Surgeon experience with laparoscopic-assisted colorectal surgery in Washington State

PURPOSE: To describe the current practice and opinions held by surgeons performing colorectal surgery in Washington regarding laparoscopic colorectal surgery. METHODS: After attempting to identify all surgeons with hospital privileges in colorectal surgery in Washington, a survey was sent to 303 surgeons. The survey asked about the surgeon's practice, volume of colon surgery in the preceding year, the number of laparoscopic colon resections ever performed, the surgeon's opinion on the future practice of laparoscopic colorectal surgery, and whether faced with the personal need to undergo colon resection at the present time, would the surgeon elect to have laparoscopic or open colon resection. RESULTS: In all 170 surveys were returned; 154 returned surveys were from surgeons who had performed at least one colon resection in the preceding year; 53 (34%) respondents had experience with fewer than 20 laparoscopic resections and 83 (55%) have never performed laparoscopic-assisted colectomy (LAC). Only 4 (3%) surgeons had performed more than 50 laparoscopic colon resections. Forty-five percent of respondents indicated that they would currently seek a laparoscopic resection for themselves to treat either a benign condition or an incurable malignancy, and 84% of respondents indicated they would have an open colectomy for a curable malignancy. CONCLUSIONS: The majority of surgeons performing colorectal resections in Washington have limited experience with LAC. Surgeon opinion regarding the role of laparoscopic colorectal surgery in clinical practice is mixed. We suggest a model for proctoring of LAC for surgeons interested in implementing laparoscopic colorectal resection into their practice.     

Accelerated learning curve for colorectal resection, open versus laparoscopic approach, can be attained with expert supervision

Background

Laparoscopic colorectal resection (LCR) is gaining popularity. Nonetheless, open surgery remains an important technique. Thus, surgeons should be technically proficient in both open and laparoscopic surgery. One question however remains unanswered: Can training for open and LCR occur simultaneously? The objective of this paper is to review the learning curve for open and laparoscopic colon resection of one surgeon who underwent a rigorous training program.

Methods

A review of consecutive patients who underwent surgery for colon and rectosigmoid junction cancers by one trainee surgeon was performed. This surgeon had completed his basic surgical residency but had limited experience in colorectal cancer surgery. In total, 75 patients were included in this study. All operations were supervised by at least one staff surgeon with experience of more than 300 LCR cases. The trainee surgeon was allowed to train in both laparoscopic and open colorectal resection simultaneously.

Results

Forty-three patients underwent laparoscopic resection, while 32 patients underwent open surgery. Age, gender, mean body mass index (BMI), preoperative risk, and history of past abdominal surgery showed no significant difference between laparoscopic and open groups. There were no differences in tumor stage [International Union against Cancer (UICC)] or tumor size (p = 0.068 and 0.228, respectively). The morbidity rate for open and laparoscopic surgery was 3.1% (1/32) and 4.7% (2/43), respectively (p = 0.484). Operation time decreased with increasing experience, and plateaued after 25 cases in the laparoscopic group and 22 cases in the open group. The learning curve for open cases was 11 cases, and 7 for laparoscopic surgery.

Conclusions

Surgeons who have completed a basic surgical residency but have limited colorectal surgery experience can learn both open and laparoscopic colorectal surgery simultaneously in an effective manner under supervision by well-experienced surgeons.     

Learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer: single-institute, three-surgeon experience

Background  Laparoscopic surgery demands mastery of a steep learning curve. Defining a learning curve in laparoscopic surgery is useful for planning training programs or clinical trials. This study aimed to define the learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer by evaluating early surgical outcome data from three colorectal surgeons. Methods  This study analyzed data from 138 consecutive patients undergoing laparoscopic sigmoidectomy for curable sigmoid colon cancer performed by three colorectal surgeons between May 2001 and November 2006. The learning curve for each surgeon were generated using the moving average method to assess changes in operation time and cumulative sum (CUSUM) analysis to assess changes in failure rates [(failure = conversion to open surgery, major perioperative complication, or failure to harvest an adequate number of lymph nodes (<12 nodes)]. Results  Learning curves generated with the moving average method indicated that the operation time reached a steady state after 42 cases for surgeon A, 35 cases for surgeon B, and 30 cases for surgeon C. The overall open conversion rate was 2.9%. There was only one laparoscopy-related perioperative major complication (0.7%). An inadequate number of lymph nodes was harvested in 10 cases (7.2%): 6 (10.5%) for surgeon A, 1 (2.4%) for surgeon B, and 3 (7.7%) for surgeon C. Learning curves generated using CUSUM analysis based on a 90% success rate showed that adequate learning occurred after 10 cases for surgeon A, 17 cases for surgeon B, and 5 cases for surgeon C. Conclusion  Pertinent learning curves for laparoscopic sigmoidectomy used to manage curable sigmoid colon cancer can be generated using the moving average method and CUSUM analysis. These results are likely to be useful in designing laparoscopic training programs and clinical trials aimed at investigating outcomes of laparoscopic colorectal cancer surgery. Presented at the Congress of Endoscopic and Laparoscopic Surgeons of Asia 2006, Seoul, Korea, 20 October 2006     

Competence Acquisition for Single-Incision Laparoscopic Cholecystectomy

Methods:We performed a retrospective review 290 single-incision laparoscopic cholecystectomies performed by a group of general surgeons, with varying levels of experience and training, at 3 institutions between May 2008 and September 2010. The procedure times were recorded for each single-incision laparoscopic cholecystectomy, ordered chronologically for each surgeon, and subsequently plotted on a graph. The patients were also combined into cohorts of 5 and 10 cases to further evaluate for signs of improvement in operative efficiency.Results:Of the 4 surgeons involved in the study, only 1 (surgeon 4, laparoscopic fellowship trained with <5 years'' experience) confirmed the presence of a learning curve, reaching proficiency within the first 15 cases performed. The other surgeons had more variable procedure times, which did not show a distinct trend. When we evaluated the cases by cohorts of 5 cases, surgeon 4 had a significant difference between the first and last cohort. Increased body mass index resulted in a slightly longer operative time (P < .0063). The conversion rate to multiport laparoscopic surgery was 3.1%.Conclusions:Our results indicate that among experienced general surgeons, there does not seem to be a significant learning curve when transitioning from conventional laparoscopic cholecystectomy to single-incision laparoscopic cholecystectomy. The least experienced surgeon in the group, surgeon 4, appeared to reach proficiency after 15 cases. Greater than 5 years of experience in laparoscopic surgery appears to provide surgeons with a sufficient skill set to obviate the need for a single-incision laparoscopic cholecystectomy learning curve.     

Laparoscopic Colectomy: Does the Learning Curve Extend Beyond Colorectal Surgery Fellowship?

Background and Objectives:

As minimally invasive colon and rectal resection has become increasingly prevalent over the past decade, the role that fellowship training plays has become an important question. This analysis examines the learning curve of one fellowship-trained colorectal surgeon in his first 100 cases.

Methods:

This was a prospectively collected retrospective analysis of the first 100 laparoscopic colon and rectal resections performed between July 2007 and July 2008 by a colorectal (CRS) fellowship trained surgeon at a Veteran''s Administration (VA) and county hospital. Included were all emergent and nonemergent laparoscopic cases.

Results:

Mean age was 63(range, 36 to 91). The 100 resections included 42 right, 6 left, 32 sigmoid, 13 rectal, and 7 total abdominal colectomies. Indications were 55% cancer, 20% unresectable polyp, 18% diverticular, 4% inflammatory, and 3% other. Overall mortality was 3%. Overall morbidity including wound infection was 24%. Early and late groups were similar in age, ASA score, and indication. Conversion rate was 4%. No statistical difference was seen in mortality, morbidity, EBL, LOS, margin, lymph nodes, or conversions between the first and second 50 cases (P<0.05). Right and sigmoid colectomy operative time decreased by 40.0% and 19.6%, respectively.

Conclusion:

Prior investigators have demonstrated a significant learning curve for laparoscopic colorectal surgery. In the first 100 cases, there is no difference in mortality or morbidity between early and late cases. Alternatively, operative times decreased with experience. Laparoscopic training during CRS fellowship surpasses the learning curve in regard to safety and outcome, whereas operative efficiency improves over the first year of practice.     

Operative time is a poor surrogate for the learning curve in laparoscopic colorectal surgery

Background Previous studies have relied on conversion rate and operative time for construction of learning curves in laparoscopic colorectal surgery. The authors hypothesized that conversion rate and operative time were less important than complication and readmission rates in defining good outcomes and hence the learning curve. Methods A database of 287 consecutive laparoscopic colorectal resections from a single tertiary referral center was analyzed. Outcome measures included operative time, conversion rate, major and minor complications, length of hospital stay, and the 15- and 30-day hospital readmission rate. Data were analyzed both by surgeons and by quartile case numbers. Results A total of 151 right colectomies and 136 left colectomies were performed between 1995 and 2005. For both right and left colectomies, the conversion rate decreased in each of the first three quartiles, reaching a nadir of 0% for right colectomies and 3% for left colectomies in the third quartile. The conversion rates increased slightly in the fourth quartile. The operative time remained stable for three quartiles, then increased slightly in the fourth quartile. Two surgeons managed 199 of the 287 cases. Analysis of the two high-volume surgeons demonstrated that for left-sided resections, the surgeon with the shorter operative times had the higher major complication rate (13% vs 2%), overall complication rate (22% vs 2%), 30-day readmission rate (13% vs 0%), and length of stay (3.8 vs 3.1 days) (p < 0.05 for all comparisons). Conclusions In this series, operative time failed to decrease with experience, and shorter operative times did not correlate with better clinical outcomes. The failure of operative time to decline with experience often reflects surgeons’ willingness to attempt more difficult cases rather than an accurate representation of a “learning curve.” Therefore, complication and readmission rates are more important than operative time and conversion rates for evaluating the learning curve and quality of laparoscopic colorectal surgery.     

A learning curve for laparoscopic fundoplication. Definable,avoidable, or a waste of time?

OBJECTIVE: The objective of this study was to determine whether a learning curve for laparoscopic fundoplication can be defined, and whether steps can be taken to avoid any difficulties associated with it. SUMMARY BACKGROUND DATA: Although early outcomes after laparoscopic fundoplication have been promising, complications unique to the procedure have been described. Learning curve problems may contribute to these difficulties. Although training recommendations have been published by some professional bodies, there is disagreement about what constitutes adequate supervised experience before the solo performance of laparoscopic antireflux surgery, and the true length of the learning curve. METHODS: The outcome of 280 laparoscopic fundoplications undertaken by 11 surgeons during a 46-month period was assessed prospectively. The experience was analyzed in three different ways: 1) by an assessment of the overall learning experience within chronologically arranged groups, 2) by an assessment of all individual experiences grouped according to the experience of individual surgeons, and 3) by a comparison of early outcomes of operations performed by the surgeons who initiated laparoscopic fundoplication with the early experience of surgeons beginning laparoscopic fundoplication later in the overall institutional experience. RESULTS: The complication, reoperation, and laparoscopic to open conversion rates all were higher in the first 50 cases performed by the overall group, and in the first 20 cases performed by each individual surgeon. These rates were even higher in the initial first 20 cases, and the first 5 individual cases. However, adverse outcomes were less likely when surgeons began fundoplication later in the overall experience, when experienced supervision could be provided. CONCLUSIONS: A learning curve for laparoscopic fundoplication can be defined. Experienced supervision should be sought by surgeons beginning laparoscopic fundoplication during their first 20 procedures. This should minimize adverse outcomes associated with an individual's learning curve.     

A prospective randomized trial on heart rate variability of the surgical team during laparoscopic and conventional sigmoid resection

HYPOTHESIS: Mental strain measured by heart rate variability differs during laparoscopic and conventional sigmoid resections. DESIGN: Prospective randomized study. SETTING: University hospital. PARTICIPANTS: Two surgeons performed 10 conventional and 10 laparoscopic sigmoid resections, alternating roles as primary surgeon and assistant. The kind of technique was randomly chosen each time. INTERVENTION: Electrocardiograms of the surgeon and assistant were continuously recorded during the procedures and heart rate variability was analyzed off-line. The first 10 procedures (5 laparoscopic and 5 conventional) were performed by the more experienced and the next 10 by the less experienced surgeon. MAIN OUTCOME MEASURES: Heart rate variability was determined by power spectral analysis as heart rate in beats per minute, high frequency (HF) and low frequency (LF) components in normalized units, and LF/HF ratio. RESULTS: Results are given for heart rate, HF, LF, and LF/HF ratio for the following variables: laparoscopic surgery: 87.9, 14.7, 90.1, 7.5; conventional surgery: 90.2, 17.1, 87.6, 6.4; surgeon: 94.0, 13.5, 91.4, 8.4; first assistant: 84.1, 17.8, 86.3, 5.6; more experienced surgeon: 93.1, 16.5, 87.8, 6.4; and less experienced surgeon: 85.0, 14.8, 90.0, 7.5. The LF/HF ratio was significantly higher (P<.05) for laparoscopic compared with conventional surgery and for the surgeon compared with the assistant (P<.001), but not between the less and the more experienced surgeons. CONCLUSION: Performing laparoscopic colorectal surgery causes higher mental strain in surgeons than performing conventional surgery.     

Examining the learning curve of laparoscopic fundoplications at an urban community hospital

BACKGROUND: Laparoscopic fundoplication for gastroesophageal reflux disease is a procedure associated with specific complications, especially in a surgeon's early experience. The learning curve of this procedure was examined at a tertiary community institution. METHODS: A retrospective review of the first 100 cases performed at Royal Columbian Hospital was conducted. Two surgeons performed the majority of cases and routinely assisted each other. Patients were grouped chronologically with the first 50 cases defined as early institutional experience and a surgeon's first 20 cases defined as early personal experience. RESULTS: Operative time was longer in both the early institutional (117.8 versus 91.3 minutes, P < .001) and personal experience (126.8 versus 89.7 minutes, P < .001). The rate of dysphagia requiring intervention was higher during the early institutional (22% versus 4%, P = .017) but not personal experience (19% versus 8%, P = not significant). The conversion rate was 0%, reoperation rate was 1%, mean length of stay was 2.5 +/- 1.4 days, and the readmission rate was 5%; these outcomes were unaffected by the learning curve. CONCLUSIONS: There is a definable learning curve in laparoscopic fundoplication in terms of operative time. However, an acceleration of the personal learning curve in terms of dysphagia was observed with a two-surgeon collaborative approach. With careful patient selection conversion, reoperation, readmission, and complication rates equivalent to experienced centers can be achieved in the community setting early in the personal and institutional experience.     

Robotic-assisted laparoscopic low anterior resection with total mesorectal excision for rectal cancer

Background With advanced stereoscopic vision, lack of tremor, and the ability to rotate the instruments surgeons find that robotic systems are ideal laparoscopic tools. Because of its high operating cost, however, robotic surgery should be reserved to procedures in which the technology can be of maximum benefit, usually when precise dissections in confined spaces are required. Because conventional laparoscopic total mesorectal excision is a challenging procedure, we have sought to assess the utility of the DaVinci robotic system in laparoscopic low anterior resections for cancer of the rectum. Methods Between November 2004 and May 2005 robotic-assisted low anterior resection with total mesorectal excision was performed on six consecutive patients with rectal cancer. These cases were compared with six consecutive low anterior resections performed with conventional laparoscopic techniques by the same surgeon. Results There were no conversions in either group. Operative and pathological data, complications, and hospital stay were similar in the two groups. Robotic operations appeared to cause less strain for the surgeon. Conclusions Robotic-assisted laparoscopic low anterior resection for rectal cancer is feasible in experienced hands. This technique may facilitate minimally invasive radical rectal surgery. Presented, in part, at the 14th International Congress of the Society of Laparoendoscopic Surgeons, September 14–17, 2005 San Diego, California.     

Single-incision laparoscopic cholecystectomy: a combined analysis of resident and attending learning curves at a single institution

Single-incision laparoscopic cholecystectomy (SILC) is a recent technical modification on standard laparoscopic cholecystectomy that has been shown to be safe and feasible. Recent studies suggest that experienced laparoscopic surgeons have a short learning curve to become proficient in SILC. However, little is known about the interaction of the learning curves of residents and attending surgeons at academic programs. We prospectively evaluated various metrics of both attending and resident surgeons as they progressed in their experience with SILC. Patients were placed into cohorts of 25 based on teaching surgeon experience. Data recorded included patient-specific and operative variables along with complications, conversion to standard laparoscopic cholecystectomy, and outcomes. One hundred one patients underwent SILC. Twelve per cent of patients required conversion to standard laparoscopic cholecystectomy. No significant difference was found in operative times compared within the experience-based cohorts (P = 0.21). A reduction in operative time was shown in residents who were proficient in standard laparoscopic cholecystectomy (SLC) along their learning curve. Operative times remained the same for the teaching surgeon regardless of experience of resident surgeon. SILC has a short learning curve for resident surgeons who are proficient in standard laparoscopic surgery. SILC can be effectively taught with few complications and outcomes similar to SLC with preservation of operative efficiency and safety. Further studies are warranted, however, at a national/international level to define the place and use for SILC as well as the incorporation of single-incision techniques into resident curriculum.     

Preservation of sexual and bladder function after laparoscopic rectal surgery

Background  There have recently been reports of higher levels of bladder and sexual dysfunction in men after laparoscopic rectal surgery when compared with those undergoing open surgery. This has led some surgeons to question the role of the laparoscopic approach to rectal surgery.
Method  This study represents a retrospective analysis of a prospectively collected database for a single unit, comprising 2406 patients undergoing laparoscopic colorectal surgery. Bladder function, potency and ejaculation were assessed at postoperative clinic visits for men undergoing laparoscopic low or ultra-low anterior resection and abdominoperineal excision of the rectum.
Results  A total of 101 males were identified (median age 62 years: range 20–90 years). Urinary dysfunction was reported by six (6%) patients. Six (6%) patients had sexual dysfunction, manifesting as retrograde ejaculation in four patients and erectile dysfunction in a further two patients.
Conclusions  The low rates of sexual dysfunction in this unit may be attributable to pelvic dissection only being undertaken by experienced, dedicated laparoscopic colorectal surgeons. Laparoscopic restorative surgery for rectal cancer has been performed here only since 2001 after considerable experience accrued in operating on benign rectal disease and colon cancer. Studies from elsewhere reporting poorer functional outcomes have probably included a significant number of patients on the surgeons'learning curve'.     

The technique of single-stage totally robotic low anterior resection

To keep pace with the rapidly growing incidence of colorectal cancer, substantial progress has been made in colorectal cancer management in recent decades. Minimally invasive surgery is rapidly gaining acceptance for surgical management of colorectal cancer; however, laparoscopic colorectal surgery is technically demanding and has a steep learning curve. Although many colorectal surgeons have great expectations of the robotic surgical system to overcome the pitfalls of laparoscopic surgery, the application of robots in colorectal cancer surgery seems to be delayed when compared with other surgical fields. However, in recent years, there has been an increasing number of reports on robotic colorectal surgery and much attention is given to it in the colorectal community. Most of the interest has been in robotic total mesorectal excision for rectal cancer. In contrast, the use of robotics for colon resections does not confer significant advantages. We summarize the current evidence on clinical and oncologic outcomes of robotic colorectal surgery.     

Current status of robotic colorectal surgery

To keep pace with the rapidly growing incidence of colorectal cancer, substantial progress has been made in colorectal cancer management in recent decades. Minimally invasive surgery is rapidly gaining acceptance for surgical management of colorectal cancer; however, laparoscopic colorectal surgery is technically demanding and has a steep learning curve. Although many colorectal surgeons have great expectations of the robotic surgical system to overcome the pitfalls of laparoscopic surgery, the application of robots in colorectal cancer surgery seems to be delayed when compared with other surgical fields. However, in recent years, there has been an increasing number of reports on robotic colorectal surgery and much attention is given to it in the colorectal community. Most of the interest has been in robotic total mesorectal excision for rectal cancer. In contrast, the use of robotics for colon resections does not confer significant advantages. We summarize the current evidence on clinical and oncologic outcomes of robotic colorectal surgery.     

The pitfalls of laparoscopic surgery: challenges for robotics and telerobotic surgery

After its debut in 1988, laparoscopic cholecystectomy rapidly became the standard of care for cholelithiasis, yet very few surgeons use minimally invasive techniques for other abdominal operations. Why do most surgeons continue to perform traditional open gastrointestinal operations? We believe that the answer to this question lies in the fact that advanced laparoscopic operations are difficult to learn, perform, and master. A number of inherent pitfalls of laparoscopy hinder the performance of these operations even after the surgeon has accumulated years of experience. These pitfalls include an unstable video camera platform, limited motion (degrees of freedom) of straight laparoscopic instruments, two-dimensional imaging, and poor ergonomics for the surgeon. Inexperienced or bored laparoscopic camera-holders move the camera frequently and rotate it away from the horizon. The long, straight laparoscopic instruments are limited in their motion by the fixation enforced by the abdominal wall trocars. Similarly, the standard two-dimensional video imaging used in most laparoscopic operations impedes the surgeon's depth perception, compounding the limitations of laparoscopic instruments. In addition, surgeons are forced to assume ergonomically awkward stances in performing many laparoscopic operations. These four factors hinder a surgeon's efforts to learn and to perform advanced laparoscopic operations, significantly lengthening the learning curve. The articles presented in this issue suggest that robotics and telerobotics offer solutions to these nagging pitfalls of laparoscopic surgery.     

Early results of a prospective multicenter study on 500 consecutive cases of laparoscopic colorectal surgery

Background: Prospective randomized multicenter studies comparing laparoscopic with open colorectal surgery are not yet available. Reliable data from prospective multicenter studies involving consecutive patients are also lacking. On the basis of the personal caseloads of specialized surgeons or of retrospective analyses, it is difficult to judge the true effectiveness of this new technique. This study aims to investigate the results of laparoscopic colorectal surgery in consecutive patients operated on by unselected surgeons. Methods: This observational study was begun August 1, 1995, in the German-speaking part of Europe (Germany and Austria) and 43 centers initially agreed to participate. All consecutive cases were documented. All data were rendered anonymous. Analysis was performed on an intention-to-treat basis. The study committee was blinded to the participating center. Results: By the end of the 1st year, 500 patients (M:F ratio 0.83, mean age 62.9 years) had been treated by 18 centers; 269 operations were performed for benign indications and 231 for cancer (palliative and curative). Most operations were done on the distal colon or rectum. An anastomosis was performed in 84%, with an overall leakage rate of 5.3% (colon 3.6% and rectum 11.8%), which required surgical reintervention in 1.7%. The mean operating time was 176 min and showed a decreasing tendency over the period under study. The conversion rate was 7.0% and the overall complication rate 21.4%. The reoperation rate was 6.6%; the most common cause was bleeding. There was one ureteral lesion (0.2%), but urinary tract infections were fairly common (4.8%). A postoperative pneumonia was diagnosed in 1.6% of the cases. No thromboembolic complications were reported. The 30-day mortality rate was 1.4% and overall hospital mortality 1.8%. Conclusions: Laparoscopic colorectal operations are still rare (about 1% of all colorectal operations in Germany). Laparoscopic procedures are more common on the left colon and rectum than on the right colon. The surgical complication rate is acceptable, comparable with rates reported by others for open surgery. Cardiopulmonary and thromboembolic complications were rarely seen. Mortality and surgical morbidity rates do not differ significantly among participating centers. A learning curve, reflected by a shortening of the operating time and a somewhat lower conversion rate, was observed over the observation period. Received: 3 February 1997/Accepted: 22 April 1997     

Laparoscopic colon surgery for benign disease: a comparison to open surgery.

BACKGROUNDS AND OBJECTIVES: There remains a debate in the literature about the advisability of laparoscopic surgery for malignant disease of the colon. Current prospective studies will hopefully answer this question. However, for benign diseases of the colon, we believe laparoscopic surgery offers many advantages including decreased postoperative pain, early discharge from the hospital, and early return to normal activities. We retrospectively reviewed our experience with laparoscopic colectomies for benign disease to see whether these procedures could be done safely and if the proposed advantages could be realized. METHODS: Thirty-eight laparoscopic colon resections performed for benign disease were compared to 39 open colon resections with respect to operating times, length of hospital stay, estimated blood loss, days until first postoperative bowel movement, and complications. RESULTS: The laparoscopic colon resection group had decreased length of stay, less blood loss, earlier return of bowel function, and an equivalent number of complications. Laparoscopic cases did take an average of 24 minutes longer. CONCLUSION: The use of laparoscopic colon surgery for benign disease not only affords the patient the advantage of the laparoscopic approach, but also allows the surgeon to gain experience while awaiting the results of ongoing trials for laparoscopic colon surgery in malignant disease.