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

Laparoscopic Colorectal Surgery: Getting Started Innovators Early Adopters Early Majority Late Majority Laggards Uptake Of a New Surgical Procedure

Laparoscopic Colorectal Surgery: Getting Started Early adopters versus the laggards

Laparoscopic Colorectal Surgery: Getting Started 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”

Laparoscopic Colorectal Surgery: Getting Started

Where do we stand now?

Laparoscopic Colorectal Surgery: Getting Started Comparison with Australia

Laparoscopic Colorectal Surgery: Getting Started Comparison with USA

Laparoscopic Colorectal Surgery: Getting Started Where do we stand now?

Laparoscopic Colorectal Surgery: Getting Started Where do we stand now?  Response rate: 200/540  45 surgeons performing lap colorectal surgery  Mainly right hemi-colectomy & stoma formation

Laparoscopic Colorectal Surgery: Getting Started Where do we stand now?

Laparoscopic Colorectal Surgery: Getting Started So, what’s the problem?

Laparoscopic Colorectal Surgery: Getting Started How do I get started?  The evidence  The guidelines  Training & competency  Getting support

Laparoscopic Colorectal Surgery: Getting Started Powell presents “smoking gun” evidence to UN

Laparoscopic Colorectal Surgery: Getting Started 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

Laparoscopic Colorectal Surgery: Getting Started 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

Laparoscopic Colorectal Surgery: Getting Started 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)

Laparoscopic Colorectal Surgery: Getting Started COST trial  872 patients  428 open, 435 lap la  66 surgeons at 48 institutions  R & L colon ca only  Primary end point – tumour recurrence

Laparoscopic Colorectal Surgery: Getting Started COST TRIAL  Recurrence at 3 years  16% laparoscopic vs 18% open  Survival at 3 years  86% laparoscopic vs 85% open

Laparoscopic Colorectal Surgery: Getting Started 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)

Laparoscopic Colorectal Surgery: Getting Started COST trial Conclusion  “...the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.”

Laparoscopic Colorectal Surgery: Getting Started COST trial  872 patients  428 open, 435 lap la  66 surgeons at 48 institutions  R & L colon ca only  Primary end point – tumour recurrence

Laparoscopic Colorectal Surgery: Getting Started CLASICC trial  794 patients  526 laparoscopic, 268 open  32 surgeons (83% of patients recruited from surgeons >20 patients)  Colon and rectal cancer

Laparoscopic Colorectal Surgery: Getting Started CLASICC trial - uniqueness  Central pathology analysis  Pathological endpoints  Inclusion of rectal cancer cases

Laparoscopic Colorectal Surgery: Getting Started CLASICC trial - primary endpoints  CRM, longitudinal and high tie margins  30-day mortality  Local recurrence  Disease-free & overall survival

Laparoscopic Colorectal Surgery: Getting Started CLASICC trial - conclusions  LR as effective as OR for colon cancer  Pathological features after LR “do not yet justify routine use in rectal cancer”

Laparoscopic Colorectal Surgery: Getting Started

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....

Laparoscopic Colorectal Surgery: Getting Started 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

Laparoscopic Colorectal Surgery: Getting Started Guidelines  NICE Guidelines  ASCRS

Laparoscopic Colorectal Surgery: Getting Started

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

Laparoscopic Colorectal Surgery: Getting Started

Who is competent?

Laparoscopic Colorectal Surgery: Getting Started Training & competency

Laparoscopic Colorectal Surgery: Getting Started Training & Competency  SpR Training  Skills Centres  Masterclasses & Symposia  Laparoscopic Colorectal Fellowship  Preceptorship

Laparoscopic Colorectal Surgery: Getting Started SpR Training

Laparoscopic Colorectal Surgery: Getting Started SpR Training

Laparoscopic Colorectal Surgery: Getting Started Skills centres - LIMIT

Laparoscopic Colorectal Surgery: Getting Started Ethicon Surgical Institute

Laparoscopic Colorectal Surgery: Getting Started Laparoscopic colorectal fellowships  St Marks - R Kennedy  Colchester - R Motson  Leeds - PM Sagar

Laparoscopic Colorectal Surgery: Getting Started Ethicon Laparoscopic Colorectal Fellow Fellow Logbook – 5 Mths  PROCEDUREPrimary OperatorAssisting  Laparoscopy3  Lap Appendicectomy14  Lap Ileocaecetomy51  Lap Right Hemi-Colectomy4  Lap Anterior Resection131  Lap (Sub)Total Colectomy6  Lap Colectomy/Ileo-anal Pouch13  Lap Panproctocolectomy1  Lap AP Resection11  Lap Sacrocolporectopexy11  Lap Cholecystectomy6  TOTAL654

Laparoscopic Colorectal Surgery: Getting Started

Preceptorship  Training consultants  Preceptorships cases  Consultants should have seen >10 live resections  Courses  Personal visits

Laparoscopic Colorectal Surgery: Getting Started Preceptorships  Preceptors - >100 cases with annual workload of >25 cases  Audit data - NBOCAP, MDT  Video material - aide memoire  ( US - >20 benign cases but BEWARE…) 

Laparoscopic Colorectal Surgery: Getting Started

Equipment

Laparoscopic Colorectal Surgery: Getting Started Trocars

Laparoscopic Colorectal Surgery: Getting Started Graspers

Laparoscopic Colorectal Surgery: Getting Started Harmonic Scalpel

Laparoscopic Colorectal Surgery: Getting Started Endoscopic Circular Stapler ECS29

Laparoscopic Colorectal Surgery: Getting Started Linear cutter stapler

Laparoscopic Colorectal Surgery: Getting Started Wound protector

Laparoscopic Colorectal Surgery: Getting Started So, what’s the problem?  Lack of Local Support  Lack of Cases  Lack of Theatre Time  Cost/Funding

Laparoscopic Colorectal Surgery: Getting Started Local Support  Medical Director  Audit  Consultant Colleagues  Case volume  Cancer cases  Nursing & Anaesthetic Staff  Operating Time  Theatre Assistants

Laparoscopic Colorectal Surgery: Getting Started Convince people

Laparoscopic Colorectal Surgery: Getting Started Cost analysis  Open vs laparoscopic sigmoid resection (diverticular disease)  Lap cost per case - $3458 +/- 437  Open cost per case - $4321 +/- 501  Dis Colon Rectum 2002; 45:

Laparoscopic Colorectal Surgery: Getting Started Making a business case  Conor Delaney  Mark Thomas

Laparoscopic Colorectal Surgery: Getting Started Patients’ perceptions  “Patients intuitively perceive that laparoscopic procedures are more advantageous than open operations”

Laparoscopic Colorectal Surgery: Getting Started How do we change attitudes?  New techniques & equipment  Educational programs  Teaching methods  “The world of colorectal surgery must adapt”

Laparoscopic Colorectal Surgery: Getting Started Effector arms of the da Vinci surgical robot

Laparoscopic Colorectal Surgery: Getting Started Natural Orifice Transluminal Endoscopic Surgery

Laparoscopic Colorectal Surgery: Getting Started “..the end of the beginning.”

Laparoscopic Colorectal Surgery: Getting Started

Port site recurrence  1-21% incidence  3 of 14 patients  ASCRS registry 1.1%  Incidence in open wounds = 1%  Not a problem

Laparoscopic Colorectal Surgery: Getting Started Laparoscopic Colorectal Cancer Resections

Laparoscopic Colorectal Surgery: Getting Started

Who is competent?

Laparoscopic Colorectal Surgery: Getting Started  Conversion rate:  Right sided Lesions: 8%  Left Sided Lesions:15%  Independent Predictors of Conversion  BMI  ASA grade  Type of resection  Intra-abdominal abscess/fistula  Surgeon’s experience

Laparoscopic Colorectal Surgery: Getting Started  Learning Curve:  Right sided lesions:55 cases  Left sided lesions: 62 Cases

Laparoscopic Colorectal Surgery: Getting Started  Two surgeons  721 laparoscopic colorectal procedures  Learning Curve: Procedures  Operating time  Conversion rates

Laparoscopic Colorectal Surgery: Getting Started

 Risk Factors for Recurrence: Lap Repair  Inexperienced Surgeon  Surgeon’s age: > 45 years  Odds of Recurrence for older inexperienced surgeon  1.72 times that of younger inexperienced surgeon: Lap repair  Open repair: Only very inexperienced had increased recurrence rates

Laparoscopic Colorectal Surgery: Getting Started Financial Support  Stepwise increase use  Item per item basis  Submit a formal business plan  Discuss with Clinical & Business Manager  Outline case for laparoscopic surgery  Potential annual case load and expected growth with time  Cost Implications and potential cost savings  Identify standard/basic disposables set  Generic business Plan

Laparoscopic Colorectal Surgery: Getting Started Financial Support  Stepwise increase use  Item per item basis  Submit a formal business plan  Discuss with Clinical & Business Manager  Outline case for laparoscopic surgery  Potential annual case load and expected growth with time  Cost Implications and potential cost savings  Identify standard/basic disposables set  Generic business Plan