Laparoscopic Colorectal Surgery - Getting Started

Peter Sagar

Powerpoint File

The United Kingdom has fallen behind many Western nations in the development of laparoscopic colorectal surgery. There is a need for a change in attitude. Several educational programs are available and new techniques and equipment are helping to increase the uptake of laparoscopic procedures for both benign & malignant disease.

The evidence
1. Clinical effectiveness
reduced length of stay
reduced complications
less loss of blood
reduced post op pain and analgesia
quicker return to normal activities
improved cosmesis

2. Disease free survival – randomised controlled trials
UK (CLASICC 2005)
USA (COST 2004)
Hong Kong (Leung 2004)
Barcelona (Lacy 2002)

The guidelines

1. NICE:

Laparoscopic surgery is recommended as an alternative to open surgery for patients with colorectal cancer…..(if) the surgeon has been trained in laparoscopic surgery for colorectal cancer and performs the operation often enough to keep his or her skills up to date.

1. ASCRS:

Laparoscopic colectomy for curable cancer results in equivalent cancer related survival to open colectomy when performed by experienced surgeons. Based on the COST trial, prerequisite experience should include at least 20 laproscopic colorectal resections with anastomosis for benign disease or metastatic colon cancer before using the technique to treat curable cancer.

Training

1. SpR training
2. Skills centres
   1. 1 day advanced laparoscopic course that aims to provide candidates with a strategy to start laparoscopic colorectal surgery. Short lectures cover equipment requirements, theatre set up and step by step guidance on how to do it
   2. 2 day course that incorporates live surgical demonstrations of procedures such as right hemicolectomy and anterior resection.
3. Ethicon Surgical Institute – a 2 day course that involves simulators, suturing techniques and training in the wet lab
4. Masterclass – a 1 day course of advanced laparoscopic techniques. Team approach is emphasised. Lead surgeon is accompanied by theatre staff.
5. Laparoscopic colorectal fellowships – Ethicon sponsored fellowships – 6 each year of 6 months duration in St Marks, Colchester and Leeds General Infirmary. Designed for SpRs in year 5 or 6 of their training. Fellows can expect  to be able to perform laparoscopic colorectal surgery on completion of the posts. Clinical hands-on fellowships. Details & application form available at www.alsgbi.org

1. Preceptorships

a – Consultants wishing to be preceptored should have seen at least 10 live laparoscopic colorectal resections – this can be achieved by attending  recognised courses such as those run in the various Minimal Access Training Units, or by personal visits to established laparoscopic colorectal surgeons.

b – Appropriate laparoscopic equipment suitable for this sort of surgery is not always available in all hospitals.  The Theatre team (senior scrub nurse, second theatre nurse, ODA and theatre manager) undertaking this intervention need to be trained in order to support the development.

c -  The preceptor will either travel to the hospital of the consultant wishing to be preceptored or the reverse might happen depending on the preceptors’ wishes.  It is recommended that preceptorship involves 2-4 cases.

d - Those being preceptored would be responsible for auditing their own data, which must be entered in the national database (NBOCAP Database) and reviewed by the preceptored surgeons’ peers at their local hospital MDT meeting.  Data should be audited locally in line with advice from the General Medical Council regarding the introduction of new techniques.

e - After preceptorship, it is advisable that surgeons should undertake at least 20 straightforward colorectal resections before undertaking more complex procedures ie avoid BMI >30, patients who have undergone previous intra-abdominal surgery and rectal cancer surgery. The most straightforward resections are sigmoid, right colonic and left colonic resections.  Although the advice from the United States has been that surgeons should undertake at least 20 laparoscopic resections for benign disease or resections in patients with metastatic colon cancer, before treating potentially curable colonic cancer, this advice has been modified in Britain and Ireland.  It is not felt to be appropriate to restrict the first 20 resections to benign disease as often such resections can be difficult and appropriately selected procedures for malignancy are frequently the most straightforward.