseases is still low (at least 17%). Future efforts should focus on providing supervised training, proctorship during the initial experience and help instrumental acquisition in centers willing to change their routine and perspectives.

What to consider when designing a laparoscopic colorectal training curriculum: a review of the literature

Multiple studies have demonstrated the benefits of laparoscopic colorectal surgery (LCS), but in several countries it has still not been widely adopted. LCS training is associated with several challenges, such as patient safety concerns and a steep learning curve. Current evidence may facilitate designing of efficient training curricula to overcome these challenges. Basic training with virtual reality simulators has witnessed meteoric advances and may be essential during the early parts of the learning curve. Cadaveric and animal model training still constitutes an indispensable training tool, due to a higher degree of difficulty and greater resemblance to real operative conditions. In addition, recent evidence favors the use of novel training paradigms, such as proficiency-based training, case selection and modular training. This review summarizes the recent advances in LCS training and provides the evidence for designing an efficient training curriculum to overcome the challenges of LCS training.

Provider Experience and the Comparative Safety of Laparoscopic and Open Colectomy

OBJECTIVE

To evaluate the comparative safety of laparoscopic and open colectomy across surgeons varying in experience with laparoscopy.

DATA SOURCES

National Medicare data (2008-2010) for beneficiaries undergoing laparoscopic or open colectomy.

STUDY DESIGN

Using instrumental variable methods to address selection bias, we evaluated outcomes of laparoscopic and open colectomy. Our instrument was the regional use of laparoscopy in the year prior to a patient's operation. We then evaluated outcomes stratified by surgeons' annual volume of laparoscopic colectomy.

PRINCIPAL FINDINGS

Laparoscopic colectomy was associated with lower mortality (OR: 0.75, 95 percent CI: 0.70-0.78) and fewer complications than open surgery (OR: 0.82, 95 percent CI: 0.79-0.85). Increasing surgeon volume was associated with better outcomes for both procedures, but the relationship was stronger for laparoscopy. The comparative safety depended on surgeon volume. High-volume surgeons had 40 percent lower mortality (OR: 0.60, 95 percent CI: 0.55-0.65) and 30 percent fewer complications (OR: 0.70, 95 percent CI: 0.67-0.74) with laparoscopy. Conversely, low-volume surgeons had 7 percent higher mortality (OR: 1.07, 95 percent CI: 1.02-1.13) and 18 percent more complications (OR: 1.18, 95 percent CI: 1.12-1.24) with laparoscopy.

CONCLUSIONS

This population-based study demonstrates that the comparative safety of laparoscopic and open colectomy is influenced by surgeon volume. Laparoscopic colectomy is only safer for patients whose surgeons have sufficient experience.

Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference

BACKGROUND AND AIM

The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome.

METHOD

An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM).

RESULTS AND CONCLUSION

The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.

Simulation and its role in training

Despite its short history, surgical simulation has been successfully introduced into surgical residency programs in an effort to augment training. A wide range of simulator types and levels of complexity have proven an effective teaching method for surgical trainees. They have been used for training in areas such as general surgery, urology, gynecology, and ophthalmology among others. Coincident with the introduction of simulators is the need for objective evaluation of skills learned on them, which has led to the development and validation of multiple evaluation tools. This article evaluates the drivers for simulation, types of simulators, training, and evaluation of them especially as it pertains to laparoscopic colorectal surgery.

Pitfalls of laparoscopic colorectal surgery and how to avoid them

SUMMARY Laparoscopic surgery is commonly used for colorectal diseases. Recently, laparoscopy for colorectal carcinoma has increased in use, especially by colorectal surgeons. Laparoscopy is associated with potential pitfalls that pose challenges to the surgeon and team. The identification and management of these pitfalls may not directly parallel those during an open approach. As such, it is essential for the surgeon to have a good working knowledge of how to avoid potential problems and how to best manage them when they do occur. This review highlights common pitfalls of laparoscopic colorectal surgery, as well as offering practical approaches to their management. Technical, patient and surgeon factors are all discussed.