Laparoscopic Surgery Training Tips How to start

How to improve

AdelaideSouth Australia

What is the Learning Curve?

• The number of cases to be deemed proficient in the technique.

• 20 cases to be eligible for the ALCCaS and CLASSIC studies.

• More than this are probably necessary.

• The number may vary for different procedures (RHC, LHC, Rectal resection)

What is an acceptable conversion rate?

What is a conversion?• Alteration in the planned site or length of

incision. This may still have a laparoscopic component.

Rate?• 20% or less• May fall or increase with time (experience and

case mix)• Northern Colorectal Unit rate for 32004 and

32024 20%• Reversal Hartmann’s 40+%

What are acceptable operating and surgical parameters?

Should we set limits?

• Operating time.

• Blood loss and transfusion rates

• Ability to achieve a high tie??

• Complication rates

• Pathological margins

• Lymph node yields

Training – What is Available?

• Literature, video, internet• Computer simulation• Case observation• Laparoscopic courses• Surgeon mentoring• Surgical fellowship

How to start

• Understand the principles of OPEN colorectal surgery

• Basic general training in laparoscopy (appendix, gallbladder)

• Application of these principles to laparoscopic colorectal surgery

How to start

Get the Hospital on side

• Discuss the operation, instruments

• Dedicated nursing staff in theatre

• Post-operative care plan

• Cost

• Length of stay – Short vs Long stay

• What will the health funds pay for?

How to start

Choose a suitable case• Lap stoma• Benign vs Malignant• Right vs Left resection• Male vs Female• Size of pathology• BMI• ASA grade• Realistic patient

expectations

How to start

Allow plenty of time

Get it correct from the start• Anaesthetic• Patient set up• Scrub nurse• Assistant• Instruments

How to start

Accurately locate the pathology• Spot, Barium enema, CT scan• Don’t accept the stated site from a colonoscopy

report (unless you can see the ileo-caecal valve)

Set yourself achievable goals• Mobilisation and delineation anatomy (ureter)• Ligation vessels• Resection• Anastomosis

Tips

Conversion• Early assessment of the

pathology and feasibility• Open early if not going well• Use a midline incision• Don’t consider it a failure• Consider an extra port as an

extension of the wound• Hand port ???

Tips

• Mobilise more than you need (LHC)• Place your incision at point where mobilised

bowel will reach easily (RHC)

Oncological Principles

• Suture port sites in position• Limited tumour manipulation• Adhere to standard tissue planes• Wound protector• Cytocidal washout abdominally and where

appropriate rectally

Tips

Approach

• Medial vs Lateral

• Do what you are used to (don’t change)

• Achieve a goal (eg mobilise the left colon and splenic flexure then use a lower ML incision – the patient still benefits)

Tips

• Be versatile with port placement• Be versatile with incision placement• Midline vs Pfannensteil incision

How to Improve

• Operate with someone else who is interested (Collaborate)

• Regionalise experience

• Video and review each case

• Keep a database

• Do an audit

• Know your results

Summary

Conclusions