Laparoscopic colorectal surgery - getting started

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Laparoscopic colorectal surgery- getting started

• Peter Sagar
• The General Infirmary at Leeds
• Leeds, UK

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Uptake Of a New Surgical Procedure
Laggards
Late Majority
Early Majority
Early Adopters
Innovators
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Early adopters versus the laggards
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Why Not?

• Its too hard
• It takes too long
• I cant spare the time to learn
• I cant train my registrars
• Its too expensive

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Where do we stand now?
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Comparison with Australia
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Comparison with USA
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Where do we stand now?
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Where do we stand now?

• Response rate 200/540
• 45 surgeons performing lap colorectal surgery
• Mainly right hemi-colectomy stoma formation

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Where do we stand now?
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So, whats the problem?
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How do I get started?

• The evidence
• The guidelines
• Training competency
• Getting support

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Powell presents smoking gun evidence to UN
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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

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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

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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)

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COST trial

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

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COST TRIAL

• Recurrence at 3 years
• 16 laparoscopic vs 18 open
• Survival at 3 years
• 86 laparoscopic vs 85 open

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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)

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COST trialConclusion

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

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COST trial

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

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CLASICC trial

• 794 patients
• 526 laparoscopic, 268 open
• 32 surgeons (83 of patients recruited from
  surgeons gt20 patients)
• Colon and rectal cancer

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CLASICC trial- uniqueness

• Central pathology analysis
• Pathological endpoints
• Inclusion of rectal cancer cases

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CLASICC trial- primary endpoints

• CRM, longitudinal and high tie margins
• 30-day mortality
• Local recurrence
• Disease-free overall survival

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CLASICC trial- conclusions

• LR as effective as OR for colon cancer
• Pathological features after LR do not yet
  justify routine use in rectal cancer

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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....

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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

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Guidelines

• NICE Guidelines
• ASCRS

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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

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Who is competent?
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Training competency
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Training Competency

• SpR Training
• Skills Centres
• Masterclasses Symposia
• Laparoscopic Colorectal Fellowship
• Preceptorship

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SpR Training
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SpR Training
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Skills centres - LIMIT
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Ethicon Surgical Institute
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Laparoscopic colorectal fellowships

• St Marks - R Kennedy
• Colchester - R Motson
• Leeds - PM Sagar

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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

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Preceptorship

• Training consultants
• Preceptorships - 2-4 cases
• Consultants should have seen gt10 live resections
• Courses
• Personal visits

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Preceptorships

• Preceptors - gt100 cases with annual workload of
  gt25 cases
• Audit data - NBOCAP, MDT
• Video material - aide memoire
• ( US - gt20 benign cases but BEWARE)
• www.alsgbi.org

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Equipment
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Trocars
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Graspers
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Harmonic Scalpel
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Endoscopic Circular Stapler ECS29
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Linear cutter stapler
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Wound protector
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So, whats the problem?

• Lack of Local Support
• Lack of Cases
• Lack of Theatre Time
• Cost/Funding

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Local Support

• Medical Director
• Audit
• Consultant Colleagues
• Case volume
• Cancer cases
• Nursing Anaesthetic Staff
• Operating Time
• Theatre Assistants

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Convince people
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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 45 485-490

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Making a business case

• Conor Delaney
• Mark Thomas

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Patients perceptions

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

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How do we change attitudes?

• New techniques equipment
• Educational programs
• Teaching methods
• The world of colorectal surgery must adapt

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Effector arms of the da Vinci surgical robot
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Natural Orifice Transluminal Endoscopic Surgery
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..the end of the beginning.
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Port site recurrence

• 1-21 incidence
• 3 of 14 patients
• ASCRS registry 1.1
• Incidence in open wounds 1
• Not a problem

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Laparoscopic Colorectal Cancer Resections
1990
2003
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Who is competent?
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• Conversion rate
• Right sided Lesions 8
• Left Sided Lesions 15
• Independent Predictors of Conversion
• BMI
• ASA grade
• Type of resection
• Intra-abdominal abscess/fistula
• Surgeons experience

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• Learning Curve
• Right sided lesions 55 cases
• Left sided lesions 62 Cases

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• Two surgeons
• 721 laparoscopic colorectal procedures
• Learning Curve 70-80 Procedures
• Operating time
• Conversion rates

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• Risk Factors for Recurrence Lap Repair
• Inexperienced Surgeon
• Surgeons age gt 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

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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

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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