laparoscopic colorectal surgery - getting started

Laparoscopic colorectal surgery- getting startedPeter SagarThe General Infirmary at LeedsLeeds, UK

Laparoscopic Colorectal Surgery: Getting Started

InnovatorsEarly AdoptersEarly MajorityLate MajorityLaggardsUptake Of a New Surgical Procedure


Early adopters versus the laggards


Why Not?

Its too hard

It takes too long

I cant spare the time to learn

I cant train my registrars

Its too expensive



Where do we stand now?


Comparison with Australia


Comparison with USA




Where do we stand now?Response rate: 200/54045 surgeons performing lap colorectal surgeryMainly right hemi-colectomy & stoma formation




So, whats the problem?


How do I get started?

The evidence

The guidelines

Training & competency

Getting support


Powell presents smoking gun evidence to UN


Evidence to Support Laparoscopic Colorectal SurgeryClinical EffectivenessShorter length of stayFewer complicationsLess blood loss & use of blood productsLess pain & analgesiaQuicker return to normal activitiesBetter cosmesisIncidence of port site metastases is 1%Equivalent to open surgery


Evidence to Support Laparoscopic Colorectal SurgeryCost EffectivenessOperating costs are higherLonger operating timeCapital and recurring costs are higher

Higher costs appear to be offset byFewer complications, especially wound related problemsShorter hospital stayLess use of analgesiaLess use of blood products

Overall costs to society are comparable


Evidence to Support Laparoscopic Colorectal SurgeryDisease Free Survival: Comparative Randomised StudiesBarcelona (Lacy 2002)USA (COST 2004)Hong Kong RCT (Leung 2004)New Mexico (Curet 2000)Los Angeles (Kaiser 2004)


COST trial

872 patients 428 open, 435 lap la66 surgeons at 48 institutionsR & L colon ca onlyPrimary end point tumour recurrence

N Engl J Med 2004; 350: 2050-9


COST TRIAL

Recurrence at 3 years16% laparoscopic vs 18% open

Survival at 3 years86% laparoscopic vs 85% open


COST trial- short term outcome

Laparoscopic benefits:Shorter LOS ( 5 vs 6 days)Reduced use of narcotics (3 vs 4 days)Reduced use of oral analgesia (1 vs 2 days)


COST trialConclusion

...the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.

N Engl J Med 2004; 350: 2050-9


COST trial

872 patients 428 open, 435 lap la66 surgeons at 48 institutionsR & L colon ca onlyPrimary end point tumour recurrence

N Engl J Med 2004; 350: 2050-9


CLASICC trial

794 patients526 laparoscopic, 268 open32 surgeons (83% of patients recruited from surgeons >20 patients)Colon and rectal cancer

Lancet 2005; 365:1718-1726


CLASICC trial- uniqueness

Central pathology analysisPathological endpointsInclusion of rectal cancer cases


CLASICC trial- primary endpoints

CRM, longitudinal and high tie margins30-day mortalityLocal recurrenceDisease-free & overall survival


CLASICC trial- conclusions

LR as effective as OR for colon cancer

Pathological features after LR do not yet justify routine use in rectal cancer



Lap colorectal surgery leads to better results than open surgery?

219 patients randomised111 lap, 108 openImproved 3 yr survival and lower rates of recurrence But....

Lacy et al Lancet 2002; 359: 2224-9


The infamous Spanish trial

Morbidity; 11% LR vs 29% ORLocal complication rate; 10% LR vs 34% ORTotal complication rate; 13% LR vs 34% OR


GuidelinesNICE Guidelines

ASCRS



NICE guidelines laparoscopic colorectal cancer - August 2006Laparoscopic surgery is recommended as an alternative to open surgery for colorectal cancer..

The surgeon has been trained in laparoscopic surgery for colorectal cancer and performs the operation often enough to keep his skills up to date



Who is competent?


Training & competency


Training & CompetencySpR TrainingSkills CentresMasterclasses & SymposiaLaparoscopic Colorectal FellowshipPreceptorship


SpR Training


SpR Training


Skills centres - LIMIT


Ethicon Surgical Institute


Laparoscopic colorectal fellowships

St Marks - R Kennedy

Colchester - R Motson

Leeds - PM Sagar


Ethicon Laparoscopic Colorectal FellowFellow Logbook 5 MthsPROCEDUREPrimary OperatorAssistingLaparoscopy3Lap Appendicectomy14Lap Ileocaecetomy51Lap Right Hemi-Colectomy4Lap Anterior Resection131Lap (Sub)Total Colectomy6Lap Colectomy/Ileo-anal Pouch13Lap Panproctocolectomy1Lap AP Resection11Lap Sacrocolporectopexy11Lap Cholecystectomy6

TOTAL654




Preceptorship

Training consultants

Preceptorships - 2-4 cases

Consultants should have seen >10 live resectionsCoursesPersonal visits


Preceptorships

Preceptors - >100 cases with annual workload of >25 cases

Audit data - NBOCAP, MDT

Video material - aide memoire

( US - >20 benign cases but BEWARE)

www.alsgbi.org



Equipment


Trocars


Graspers


Harmonic Scalpel


Endoscopic Circular Stapler ECS29


Linear cutter stapler


Wound protector


So, whats the problem?

Lack of Local Support

Lack of Cases

Lack of Theatre Time

Cost/Funding


Local SupportMedical Director AuditConsultant ColleaguesCase volumeCancer casesNursing & Anaesthetic StaffOperating TimeTheatre Assistants


Convince people


Cost analysis

Open vs laparoscopic sigmoid resection (diverticular disease)

Lap cost per case - $3458 +/- 437Open cost per case - $4321 +/- 501

Dis Colon Rectum 2002; 45: 485-490


Making a business case

Conor Delaney

Mark Thomas


Patients perceptions

Patients intuitively perceive that laparoscopic procedures are more advantageous than open operations

N Engl J Med 2004; 350: 2091


How do we change attitudes?

New techniques & equipmentEducational programsTeaching methods

The world of colorectal surgery must adapt


Effector arms of the da Vinci surgical robot


Natural Orifice Transluminal Endoscopic Surgery


..the end of the beginning.



Port site recurrence1-21% incidence3 of 14 patients

ASCRS registry 1.1%Incidence in open wounds = 1%

Not a problem


Laparoscopic Colorectal Cancer Resections19902003





Who is competent?


Conversion rate:Right sided Lesions: 8%Left Sided Lesions:15%

Independent Predictors of ConversionBMIASA gradeType of resectionIntra-abdominal abscess/fistulaSurgeons experience


Learning Curve:Right sided lesions:55 casesLeft sided lesions: 62 Cases


Two surgeons721 laparoscopic colorectal procedures

Learning Curve: 70-80 ProceduresOperating timeConversion rates



Risk Factors for Recurrence: Lap RepairInexperienced SurgeonSurgeons age: > 45 years

Odds of Recurrence for older inexperienced surgeon1.72 times that of younger inexperienced surgeon: Lap repairOpen repair: Only very inexperienced had increased recurrence rates


Financial SupportStepwise increase useItem per item basis

Submit a formal business planDiscuss with Clinical & Business Manager

Outline case for laparoscopic surgeryPotential annual case load and expected growth with timeCost Implications and potential cost savingsIdentify standard/basic disposables set

Generic business Plan


Financial SupportStepwise increase useItem per item basis

Submit a formal business planDiscuss with Clinical & Business Manager

Outline case for laparoscopic surgeryPotential annual case load and expected growth with timeCost Implications and potential cost savingsIdentify standard/basic disposables set

Generic business Plan

laparoscopic colorectal surgery - getting started

Documents

lap colorectal surgerymainly

laparoscopic vs

laparoscopic approach

startedcost trial872

startedcost trialrecurrence

startedcost trialconclusion

daysreduced use of narcotics

lap la66 surgeons