Laparoscopic colorectal surgery in Great Britain and Ireland--where are we now?

A Structured Modular Approach: The Answer to Training in Laparoscopic Colorectal Surgery

Bakground: Laparoscopic techniques are now an integral part of the operative management of colorectal diseases. However, the specialist training that is required for this is not uniformly available. There is, therefore, a need for a structured competency-based training method so that trainees can navigate the learning curve safely. Aim. To develop a modular structured training programme for laparoscopic colorectal surgery (LCS) with the capability of ensuring competency-based progression from a novice level to independent operator. Methodology. Over the past decade, we have developed a structured approach, starting with junior surgical trainees and progressing through to consultant level, with 7 clearly defined levels of progression attending courses to achieving a trainer status. This approach allows trainees to maintain objective records of their progression and trainers to provide targeted learning opportunities. It also allows for several trainees of varying experience to be trained during the same procedure. Conclusion. Our structured training module for junior surgeons has successfully produced several competent laparoscopic colorectal surgeons in the United Kingdom and around the world. This approach may also be adaptable to training in other laparoscopic procedures as the levels of progression are generic and not procedure-specific.

SICE national survey: current state on the adoption of laparoscopic approach to the treatment of colorectal disease in Italy

The real diffusion of laparoscopy for the treatment of colorectal diseases in Italy is largely unknown. The main purpose of the present study is to investigate among surgeons dedicated to minimally invasive surgery, the volume of laparoscopic colorectal procedures, the type of operation performed in comparison to traditional approach, the indication for surgery (benign and malignant) and to evaluate the different types of technologies used. A structured questionnaire was developed in collaboration with an international market research institute and the survey was published online; invitation to participate to the survey was issued among the members of the Italian Society of Endoscopic Surgery (SICE). 211 surgeons working in 57 surgical departments in Italy fulfilled and answered the online survey. A total of 6357 colorectal procedures were recorded during the year 2015 of which 4104 (64.1%) were performed using a minimally invasive approach. Colon and rectal cancer were the most common indications for laparoscopic approach (83.1%). Left colectomy was the operation most commonly performed (41.8%), while rectal resection accounted for 23.5% of the cases. Overall conversion rate was 5.9% (242/4104). Full HD standard technology was available and routinely used in all the responders' centers. The proportion of colorectal resections that are carried out laparoscopically in dedicated centers has now reached valuable levels with a low conversion rate.

Intravenous lidocaine for effective pain relief after a laparoscopic colectomy: a prospective, randomized, double-blind, placebo-controlled study

A perioperative intravenous lidocaine infusion has been reported to decrease postoperative pain. The goal of this study was to evaluate the effectiveness of intravenous lidocaine in reducing postoperative pain for laparoscopic colectomy patients. Fifty-five patients scheduled for an elective laparoscopic colectomy were randomly assigned to 2 groups. Group L received an intravenous bolus injection of lidocaine 1.5 mg/kg before intubation, followed by 2 mg/kg/h continuous infusion during the operation. Group C received the same dosage of saline at the same time. Postoperative pain was assessed at 2, 4, 8, 12, 24, and 48 hours after surgery by using the visual analog scale (VAS). Fentanyl consumption by patient-controlled plus investigator-controlled rescue administration and the total number of button pushes were measured at 2, 4, 8, 12, 24, and 48 hours after surgery. In addition, C-reactive protein (CRP) levels were checked on the operation day and postoperative days 1, 2, 3, and 5. VAS scores were significantly lower in group L than group C until 24 hours after surgery. Fentanyl consumption was lower in group L than group C until 12 hours after surgery. Moreover, additional fentanyl injections and the total number of button pushes appeared to be lower in group L than group C (P < 0.05). The CRP level tended to be lower in group L than group C, especially on postoperative day 1 and 2 and appeared to be statistically significant. The satisfaction score was higher in group L than group C (P = 0.024). Intravenous lidocaine infusion during an operation reduces pain after a laparoscopic colectomy.

Current State of Laparoscopic Colonic Surgery in Austria: A National Survey

PURPOSE

Several studies have demonstrated that laparoscopic colonic resection has significant benefits in comparison with open approaches in patients with benign and malignant disease. The proportion of colonic and rectal resections conducted laparoscopically in Austria is not currently known; the aim of this study was to evaluate the current status of laparoscopic colonic surgery in Austria.

MATERIALS AND METHODS

A questionnaire was distributed to all general surgical departments in Austria. In collaboration with IMAS, an Austrian market research institute, an online survey was used to identify laparoscopic and open colorectal resections performed in 2013. The results were compared with data from the National Hospital Morbidity Database (NHMD), in which administrative in-patient data were also collected from all general surgical departments in Austria in 2013.

RESULTS

Fifty-three of 99 surgical departments in Austria responded (53.5%); 4335 colonic and rectal resections were carried out in the participating departments, representing 50.5% of all NHMD-recorded colorectal resections (n = 8576) in Austria in 2013. Of these 4335 colonic and rectal resections, 2597 (59.9%) were carried out using an open approach, 1674 (38.6%) were laparoscopic, and an exact classification was not available for 64 (1.5%). Among the NHMD-recorded colonic and rectal resections, 6342 (73.9%) were carried out with an open approach, and 2234 (26.1%) were laparoscopic.

CONCLUSIONS

The proportion of colorectal resections that are carried out laparoscopically is low (26.1%). Technical challenges and a learning curve with a significant number of cases may be reasons for the slow adoption of laparoscopic colonic surgery.

Short-term results of quality of life for curatively treated colorectal cancer patients in Lithuania

BACKGROUND AND OBJECTIVE

Treatment options for colorectal cancer patients create the need to assess the quality of life (QoL) of colorectal cancer patients in the early postoperative period when changes are potentially greatest. The aim of the current study was to assess the QoL of colorectal cancer patients following open and laparoscopic colorectal surgery.

MATERIALS AND METHODS

A total of 82 consecutive patients requiring elective open or laparoscopic colorectal surgery were recruited to the study for 3 months in the three colorectal surgery centers of Lithuania. Patients completed the EORTC QLQ-C30 (version 3.0) questionnaire before surgery, 2 and 5 days, 1 and 3 months after operation. The EORTC QLQ-CR29 questionnaire was completed before surgery and at 1 and 3 months after operation. Analysis was done according to the manual for each instrument.

RESULTS

EORTC QLQ-C30 reflected the postoperative recovery of QoL. The global health status, cognitive and emotional functioning came back to the preoperative level in one month after operation. Physical and role functioning for laparoscopic group was significantly improved in 1 month after operation and in 3 months for open surgery group respectively. Colorectal module EORTC-QLQ-CR29 found that future perspective increased significantly in laparoscopic group 1 month after operation.

CONCLUSIONS

The present study showed that majority of functional scale scores came back to the preoperative level during the first 3 months after colorectal cancer surgery. Differences in QoL according to surgical approach are mostly expressed on this period.

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.

Intravenous lidocaine for post-operative pain relief after hand-assisted laparoscopic colon surgery: a randomized, placebo-controlled clinical trial

BACKGROUND

Perioperative intravenous (IV) infusion of lidocaine has been shown to decrease post-operative pain, shorten time to return of bowel function, and reduce the length of hospital stay. This randomized, prospective, double-blinded, placebo-controlled clinical trial evaluated the impact of IV lidocaine on the quality of post-operative analgesia and other outcomes after hand-assisted laparoscopic colon surgery.

METHODS

Sixty four patients with colon cancer scheduled for elective colon resection were involved in this study. Patients were randomized to receive either lidocaine infusion [lidocaine group (LG)] or normal 0.9 % saline infusion [placebo group (PG)] for a period of 24 h. Anaesthetic and surgical techniques were standardized. Twenty-four-hour post-operative analgesia in the recovery area was maintained by continuous infusion of 0.1 μg/kg/h fentanyl. The primary outcome of the study was post-operative pain control. Pain was assessed using visual analogue scale (VAS) scores at 2, 4, 8, 12, and 24 h after surgery. Patients with a VAS score >3 were treated with ketorolac 30 mg as needed. Secondary outcomes included time to resumption of bowel function and length of hospital stay. Data in the two groups were compared using the two-tailed Student's t test. All statistical tests were two-tailed at a significance level of 0.05.

RESULTS

Demographic characteristics and clinical features of both groups were similar. Intensity of pain at rest in LG compared with PG was significantly lower during the first 24 h post-operatively. LG patients reported significantly less pain during movements at 2-, 12-, and 24-h post-surgery than PG patients. The study showed that ketorolac consumption was significantly higher in PG: mean ketorolac consumption in LG was 43.77 ± 13.86 mg and in PG 51.67 ± 13.16 mg (p = 0.047). Compared with placebo, lidocaine infusion produced a 32 % reduction in time to the first drink (Cohen's d = 3.85), 16 % reduction in time to the first full diet (Cohen's d = 3.35), and 18 % reduction in time to the first bowel movement (Cohen's d = 2.30). Patients who received lidocaine stayed in hospital 1.2 days less than patients who received placebo (p < 0.01, Cohen's d = 0.72). There were no significant differences in surgery-related complications between the two groups.

CONCLUSIONS

Perioperative continuous IV lidocaine infusion has a beneficial effect as regards post-operative pain, restoration of bowel function, and length of hospital stay in patients who have undergone hand-assisted laparoscopic colon surgery.

Laparoscopic versus open right hemicolectomy for colon cancer: a meta-analysis

OBJECTIVE

This meta-analysis was designed to assess the feasibility and safety of laparoscopic right hemicolectomy for colon cancer.

RESEARCH DESIGN

A systematic search of the MEDLINE, EMBASE, and Cochrane databases identified 12 studies that met the inclusion criteria for data extraction. Publications that compared laparoscopic right hemicolectomy and open right hemicolectomy for treatment of colon cancer in the past 20 years were collected for review. The primary outcomes used for meta-analysis were operating time, blood loss, number of harvested lymph nodes, time to first flatus, postoperative hospital stay, postoperative complications, mortality, and rate of recurrence.

RESULTS

Twelve studies that included 1057 patients were examined. Of these patients, 475 and 582 had undergone laparoscopic right hemicolectomy and open right hemicolectomy, respectively. There were significant reductions in blood loss, time to first flatus, postoperative hospital stay, and rate of wound but a operating time for laparoscopic right hemicolectomy compared with open right hemicolectomy. Other outcome variables such as number of harvested lymph nodes, postoperative complications except wound infection, mortality, and rate of recurrence were not found to be statistically significant for either group.

CONCLUSIONS

Compared with open right hemicolectomy, laparoscopic right hemicolectomy has the advantages of minimal invasion, faster recovery, and a lower rate of wound infection, and it can achieve the same degree of radicality and short-term prognosis as open right hemicolectomy. The drawback is that the operative time is longer.

Laparoscopic and open colorectal surgery: a prospective cost analysis

AIM

Cost has been perceived to be a factor limiting the development of laparoscopic colorectal surgery. This study aimed to compare the costs of laparoscopic and open colorectal surgery.

METHOD

Patients undergoing laparoscopic or open elective colorectal surgery were recruited into a prospective study to evaluate the healthcare costs of each operative procedure in a district general hospital in England. All healthcare resources used (operation, hospital and community) were recorded and converted to costs in British pounds, 2006-2007. Costs of laparoscopic and open surgery were compared.

RESULTS

In all, 201 consecutive patients consented and were recruited (131 laparoscopic, 70 open). Operative costs were greater in the laparoscopic group (£2049 vs£1263, P < 0.001) due to the costs of disposable instruments, but the hospital costs were less (£1807 vs£3468, P < 0.001) due to longer lengths of stay in the open group. Community costs were similar in the two groups and had little impact on the overall costs, which were not significantly different (£3875 laparoscopic vs£4383 open, P = 0.308). In the subgroup of patients with a stoma, overall costs in the laparoscopic group are higher (not significant).

CONCLUSION

The costs of laparoscopic and open colorectal surgery are broadly equivalent. If there is an associated improvement in patient benefit, then laparoscopic colorectal surgery may be considered to be cost effective compared with open surgery.

Robot-assisted laparoscopic abdominoperineal resection for low rectal cancer

BACKGROUND

This article reports on patients with low rectal cancer treated with robot-assisted laparoscopic abdominoperineal resection.

METHODS

Robot-assisted laparoscopic abdominoperineal resection was performed on seven patients in the General Surgery Clinic of Umraniye Training and Research Hospital between 2010 and 2011 by performing abdominal and perineal skin incisions using the same technique. Gender, age of the patients, intraoperative and postoperative complications, morbidity and mortality were evaluated.

RESULTS

Five of the patients were male and two of them were female. Mean age was 59.2 years. All of the procedures were completed robotically. No intraoperative complication occurred, whereas urinary bladder dysfunction (n = 1) and chylous ascites (n = 1), treated conservatively, developed in the postoperative period. On histopathological examination, surgical and circumferential margins were found to be negative in all specimens. Early recurrence was not found on postoperative follow-up.

CONCLUSION

Robot-assisted laparoscopic surgery can be performed safely in narrow and deep anatomical areas, such as the pelvis.

Impact of the English National Training Programme for laparoscopic colorectal surgery on training opportunities for senior colorectal trainees

BACKGROUND

There is growing concern that the recently introduced National Training Programme for consultants in laparoscopic colorectal surgery will have a negative impact on the training of senior colorectal trainees by minimizing the opportunities available. This study aimed to determine the impact that local implementation of the National Training Programme has had on the operating experience of senior colorectal trainees.

METHODS

A prospective study was conducted at a designated national training center for laparoscopic colorectal surgery based in a large district general hospital in England, United Kingdom. All patients undergoing laparoscopic colorectal surgery in our unit between October 2006-September 2008 and October 2008-September 2010 were included in the study. The study variables included number and type of procedure, patient demographics, American Society of Anesthesiology grade, body mass index, conversion rates, previous abdominal surgery, and median operating time. The main outcome measure was the number of procedures performed by senior colorectal trainees before and after commencement of National Training Programme training in October 2008.

RESULTS

A total of 746 laparoscopic colorectal resections were performed. Senior colorectal trainees performed 175 cases before commencement of the National Training Programme and 184 cases afterward. The difference was not significant. National Training Programme consultants performed 126 cases. Data were analyzed using Fisher's exact test and the Mann-Whitney U test. The study groups were found to be well matched. The median operating time was significantly longer after commencement of the National Training Programme. The study was limited in terms of ability to extrapolate results to smaller units wishing to participate in training programs.

CONCLUSION

Implementation of the National Training Programme in our hospital has not had a negative impact on the training opportunities for senior colorectal trainees. However, any unit wishing to participate in the National Training Programme must ensure that an adequate operative caseload and extra resources for operative lists are available for training.

A unique approach to quantifying the changing workload and case mix in laparoscopic colorectal surgery

AIM

Laparoscopic colorectal surgery includes a range of operations with differing technical difficulty, and traditional parameters, such as conversion and complication rates, may not be sensitive enough to assess the complexity of these procedures. This study aims to define a reproducible and reliable tool for quantifying the total workload and the complexity of the case mix.

METHOD

This is a review of a single surgeon's 10-year experience. The intermediate equivalent value scoring system was used to code complexity of cases. To assess changes in the workload and case mix, the period has been divided into five phases.

RESULTS

Three hundred and forty-nine laparoscopic operations were performed, of which there were 264 (75.6%) resections. The overall conversion rate was 17.8%, with progressive improvement over the phases. Complex major operation (CMO), as defined in the British United Provident Association (BUPA) schedule of procedures, accounted for 35% of the workload. In spite of similar numbers of cases in each phase, there was a steady increase in the workload score, correlating with the increasing complexity of the case mix. There was no significant difference in the conversion and complications rates between CMO and non-CMO. The paradoxical increase in the mean operating time with increasing experience corresponded to the progressive increase in the workload score, reflecting the increasing complexity of the case mix.

CONCLUSION

This article establishes a reliable and reproducible tool for quantifying the total laparoscopic colorectal workload of an individual surgeon or of an entire department, while at the same time providing a measure of the complexity of the case mix.

Laparoscopic colorectal surgery - why would you not want to have it and, more importantly, not be trained in it? A consecutive series of 500 elective resections with anastomoses

AIM

We analysed the outcome of a consecutive series of 500 unselected patients who underwent elective laparoscopic colorectal resection with anastomosis (ELCRA) under the care of a single surgeon.

METHOD

A prospectively collected electronic database of all laparoscopic procedures conducted from April 2001 to September 2008 was analysed.

RESULTS

A total of 500 ELCRAs were performed [230 male and 270 female patients; mean age 65.6 years (range 19-93 years; American Society of Anesthesiologists grade I (103), II (246), III (145) and IV (6)]. Of these, 217 patients underwent high anterior resection. A total of 131 total mesorectal excisions (55 covering ileostomies), 152 right/extended right resections and 240 operations were performed by trainees under supervision. The indications for surgery included cancer (340), diverticular disease (96), Crohn's disease (40) and polyps (24). Mean operating time was 115 min (range 35-550 min). There were eight (1.6%) conversions. The mean length of hospital stay was 5.2 days (median 4 days). A total of 93 (18.6%) patients had an inpatient complication, including ileus (22), wound infection (14), anastomotic leakage (12), enterotomy (2), 'off-screen' enterotomy (2), abscess (3), ureteric injury (1), cardiac arrhythmia (12), myocardial infarction (5), pulmonary embolus (4), pneumonia (1), Clostridium difficile (3) and retention of urine (9). There were 20 (4%) readmissions for complications, including ileus (4), urinary retention (3), abscess formation (2) and leakage (2). The 30-day mortality was nine of 500 (1.8%) following anastomotic leakage (3), duodenal enterotomy (1), bleeding duodenal ulcer (1), C. difficile infection (1) and cardiac complications (3).

CONCLUSION

This unselected cohort of patients (the largest single surgeon series in the UK) demonstrates that in trained hands low conversion and complication rates can be consistently achieved.

Competency in laparoscopic colorectal surgery is achievable with appropriate training but takes time: a comparison of 300 elective resections with anastomosis

AIM

The aim of this retrospective cohort study was to compare outcomes in patients who underwent elective laparoscopic colorectal resection with anastomosis performed by a single surgeon or his training fellow.

METHOD

A prospective electronic database of all laparoscopic procedures between January 2005 and September 2008 was used. Two groups were compared; those patients operated upon by the Consultant trainer (C) and those by seven supervised Fellows (F). Fellows were either post CCT or in their last year of training. Three hundred consecutive patients undergoing laparoscopic colorectal resection with anastomosis were examined, 150 in each group. Groups were matched for indication, age, American Society of Anesthesiology (ASA) grade, cancer T stage and resection performed. Preoperative work-up, operative surgery and anaesthesia were identical between groups.

RESULTS

No significant difference was demonstrated in age, mean 67 (26-91) or ASA grade. Indications for surgery were; cancer (C) 120, (F) 126, diverticular disease (C) 22, (F) 20, Crohn's disease (C) 8, (F) 7. Fellow's mean operative time was significantly longer at 123 min (95%CI 117-134) compared to the consultant trainer -105 min. (95%CI 98-111): P < 0.01). No significant differences in the complication or conversion rates were demonstrated. Length of stay and the 30-day readmission rates were similar.

CONCLUSION

In this retrospective cohort study we have demonstrate that when matched patients are compared, supervised trainee operating time is significantly longer than that of the consultant trainer but without any significant increase in length of stay, complication or readmission rates. Training to a level of competency takes time but not at the expense of patient care.

Training in laparoscopic colorectal surgery - experience of training in a specialist unit

INTRODUCTION

Laparoscopic colorectal surgery, although technically demanding, is an increasingly desirable skill for coloproctologists. We believe that trainees with adequate supervision from an experienced trainer may perform these procedures safely with good outcome.

PATIENTS AND METHODS

Surgical logbooks of two senior trainees were reviewed over a 2-year period. A case note analysis was then undertaken. Patient data were recorded with regards to age, sex, operation type, American Society of Anesthesia (ASA) grade, conversion, length of hospital stay and complications. Lymph node yield, resection margins and grade of total mesorectal excision were recorded in oncological procedures.

RESULTS

Over the 2-year period, trainees were involved in 140 resections (age range, 23-88 years; ASA grades I-III). Seventy patients were male. Trainees were first assistant in at least 20 cases prior to undertaking the procedures themselves. Trainees performed a total of 71 operations. Median hospital stay was 7 days (range, 2-48 days). There were three conversions. Anastomotic leaks developed in two patients, one requiring a laparotomy. One patient developed small bowel obstruction secondary to a port site hernia, which was repaired laparoscopically. There was one postoperative death. All oncological resection margins were clear with adequate lymphadenectomies. All total mesorectal excisions were Quirke grade III.

CONCLUSIONS

Adequately trained and supervised trainees may perform major colorectal resections without compromising outcome.

Review of available methods of simulation training to facilitate surgical education

The old paradigm of "see one, do one, teach one" has now changed to "see several, learn the skills and simulation, do one, teach one." Modern medicine over the past 30 years has undergone significant revolutions from earlier models made possible by significant technological advances. Scientific and technological progress has made these advances possible not only by increasing the complexity of procedures, but also by increasing the ability to have complex methods of training to perform these sophisticated procedures. Simulators in training labs have been much more embraced outside the operating room, with advanced cardiac life support using hands-on models (CPR "dummy") as well as a fusion with computer-based testing for examinations ranging from the United States medical licensure exam to the examinations administered by the American Board of Surgery and the American Board of Colon and Rectal Surgery. Thus, the development of training methods that test both technical skills and clinical acumen may be essential to help achieve both safety and financial goals.

Resultados do registro de cirurgias colorretais videolaparoscópicas realizadas no Estado de Minas Gerais - Brasil de 1996 a 2009

INTRODUÇÃO: A partir de 1991, a videolaparoscopia começou a ser considerada no tratamento de doenças colorretais. O aprimoramento da técnica cirúrgica associado aos benefícios encontrados em diversos estudos publicados levou a modificações nas perspectivas da videolaparoscopia. A partir da publicação do estudo COST as ressecções oncológicas laparoscópicas foram reconhecidas como alternativa viável, com resultados semelhantes à cirurgia convencional. PACIENTES E MÉTODOS: Realizou-se pesquisa através de formulário específico e consulta a prontuários dos principais serviços de coloproctologia de Belo Horizonte. Avaliando-se sexo, idade, indicação cirúrgica, procedimento realizado, técnica laparoscópica, complicações, conversão, estadiamento e recidiva (no caso de neoplasias). RESULTADOS: Foram levantados dados sobre 503 cirurgias colorretais laparoscópicas: 347 (68,9%) em mulheres e 156 (31,1%) homens. A técnica cirúrgica foi totalmente laparoscópica em 137 casos, vídeo-assistida 245 casos. O procedimento mais realizado foi a retossigmoidectomia (41,1%), seguido pela colectomia direita (12,5%), colectomia esquerda (6,9%). Doenças benignas foram responsáveis por 259 (51,5%) casos, destes as principais indicações cirúrgicas foram endometriose 126 (48,6%), pólipos 40 (15,4%), doença diverticular 30 (11,6%). Das 240 cirurgias realizadas por doenças malignas as mais frequentes foram retossigmoidectomia 102 (42,5%), colectomia direita 46 (19,1%), colectomia esquerda 18 (7,5%), amputação abdominoperineal 18 (7,5%). Houve 54 conversões (10.7%) dos casos, 12,9% (31/240) nos casos de neoplasias, 8,5% (22/259) nos de doenças benignas. Complicações sistêmicas ou cirúrgicas ocorreram em 31 (6,1%) e 56 (11,1%) casos, respectivamente. Foram registrados onze (2,18%) óbitos nos primeiros 30 dias após a cirurgia. CONCLUSÃO: O estudo atual foi o primeiro levantamento da implantação de cirurgias colorretais laparoscópicas realizado de forma multicêntrica em Minas Gerais. Os dados levantados são consistentes com registros nacionais de videocirurgia colorretal, mostrando a eficiência do método de aprendizado com realização de cirurgias com tutor. Além disso, que pequena parte das cirurgias colorretais são realizadas por via laparoscópica no estado, restritos apenas a centros especializados, sobrecarregando esses serviços e limitando o acesso para a população.

A systematic review of postoperative analgesia following laparoscopic colorectal surgery

OBJECTIVE

The use of epidural analgesia is considered fundamental in Enhanced Recovery Protocols. However its value in the perioperative management of laparoscopic colorectal surgical patients is unclear and analgesic regimens vary. The aim of this systematic review was to examine the effects of various analgesic regimes on outcomes following laparoscopic colectomy.

METHOD

A systematic review of studies assessing analgesic regimes following laparoscopic colorectal resection was performed. The primary outcome of interest was length of hospital stay whilst the secondary outcomes included pain, time to tolerate a normal diet, return of bowel function and postoperative complications.

RESULTS

Eight studies were identified, five of which compared epidural vs patient controlled analgesia/intra-venous morphine. There were no significant differences between the groups in terms of outcomes, except pain control which was superior in the epidural group. Spinal anaesthesia using intrathecal morphine in addition to local anaesthetic, and the use of nonsteroidal anti-inflammatory agents have also been shown to reduce postoperative pain.

CONCLUSION

There is a paucity of data assessing the benefits of postoperative analgesic regimes following laparoscopic colorectal surgery and none of the protocols were shown to be clearly superior. Further studies, including the assessment of spinal analgesia are required to determine the most appropriate analgesic regime following laparoscopic colorectal surgery.

In-house colorectal laparoscopic preceptorship: a model for changing a unit's practice safely and efficiently

PURPOSE

There has been steady increase in demand for laparoscopic colonic resection as benefits are manifold compared to open and include smaller incisions, less pain, quicker recovery and convalescence, reduced morbidity and reduced analgesic demands. We devised a preceptorship programme with the aim of all four coloproctologists in our unit becoming proficient colorectal laparoscopic surgeons over a period of 12 months.

METHOD

The surgeon in the unit with significant experience of laparoscopic colorectal surgery acted as a preceptor to the remaining three. A prospective database was set up to allow analysis of the impact of the preceptorship on the units' elective practice and outcomes from January 2006.

RESULTS

Results were analysed 106 cases to assess the success of this novel method and were more than encouraging. During this period, 57 laparoscopic resections were performed compared 49 open resections. The proportion of patients undergoing laparoscopic resection had risen from 20% to 80% (p = 0.000). This was associated with a significant drop in post-operative stay from 14 to 4 days (p = 0.000). Analysis of patient demographics, pathology and type of resection found there to be no significant difference between the open and laparoscopic groups. The conversion rate was acceptably low (10.5%) and there were no re-admissions.

CONCLUSIONS

For hospitals with the facilities and an appropriately experienced preceptor, we offer this as a patient-safe, cost-neutral method of significantly increasing a units' laparoscopic practice over a relatively short period of time.

Easy sphincterotomy in patients with Billroth II gastrectomy: a new technique

BACKGROUND/AIMS

ERCP and endoscopic sphincterotomy in patients with Billroth II gastrectomy are technically more difficult due to the reversed anatomy. We developed a new guidewire sphincterotome that includes two 15-mm non-isolated metal parts, one of which is located 12 cm from the distal tip and the other in the proximal end. The aim of this study was to evaluate the feasibility of and outcomes with the new sphincterotome for sphincterotomy in patients with Billroth II gastrectomy.

METHODS

Between January 2004 and March 2007, 11 patients with Billroth II gastrectomy underwent endoscopic sphincterotomy with the new guidewire sphincterotome. Procedures were initiated by deep cannulation of the bile duct with a standard catheter and guidewire sphincterotome. After cholangiography, the catheter was withdrawn with 0.5 to 1 cm of its tip outside the duodenoscope. The distal non-isolated part of the sphincterotome was placed in the papillary orifice. In order to reach the proper position, the duodenoscope's elevator was moved to the downward position, the up-down dial was turned slightly in the downward direction, and then the duodenoscope was pushed slightly forward. Finally, sphincterotomy was performed in the 6 o'clock direction.

RESULTS

Sphincterotomy with the new sphincterotome was successfully achieved in all patients without using protective pancreatic stents. Seven patients had common bile duct stones, two pancreatitis, one odditis, and another one persistent bile duct leakage. There were no sphincterotomyrelated complications or death during this study.

CONCLUSIONS

In this pilot study, endoscopic sphincterotomy with a new guidewire sphincterotome in patients with Billroth II gastrectomy was found to be clinically successful, concise, easy to perform, efficient, and reliable. However, further large comparative studies are needed for a definite conclusion.

The uptake of laparoscopic colorectal surgery in Great Britain and Ireland: a questionnaire survey of consultant members of the ACPGBI

OBJECTIVE

The National Institute for Clinical Excellence (NICE) has recommended laparoscopic resection as an alternative to open surgery for patients with colorectal cancer. The aim of this study was to evaluate the current uptake of laparoscopic colorectal surgery in Great Britain and Ireland.

METHOD

A questionnaire was distributed to members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) regarding their current surgical practice. Results were analysed individually, by region, and nationwide.

RESULTS

Information was received on 436 consultants (in 155 replies), of whom 233 (53%) perform laparoscopic colorectal procedures. During the previous year, 25% of colorectal resections were performed laparoscopically by the respondents. However, of those surgeons who were performing laparoscopic resections, only 30% performed more than half of all their resections laparoscopically. Right hemicolectomy, left-sided resections, and rectopexy were the most frequently performed laparoscopic resections. There was an even distribution throughout the country of consultants performing laparoscopic resections (regional IQR 48-60%). The main reason for consultants not performing laparoscopic procedures was a lack of training or funding.

CONCLUSION

Laparoscopic colorectal surgery is being performed by more than half (53%) of colorectal consultants nationwide, although only a quarter of all procedures are being undertaken laparoscopically.

Systematic Review of Quality of Life following Laparoscopic and open colorectal surgery

OBJECTIVE

To compare the health-related quality of life (HRQoL) of patients following laparoscopic and open colorectal surgery.

METHODS

A systematic review was performed according to Quorum guidelines. Prospective studies comparing the HRQoL of patients after laparoscopic and open colorectal surgery were identified. The primary outcome measure was postoperative quality of life; performance status and cosmesis were secondary outcome measures.

RESULTS

23 studies were identified that satisfied the inclusion criteria; 18 assessed HRQoL, 4 performance status, and 3 cosmesis. It was not possible to perform a meta-analysis due to study heterogeneity. The studies reported outcomes for 2946 patients. The most frequent HRQoL instruments employed were SF-36, EORTC, and GIQLI. 6 studies, using a total of 12 separate measures, evaluated QoL during the first 3 post-operative months: 10 of these measures showed no significant difference, and 2 showed an improved HRQoL with laparoscopy. Twelve further studies evaluated HRQoL up to 5 years post-operatively: 9 showed no difference between the 2 groups, and 3 demonstrated a benefit for laparoscopy. Three of 4 studies assessing performance status on discharge, and all 3 studies assessing cosmesis, reported benefits with the laparoscopic approach.

CONCLUSIONS

The current evidence suggests there is no significant difference in HRQoL following laparoscopic and open colorectal surgery, although there is a lack of good quality data. There is a trend towards improved quality of life outcomes and performance status with laparoscopy in the early post-operative period. There is a need for further research, particularly assessing quality of life in the early post-operative period.

Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery

BACKGROUND

The aim of the survey was to assess the incidence of anastomotic leaks (AL) and to identify risk factors predicting incidence and gravity of AL after low anterior resection (LAR) for rectal cancer performed by colorectal surgeons of the Italian Society of Colorectal Surgery (SICCR).

METHODS

Information about patients with rectal cancers less than 12 cm from the anal verge who underwent LAR during 2005 was collected retrospectively. AL was classified as grade I to IV according to gravity. Fifteen clinical variables were examined by univariate and multivariate analyses. Further analysis was conducted on patients with AL to identify factors correlated with gravity.

RESULTS

There were 520 patients representing 64% of LAR for rectal cancer performed by SICCR members. The overall rate of AL was 15.2%. Mortality was 2.7% including 0.6% from AL. The incidence of AL was correlated with higher age (p<0.05), lower (<20 per year) centre case volume (p<0.05), obesity (p<0.05), malnutrition (p<0.01) and intraoperative contamination (p<0.05), and was lower in patients with a colonic J-pouch reservoir (p<0.05). In the multivariate analysis age, malnutrition and intraoperative contamination were independent predictors. The only predictor of severe (grade III/IV) AL was alcohol/smoking habits (p<0.05) while the absence of a diverting stoma was borderline significant (p<0.07).

CONCLUSION

Our retrospective survey identified several risk factors for AL. This survey was a necessary step to construct prospective interventional studies and to establish benchmark standards for outcome studies.

Laparoscopic resection for colorectal cancer in Japan

The first laparoscopic surgery for colorectal cancer in Japan was reported in 1992. In the early phase, many cases were indicated for early cancer. The number of operations has been increasing year by year, and now even some advanced cases undergo laparoscopic surgery. According to questionnaires administered in 2003 by the Japan Society for Endoscopic Surgery, more than half of 3,892 cases were indicated for advanced cancer. In 2004, the 60th biannual meeting of the Japanese Society for Cancer of the Colon and Rectum took up "the current status of laparoscopic resection for colorectal cancer" as one of the main topics of the meeting, and conducted a questionnaire survey of the member's opinions to laparoscopic resection for colorectal cancer prior to the meeting. It was revealed that at least ninety institutes had already performed a laparoscopic resection for colorectal cancer. In order to evaluate the feasibility of laparoscopic resection for colorectal cancer, a randomized control study comparing laparoscopic and open resection of colorectal cancer was started in 2004. This study is scheduled to collect 818 cases. The characteristic of this study was to enroll only advanced cancer cases. The primary endpoint is the survival, while the secondary end points are disease-free survival, early postoperative course, adverse events and conversion to open surgery. As more surgeons perform laparoscopic colorectal surgery, the importance for education and credentialing has been discussed. The Japan Society for Endoscopic Surgery started a system to qualify the surgeon's technique for endoscopic and laparoscopic surgery in 2004. One hundred and three surgeons took the examination for laparoscopic colorectal surgery in 2004, and 43 passed.

Laparoscopic appendicectomy: a training model for laparoscopic right hemicolectomy?

OBJECTIVE

To analyse the outcome of laparoscopic appendicectomy and right hemicolectomy and see if the surgical approach to the former can be applied to the latter.

METHOD

A prospective electronic laparoscopic database identified 330 appendicectomies and 78 right hemicolectomies (using this approach) between 1996 and 2005.

RESULTS

Three hundred and thirty patients (188 males: median age 38 years, range 17-74 years) underwent laparoscopic appendicectomy; 270 (82%) were performed by trainees (higher surgical trainee 71%, basic surgical trainee 12%). The median operative time for trainees was 35 min (14-75 min) with a conversion rate 2%. There were no intra-operative complications. The postoperative complication rate excluding minor wound infection (5.5%) was 1.5%. There were no deaths. The median hospital stay was 2 days (1-15 days). The 30-day readmission rate was 1%. Seventy-eight patients (23-93 years) underwent laparoscopic right hemicolectomy during 2004/5; trainees performed parts thereof in the majority or all of the surgery in 25 cases. The median operation time was 55 min: trainees 115 (65-145 min). There was one conversion. The median hospital stay was 4 days (2-23 days) falling to 3 for the last 20 operations (1-8 days). There were two readmissions for wound sepsis and small bowel obstruction and three deaths (3.8%): anastomotic leak (one), C difficile infection leading to renal failure (one) and duodenal perforation (one).

CONCLUSION

Laparoscopic appendicectomy is a safe, predictable, easily learnt operation and an ideal model for learning the skills and principles required for more advanced laparoscopic colorectal interventions and in particular, right hemicolectomy.

Systematic review of the costs of laparoscopic colorectal surgery

PURPOSE

Recent studies have confirmed the clinical efficacy of laparoscopic colorectal surgery; however, its use has not become widespread. One reason for this is perceived economic implications. A systematic review was undertaken examining the costs of laparoscopic colorectal surgery.

METHODS

Electronic databases were searched for articles comparing laparoscopic colorectal surgery and open surgery. Primary outcome measures were operating room, direct hospital, and indirect costs. Secondary outcomes were conversion rates and length of hospital stay. The percentage difference in costs was used for comparisons between studies.

RESULTS

Twenty-nine articles were identified in which cost data were presented (total number of patients 3,681); the economic data in most studies was limited. Operating room costs were greater for laparoscopic colorectal surgery than open surgery in all studies (median difference, 50 percent; interquartile range, 27-78 percent; P < 0.001). There was no overall difference in total hospital costs (median difference, 0 percent; interquartile range, -17.5 to 21 percent). Only two articles collected data on indirect costs, with both in favor of laparoscopic colorectal surgery. Hospital stay was shorter for laparoscopic colorectal surgery in all studies (median difference, 2.8 days; interquartile range, 1.3-3.7; P < 0.001). Median conversion rate was 7.8 percent (mean, 14 percent; interquartile range, 6-21 percent).

CONCLUSIONS

Operating room costs are greater for laparoscopic colorectal surgery than open surgery. Total hospital costs are similar. There may be societal benefits associated with lower indirect costs for laparoscopic colorectal surgery. Cost should not be a deterrent to performing laparoscopic colorectal surgery.

Telerobotic-assisted laparoscopic abdominoperineal resection for low rectal cancer: Report of the first case in Hong Kong and China with an updated literature review

Telerobotic surgery is the most advanced development in the field of minimally invasive surgery. The da Vinci surgical system, which is currently the most widely used telerobotic device, was approved by the Food and Drug Administration of the United States of America for clinical use in all abdominal operations in July 2000. The first da Vinci surgical system in China was installed in November 2005 at our institution. We herein report the first telerobotic-assisted laparoscopic abdominoperineal resection using the 3-arm da Vinci surgical system for low rectal cancer in Hong Kong and China, which was performed in August 2006. The operative time and blood loss were 240 min and 200 mL, respectively. There was no complication, and the patient was discharged on postoperative day five. An updated review of published literature on telerobotic-assisted colorectal surgery is included in this report, with special emphasis on its advantages and limitations.

HMM Assessment of Quality of Movement Trajectory in Laparoscopic Surgery

Laparoscopic surgery poses many different constraints to the operating surgeon, this has resulted in a slow uptake of advanced laparoscopic procedures. Traditional approaches to the assessment of surgical performance rely on prior classification of a cohort of surgeons' technical skills for validation, which may introduce subjective bias to the outcome. In this study, Hidden Markov Models (HMMs) are used to learn surgical maneuvers from 11 subjects with mixed abilities. By using the leave-one-out method, the HMMs are trained without prior clustering subjects into different skills levels, and the output likelihood indicates the similarity of a particular subject's motion trajectories to the group. The experimental results demonstrate the strength of the method in ranking the quality of trajectories of the subjects, highlighting its value in minimizing the subjective bias in skills assessment for minimally invasive surgery.

Laparoscopic colorectal surgery: learning curve and training implications

AIMS

This paper is a review of experience of laparoscopic colorectal surgery at a district general hospital with particular emphasis on the learning curve and training implications.

METHODS

All patients undergoing colorectal surgery where laparoscopy was attempted between March 1998 and October 2003 were included in this study.

RESULTS

There were 80 patients of which 49 had malignancy. Twenty eight stomas and 52 bowel resections were performed laparoscopically. The conversion rate for bowel resection was 32% (decreasing from 38% to 44% to 22%). This was significant (p = 0.001) when compared with stoma formation (7%). The firm has support from a specialist registrar and staff grade surgeon. In 22% of cases, one of the middle grades was the principal operating surgeon, mainly laparoscopic mobilisation and stoma formation. Only 6% of resections were performed by the middle grades. Conversely, a middle grade was the main operating surgeon in 66% of open resections and 61% of stoma formations during the same period. There were in all two deaths and 14 postoperative complications. All patients who had laparoscopic resections for malignancy had clear resection margins.

CONCLUSION

This audit highlights that there is a long learning curve in laparoscopic colorectal surgery with decrease in conversion rates with increasing experience. There is also a reduction in training opportunities in open surgery during the learning phase of the consultant, although this may be counterbalanced by the exposure to laparoscopic techniques. Laparoscopic colonic mobilisation, as a part of stoma formation, is a good starting point for specialist registrar training.