Laparoscopic colorectal surgery - getting started

1. Laparoscopic colorectal surgery- getting started Peter Sagar The General Infirmary at Leeds Leeds, UK

2. Uptake Of a New Surgical Procedure Laggards Late Majority Early Majority Early Adopters Innovators

3. Early adopters versus the laggards

4. Why Not? • “It’s too hard” • “It takes too long” • “I can’t spare the time to learn” • “I can’t train my registrars” • “It’s too expensive”

6. Where do we stand now?

7. Comparison with Australia

8. Comparison with USA

9. Where do we stand now?

10. Where do we stand now? • Response rate: 200/540 • 45 surgeons performing lap colorectal surgery • Mainly right hemi-colectomy & stoma formation

11. Where do we stand now?

12. So, what’s the problem?

13. How do I get started? • The evidence • The guidelines • Training & competency • Getting support

14. Powell presents “smoking gun” evidence to UN

15. Evidence to Support Laparoscopic Colorectal Surgery • Clinical Effectiveness • Shorter length of stay • Fewer complications • Less blood loss & use of blood products • Less pain & analgesia • Quicker return to normal activities • Better cosmesis • Incidence of port site metastases is 1% • Equivalent to open surgery

16. Evidence to Support Laparoscopic Colorectal Surgery • Cost Effectiveness • Operating costs are higher • Longer operating time • Capital and recurring costs are higher • Higher costs appear to be offset by • Fewer complications, especially wound related problems • Shorter hospital stay • Less use of analgesia • Less use of blood products • Overall costs to society are comparable

17. Evidence to Support Laparoscopic Colorectal Surgery • Disease Free Survival: • Comparative Randomised Studies • Barcelona (Lacy 2002) • USA (COST 2004) • Hong Kong RCT (Leung 2004) • New Mexico (Curet 2000) • Los Angeles (Kaiser 2004)

18. COST trial • 872 patients • 428 open, 435 lap la • 66 surgeons at 48 institutions • R & L colon ca only • Primary end point – tumour recurrence

19. COST TRIAL • Recurrence at 3 years • 16% laparoscopic vs 18% open • Survival at 3 years • 86% laparoscopic vs 85% open

20. 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)

21. COST trialConclusion • “...the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.”

22. COST trial • 872 patients • 428 open, 435 lap la • 66 surgeons at 48 institutions • R & L colon ca only • Primary end point – tumour recurrence

23. CLASICC trial • 794 patients • 526 laparoscopic, 268 open • 32 surgeons (83% of patients recruited from surgeons >20 patients) • Colon and rectal cancer

24. CLASICC trial- uniqueness • Central pathology analysis • Pathological endpoints • Inclusion of rectal cancer cases

25. CLASICC trial- primary endpoints • CRM, longitudinal and high tie margins • 30-day mortality • Local recurrence • Disease-free & overall survival

26. CLASICC trial- conclusions • LR as effective as OR for colon cancer • Pathological features after LR “do not yet justify routine use in rectal cancer”

28. Lap colorectal surgery leads to better results than open surgery? • 219 patients randomised • 111 lap, 108 open • Improved 3 yr survival and lower rates of recurrence • But....

29. The infamous Spanish trial • Morbidity; 11% LR vs 29% OR • Local complication rate; 10% LR vs 34% OR • Total complication rate; 13% LR vs 34% OR

30. Guidelines • NICE Guidelines • ASCRS

32. NICE guidelines laparoscopic colorectal cancer - August 2006 • Laparoscopic 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

34. Who is competent?

35. Training & competency

36. Training & Competency • SpR Training • Skills Centres • Masterclasses & Symposia • Laparoscopic Colorectal Fellowship • Preceptorship

37. SpR Training

38. SpR Training

39. Skills centres - LIMIT

40. Ethicon Surgical Institute

41. Laparoscopic colorectal fellowships • St Marks - R Kennedy • Colchester - R Motson • Leeds - PM Sagar

42. Ethicon Laparoscopic Colorectal FellowFellow Logbook – 5 Mths • PROCEDURE Primary Operator Assisting • Laparoscopy 3 • Lap Appendicectomy 14 • Lap Ileocaecetomy 5 1 • Lap Right Hemi-Colectomy 4 • Lap Anterior Resection 13 1 • Lap (Sub)Total Colectomy 6 • Lap Colectomy/Ileo-anal Pouch 13 • Lap Panproctocolectomy 1 • Lap AP Resection 1 1 • Lap Sacrocolporectopexy 1 1 • Lap Cholecystectomy 6 • TOTAL 65 4

44. Preceptorship • Training consultants • Preceptorships - 2-4 cases • Consultants should have seen >10 live resections • Courses • Personal visits

45. 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

47. Equipment

48. Trocars

49. Graspers

50. Harmonic Scalpel