How To Reduce the Laparoscopic Colorectal Learning Curve

Background:

The laparoscopic approach for colorectal pathologies is becoming more widely used, and surgeons have had to learn how to perform this new technique. The purpose of this work is to study the indicators of the learning curve for laparoscopic colectomy in a community hospital and to find when the group begins to improve.

Methodology:

From January 1 2005 to December 31 2012, 313 consecutive laparoscopic colorectal surgeries were performed (105 rectal and 208 colonic) by at least 60% of the same surgical team (6 members) in each operation. We evaluate the learning curve by moving averages and cumulative sums (CUSUM) for different variables related to the surgery outcomes.

Results:

Moving average curves for postoperative stay, fasting, and second step analgesia show a stabilizing trend toward improvement as we get more experience. However, intensive care unit stay, number of lymph nodes achieved, and operating time did not show a clear decreasing tendency. CUSUM curves of conversion, specimens <12 lymph nodes, and complications all show a clear turning point marked on all the charts around the procedure 60, accumulating a positive trend toward improvement. The CUSUM curve of the “learning variable” shows this improvement point at procedure 70.

Conclusions:

The laparoscopic colectomy learning curve accelerates with a collective team involvement in each procedure. The CUSUM and moving average curves are useful for initial and ongoing monitoring of new surgical procedures. The markers of the learning curve evidenced in our study are the conversion rate, postoperative surgical morbidity, and the number of patients with a lymph node count <12.

What is new in this paper?

The significance of this study is the evaluation of the learning curve, in laparoscopic colorectal surgery, of a surgical team in a community hospital, using moving average and CUSUM curves. This study demonstrated that the number of patients needed to achieve skilful practice decreased when there is collective team involvement in each procedure.     

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.     

Clinical and educational proficiency gain of supervised laparoscopic colorectal surgical trainees

Background

The self-taught learning curve in laparoscopic colorectal surgery (LCS) is between 100 and 150 cases. Supervised training has been shown to shorten the proficiency gain curve of senior specialist surgeons. Little is known about the learning curve of LCS trainees undergoing mentored training. The aim of this study was to analyze the proficiency gain curve and clinical outcomes of English surgical trainees during laparoscopic colorectal surgery fellowships.

Methods

In 2010 the educational, Web-based platform from the National Training Program in Laparoscopic Colorectal Surgery in England was newly available to surgical trainees undertaking a laparoscopic colorectal fellowship. These fellows were asked to submit clinical outcomes, including patient demographics and case specifications. In addition, self-perceived performance was evaluated using a validated task-specific self-assessment form [global assessment scale (GAS) range 1–6]. Proficiency gain curves and learning rates were evaluated using risk-adjusted (RA) cumulative sum (CUSUM) curves.

Results

Of 654 cases 608 were included for analysis. The clinical outcomes included 9.2 % conversions, 16.9 % complications, 4 % reoperations, 2.6 % readmissions and a 0.8 % in-hospital mortality rate. RA CUSUM curves for complications and reoperation do not show a learning effect. However, the RA CUSUM curve for conversion has an inflection point at 24 cases. The GAS CUSUM curves for ‘setup’ and ‘exposure’ have inflection points at case 15 and case 29 respectively. The curves for ‘mobilization of colon,’ ‘vascular pedicle’ and ‘anastomosis’ plateau towards the end of the training period. ‘Flexure’ and ‘mesorectum’ do not of reach a plateau by case 40.

Conclusions

Supervised fellowships provide training in LCS without compromising patient safety. Forty cases are required for the fellows to feel confident to perform the majority of tasks except dissection of the mesorectum and flexure, which will require further training.     

Implementation of laparoscopic sacrocolpopexy—a single centre’s experience

Introduction and hypothesis  The aim of this study was to describe the learning curve of a single surgeon to achieve the ability to perform a complication-free and anatomically successful laparoscopic sacrocolpopexy (LSC). Methods  All patients, from the first LSC onwards (1996) were included. Outcome measures were operation time, number of laparotomies, complications and anatomical failures within 3 months. Learning curves were generated using moving average method (MOA) and cumulative sum (CUSUM) analysis to assess changes in respectively operation time and failures (laparotomy, complication or anatomical failure). Results  Of the 206 patients, 83% were completed by laparoscopy. The intra-operative and major respectively minor post-operative complication rates were 2.4% (n = 5), 4.4% (n = 9) and 12.6% (n = 26). CUSUM analysis showed adequate learning after 60 cases. MOA showed that operation time declined rapidly during the first 30 procedures reaching a steady state (175 min) after 90 cases. Complications remained unchanged throughout the series. Conclusions  LSC was associated with a low complication rate but a long learning curve.     

Laparoscopic colorectal surgery for neoplasm. A large series by a single surgeon

BACKGROUND: The value and efficacy of laparoscopic colorectal surgery has been validated by large multicenter, randomized, controlled trials. However the results of a large series by a single surgeon in a single center have yet to be reported. We reviewed the short-term outcome of our series of laparoscopic colorectal procedures to better define the learning curve for acquiring these skills. METHODS: Four hundred four patients with a colorectal neoplasm underwent laparoscopic surgery between August 1998 and December 2005. Surgery was performed under 8 to 10 cm H(2)O CO(2) pneumoperitoneum. Type of operation, time of operation, and estimated blood loss were compared for each level of lymph node dissection, and the rate and reason for conversion to open procedures were determined. Time to passage of flatus, hospital stay, and postoperative complications were recorded. The learning curve for right hemicolectomy, sigmoidectomy, and low anterior resection was calculated. RESULTS: Open conversion was required in 13 patients (3.2%). Uncontrollable bleeding occurred in four cases, and inability to divide the rectum because of adhesions or local invasion occurred in three. The time of operation for D3 level lymph node dissection was longer than for D2 in ileocecal resection, right hemicolectomy, and sigmoidectomy. Estimated blood loss was similar among the different types of operation. Blood loss of last 40 right hemicolectomies was less than in the first 40 cases, and the incidence of intraoperative complications in the first 40 sigmoidectomies was higher than subsequent cases. Time of operation, estimated blood loss, and number of complications did not change over time for low anterior resection. CONCLUSION: The large series performed by a single surgeon is consistent with large multicenter studies that have validated the superiority of laparoscopic colorectal surgery over conventional open procedures. The learning curve flattens out after about 40 cases of right hemicolectomy and sigmoidectomy.     

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 curve in laparoscopic rectum surgery

Laparoscopic colorectal surgery has become increasingly more common since first being described in a publication in 1990. Despite a multitude of studies about the learning curve in laparoscopic colon surgery, there are almost no such studies with regard to laparoscopic rectum surgery. This paper aims to describe a surgeon's learning curve with regard to laparoscopic rectum surgery. Based on data collected in a prospective observational study of 180 patients, it can be established that a surgeon experienced in open colorectal surgery, with basic experience in laparoscopic surgery, after suitable preparation and having a personal interest in minimally invasive surgery, needs to perform about 35 laparoscopic rectum resections within 200 laparoscopic colon resections until selection rate, operating time and rates of general and surgical complications reach a plateau. A selection of cases suited to a surgeon's personal level of operating experience, is a prerequisite for a low rate of conversions and complications and for oncological long-term results comparable to those achieved through open surgery. However, the learning curve is dependent on a multitude of factors that are partly unknown at this point. Its duration most certainly varies between individual surgeons. Every surgeon is required to critically evaluate his or her own laparoscopic experience and select cases accordingly. Supervision by surgeons more experienced in laparoscopic colorectal surgery prevents disadvantages for patients in the early phases of the surgeon's learning curve. Training in laparoscopic colorectal surgery should take place only in institutions with a sufficient number of cases treated and a continuity in experienced teachers. CAMIC's efforts in establishing centres of competence and reference are therefore to be commended and supported.     

Learning curve for standardized laparoscopic surgery for colorectal cancer under supervision: a single-center experience

Background  

Laparoscopic resection for colorectal cancer is increasingly being performed worldwide. Although learning standardized procedures under the supervision of an experienced surgeon may be effective, there is currently no information on the learning curve under such circumstances. This single-center study aimed to evaluate the learning curve for laparoscopic resection for colorectal cancer of one surgical fellow with no previous experience with laparoscopic colectomy.     

Multidimensional analysis of the learning curve for laparoscopic colorectal surgery: lessons from 1,000 cases of laparoscopic colorectal surgery

Purpose  We consider quality of surgery throughout the learning curve and attempt to determine the learning curve for competency in performing laparoscopic colorectal surgery. Methods  The study included 1,014 patients who underwent laparoscopic colorectal resection between June 1996 and December 2007. We categorized patients into nine periods according to number of cases performed. Results  Operative time continuously decreased for right hemicolectomy (216 versus 150 min) and anterior resection (214.8 versus 147.7 min), whereas for low anterior resection it did not change over many periods and then significantly decreased after the ninth period (221.3 versus 176.4 min). The proportion of patients who had undergone previous abdominal surgery increased after the second period. Anastomotic leakage rate was 6–9% for the first 200 cases, and then decreased to less than 2%. More than 10% of operations were converted to open surgery during the first period, after which this rate significantly decreased to 2%. Number of harvested lymph nodes stabilized to 35–40 for right hemicolectomy after 200 cases, whereas for anterior and low anterior resection it was consistently 15–20 after the initial 20 cases. Overall, disease recurrence rate was 16–25%. For rectal cancer, local recurrence rate was highest (12%) in the fourth period and decreased thereafter to about 3%. Conclusion  Postoperative complications and local recurrence rate increased even after accumulation of experience because of expansion of indications for laparoscopic procedures.     

Oncological outcomes of laparoscopic colon resection for cancer after implementation of a full-time preceptorship

Background  

The learning curve for laparoscopic colectomy (LC) is considered long and difficult. The presence of a preceptor may shorten the learning curve of LC and ensure adequate oncologic and short-term results. City of Hope implemented a full-time LC preceptorship between September 2004 and March 2006 with one experienced surgeon assisting other surgeons. We review our outcomes with laparoscopic colon resection for colon adenocarcinoma after implementation of this preceptorship.     

Cancer of the sigmoid colon: left hemicolectomy or sigmoidectomy?

Left hemicolectomy is the ideal treatment of sigmoid cancer, but sometimes sigmoidectomy is a safe treatment. We radically treated 102 patients affected by sigmoid cancer: 83 were gross sigmoid cancer treated by left hemicolectomy, 19 were residual cancer after endoscopic polypectomy; of these, 4 underwent left hemicolectomy and 15 underwent sigmoidectomy. No recurrence was observed in the 15 patients treated by sigmoidectomy. In patients with sigmoid cancer accidentally associated with sigmoid diverticulitis, the surgeon should extend the resection up to a left hemicolectomy or follow-up with the patient, but sometimes sigmoidectomy could be safe. The sentinel lymph node technique in colorectal cancer could suggest indications to complementary treatments. However, in the presence of a negative node, sigmoidectomy could probably be planned as a rational treatment. In conclusion, even if more data are required, in some selected cases of sigmoid cancer, sigmoidectomy could be a safe treatment.     

MA-NOS radical sigmoidectomy: report of a transvaginal resection in the human

Background  With available laparoscopic and endoscopic instruments/technology a standard radical sigmoid resection is feasible and safe using transvaginal minilaparoscopic-assisted natural orifice surgery (MA-NOS). Methods  The intervention was a transvaginal MA-NOS sigmoidectomy in a 78-year-old woman with a sigmoid adenocarcinoma. Maintaining triangulation the surgeon positioned himself at the right side of the patient and used the transvaginal trocar for dissection and stapling of both the inferior mesenteric vessels and the upper rectum. The colonic resection was performed extracorporeally in the conventional fashion and was followed by an intra-abdominal endoscopically assisted stapled anastomosis. Results  Advantages of minimally invasive surgery seemed to be enhanced with this hybrid laparoscopic approach. Postoperative course was uneventful. All oncological principles governing resection and management were accomplished and the pathology examination confirmed a T3N1 lesion. The patient was discharged on the fourth postoperative day. Conclusion  Transvaginal MA-NOS radical sigmoidectomy is a feasible and oncologically safe procedure. MA-NOS is a realistic option for avoiding the need of assisting incisions and related morbidity in the laparoscopic resection of large intra-abdominal lesions. Combined hybrid laparoscopic NOS in humans (MA-NOS) currently provides a safe and reliable way of defining future clinical applications and advantages of NOS and NOTES. Additionally, it stimulates the active development and evaluation of the underpinning technologies and instrumentation.     

37例直肠、乙状结肠癌全电钩腹腔镜手术的临床经验总结

目的:总结腹腔镜直肠、乙状结肠癌手术及全电钩解剖的临床经验及应用价值。方法:回顾分析2013年4月至2014年1月为37例直肠癌、乙状结肠癌患者行腹腔镜手术的临床资料,术中全程使用电钩操作。结果:37例均顺利完成手术,无一例中转开腹或术中死亡。手术时间平均(183±65)min;术中出血量平均(94±28)ml;平均清扫淋巴结(13.5±5.3)枚;胃肠功能恢复时间平均(2.3±1.2)d;术后平均住院(8.2±3.4)d。无吻合口漏、出血、切口感染、输尿管损伤及近期肠梗阻等并发症发生,术后近期疗效较好。术后标本病理检查提示残端均无癌细胞残留。结论:术者严格遵循结直肠癌根治原则,熟练掌握腹腔镜操作技术,应用电钩行腹腔镜结直肠癌手术是安全、可行的,可达到结直肠癌的根治效果,同时具有来源方便、价格低廉、止血效果好等优点。     

腹腔镜结直肠手术40例学习曲线分析

目的:探讨外科医师如何尽快掌握腹腔镜结直肠癌根治术。方法:回顾分析2006年5月至2009年6月我院为40例患者行腹腔镜结直肠手术的临床资料,按手术先后次序分为4组,每组10例,以每10例手术患者为一手术学习曲线阶段,比较各阶段的手术时间,术中出血量,术中、术后并发症发生率,中转开腹率,术后住院时间,分析不同阶段的手术效果。结果:4组患者在年龄、性别、手术方式等方面无明显差别。手术时间A组(300±20.4)min,1例中转开腹,B组(180±11.5)min,C组(180±21.2)min,D组(130±18.1)min(P<0.001)。术中出血由(100±13.5)ml降至(50±11.5)ml(P<0.05),术后住院天数由18.4d降至14.3d(P<0.05)。4组均无术中、术后并发症发生。结论:行腹腔镜结直肠癌手术约30例后即可达到较熟练程度。     

The learning curve in laparoscopic resections of the colon and rectum: results and considerations

A well-designed learning curve is essential for the success of laparoscopic colorectal surgery for cancer. The aim of this study was to evaluate the results and characteristics of the learning curve in laparoscopic colorectal surgery beginning with benign diseases and eventually going on to include colonic resections for cancer. A total of 60 laparoscopic resections were performed. In the first 33 cases only benign diseases (diverticular disease and polyps) were treated. The next 27 cases included resections for cancer, initially with the following exclusion criteria: obesity, previous abdominal surgery, emergency surgery for occlusion, voluminous tumours or infiltration of surrounding organs. Since January 2002 the only applicable exclusion criteria for laparoscopic resection have been emergency surgery for occlusion and invasion of adjacent organs. The following procedures were performed: 29 left hemicolectomies, 19 sigmoid resections, 7 segmentary resections, 3 abdomino-perineal resections and 2 right hemicolectomies. The conversion rate was 11.6%. The mean length of the segment removed was 21.5 cm. The mean number of lymph nodes harvested (for cancer) was 22.3. Major complications were observed in 3.3% and minor complications in 13.3%. The operative time decreased from a mean of 207 minutes to a mean of 170 minutes in the last group of 20 patients. Laparoscopic resections are safe and give the patient the opportunity to make a rapid recovery with less pain and a better outcome. We suggest performing laparoscopic colorectal resections initially for benign diseases (diverticular disease and polyps). This is needed in order to hone the technique. Resections for cancer can be undertaken only when the surgical team can guarantee an oncologically correct procedure in terms of lymphadenectomy, intraabdominal manipulation and extraction of the diseased segment from the abdomen.     

Laparoscopic colectomy for persistent descending mesocolon in sigmoid colon cancer: A case report

A 55-year-old-man underwent laparoscopic sigmoidectomy for sigmoid colon cancer. Preoperative barium enema showed a slightly medial displacement of the descending colon, and the sigmoid colon was quite long. The operative findings showed that the descending colon was not fused with the retroperitoneum and shifted to the midline and the left colon adhered to the small mesentery and right pelvic wall. Thus, a diagnosis of persistent descending mesocolon (PDM) was made. The left colon, sigmoid colon, and superior rectal arteries often branch radially from the inferior mesenteric artery. The sigmoid mesentery shortens, and the inferior mesenteric vein is often close to the marginal vessels. By understanding the anatomical feature of PDM and devising surgical techniques, laparoscopic sigmoidectomy for sigmoid colon cancer with PDM could be performed without compromising its curative effect and safety.     

Laparoscopic intracorporal colorectal sutured anastomosis using the Radius Surgical System in a phantom model

Background  The Radius Surgical System (RSS) is a manipulator with additional degrees of freedom to enhance the dexterity of laparoscopic suturing. Our aim was to determine the feasibility and potentially added value of laparoscopic intracorporal sutured colorectal anastomosis (RSS) compared with suturing with conventional laparoscopic instruments (CLI). Methods  A total of 72 colorectal anastomoses and 30 single sutures using RSS and CLI were performed in the study. The experiment was divided as follows: One surgeon performed 40 colorectal anastomoses using RSS to assess the learning curve and the feasibility of the technique; The same surgeon performed 10 additional colorectal anastomoses with CLI which were then compared to the last 10 cases of the 40 anastomoses with RSS; Fifteen single sutures in the horizontal plane with RSS and 15 with CLI between two segments of colon were performed to compare the traction force to disrupt the suture; Twelve anastomoses were performed by the other three participants to evaluate ergonomy. Results  Three leakages (7.5%) were found in the 40 anastomoses with RSS but none after the eighth case. There was no stenosis. The mean time for the anastomoses once the learning curve was achieved was 32.7 min. After 21 anastomoses with RSS there was no improvement in the operating time. The quality of the suture was superior with RSS, with a larger anastomosis diameter, higher bursting pressure, and fewer suturing failures being found. The RSS suture withstood a higher traction force. The participants showed more discomfort suturing with CLI. Conclusion  This study demonstrated the feasibility of laparoscopic colorectal anastomosis using RSS. Anastomosis with RSS was shown to be safer. The three participants evaluating ergonomy reflected less discomfort in hand/wrist using RSS. Others ergonomic problems were comparable to CLI. An erratum to this article can be found at     

Implementation of laparoscopic colectomy with fast-track care in an academic medical center: benefits of a fully ascended learning curve and specialty expertise

BACKGROUND: There are few data describing successful institutional "conversion" from open colectomy/standard care techniques to laparoscopic colectomy/fast-track care. PURPOSE: To assess the benefits of transitioning an institution from open to laparoscopic colectomy with fast-track care while avoiding a learning curve. METHOD: Twenty consecutive laparoscopic colorectal resections (LCRs) performed by a colorectal surgeon were compared with 20 matched open colorectal resections (OCRs) performed by general surgeons before the arrival of the colorectal surgeon. RESULTS: Surgical procedures were as follows: sigmoidectomy: OCR 16 and LCR 11; right colectomy: OCR 3 and LCR 8; and total colectomy: OCR 1 and LCR 1. The mean operative time for sigmoidectomy was 250 and 109 minutes for OCR and LCR, respectively, and for right colectomy 181 and 97 minutes for OCR and LCR, respectively (P < .001). Morbidity was OCR 45% versus LCR 25%. There was no mortality. LCR showed significantly lower length of stay and direct cost (3.6 vs. 8.3 days; 4,993 dollars vs. 11,383 dollars; both P < .001). CONCLUSIONS: The data clearly show an institutional benefit for the implementation of specialty-based advanced laparoscopic procedures.