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

Laparoscopic Colorectal Surgery: Getting Started

Uptake Of a New Surgical Procedure

Innovators Late Majority Early Majority Early Adopters Laggards

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

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

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

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

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

           

PROCEDURE Laparoscopy Lap Appendicectomy Lap Ileocaecetomy Lap Right Hemi-Colectomy Lap Anterior Resection Lap (Sub)Total Colectomy Lap Colectomy/Ileo-anal Pouch Lap Panproctocolectomy Lap AP Resection Lap Sacrocolporectopexy Lap Cholecystectomy Primary Operator 3 1 1 6 14 5 4 13 6 13 1



TOTAL 65 Assisting 1 1 1 1 4

Laparoscopic Colorectal Surgery: Getting Started

Laparoscopic Colorectal Surgery: Getting Started Preceptorship  Training consultants  Preceptorships - 2-4 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…)  www.alsgbi.org

Laparoscopic Colorectal Surgery: Getting Started

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: 485-490

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

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

1990 2003

Laparoscopic Colorectal Surgery: Getting Started

Laparoscopic Colorectal Surgery: Getting Started

Laparoscopic Colorectal Surgery: Getting Started

Laparoscopic Colorectal Surgery: Getting Started Who is competent?

Laparoscopic Colorectal Surgery: Getting Started  Conversion rate:  Right sided Lesions:  Left Sided Lesions: 8% 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: Left sided lesions: 55 cases 62 Cases

Laparoscopic Colorectal Surgery: Getting Started  Two surgeons  721 laparoscopic colorectal procedures  Learning Curve: 70-80 Procedures   Operating time Conversion rates

Laparoscopic Colorectal Surgery: Getting Started

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