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Laparoscopic colorectal surgery - getting started. Peter Sagar The General Infirmary at Leeds Leeds, UK. Uptake Of a New Surgical Procedure. Laggards. Late Majority. Early Majority. Early Adopters. Innovators. Early adopters versus the laggards. Why Not?. “It’s too hard”

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laparoscopic colorectal surgery getting started

Laparoscopic colorectal surgery- getting started

Peter Sagar

The General Infirmary at Leeds

Leeds, UK

slide2

Uptake Of a New Surgical Procedure

Laggards

Late Majority

Early Majority

Early Adopters

Innovators

why not
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”
where do we stand now10
Where do we stand now?
  • Response rate: 200/540
  • 45 surgeons performing lap colorectal surgery
  • Mainly right hemi-colectomy & stoma formation
how do i get started
How do I get started?
  • The evidence
  • The guidelines
  • Training & competency
  • Getting support
evidence to support laparoscopic colorectal surgery
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
evidence to support laparoscopic colorectal surgery16
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
evidence to support laparoscopic colorectal surgery17
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)
cost trial
COST trial
  • 872 patients
  • 428 open, 435 lap la
  • 66 surgeons at 48 institutions
  • R & L colon ca only
  • Primary end point – tumour recurrence
cost trial19
COST TRIAL
  • Recurrence at 3 years
    • 16% laparoscopic vs 18% open
  • Survival at 3 years
    • 86% laparoscopic vs 85% open
cost trial short term outcome
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)
cost trial conclusion
COST trialConclusion
  • “...the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.”
cost trial22
COST trial
  • 872 patients
  • 428 open, 435 lap la
  • 66 surgeons at 48 institutions
  • R & L colon ca only
  • Primary end point – tumour recurrence
clasicc trial
CLASICC trial
  • 794 patients
  • 526 laparoscopic, 268 open
  • 32 surgeons (83% of patients recruited from surgeons >20 patients)
  • Colon and rectal cancer
clasicc trial uniqueness
CLASICC trial- uniqueness
  • Central pathology analysis
  • Pathological endpoints
  • Inclusion of rectal cancer cases
clasicc trial primary endpoints
CLASICC trial- primary endpoints
  • CRM, longitudinal and high tie margins
  • 30-day mortality
  • Local recurrence
  • Disease-free & overall survival
clasicc trial conclusions
CLASICC trial- conclusions
  • LR as effective as OR for colon cancer
  • Pathological features after LR “do not yet justify routine use in rectal cancer”
lap colorectal surgery leads to better results than open surgery
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....
the infamous spanish trial
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
guidelines
Guidelines
  • NICE Guidelines
  • ASCRS
nice guidelines laparoscopic colorectal cancer august 2006
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
training competency36
Training & Competency
  • SpR Training
  • Skills Centres
  • Masterclasses & Symposia
  • Laparoscopic Colorectal Fellowship
  • Preceptorship
laparoscopic colorectal fellowships
Laparoscopic colorectal fellowships
  • St Marks - R Kennedy
  • Colchester - R Motson
  • Leeds - PM Sagar
ethicon laparoscopic colorectal fellow fellow logbook 5 mths
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
preceptorship
Preceptorship
  • Training consultants
  • Preceptorships - 2-4 cases
  • Consultants should have seen >10 live resections
    • Courses
    • Personal visits
preceptorships
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
so what s the problem54
So, what’s the problem?
  • Lack of Local Support
  • Lack of Cases
  • Lack of Theatre Time
  • Cost/Funding
local support
Local Support
  • Medical Director
  • Audit
  • Consultant Colleagues
  • Case volume
    • Cancer cases
  • Nursing & Anaesthetic Staff
  • Operating Time
  • Theatre Assistants
cost analysis
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
making a business case
Making a business case
  • Conor Delaney
  • Mark Thomas
patients perceptions
Patients’ perceptions
  • “Patients intuitively perceive that laparoscopic procedures are more advantageous than open operations”
how do we change attitudes
How do we change attitudes?
  • New techniques & equipment
  • Educational programs
  • Teaching methods
  • “The world of colorectal surgery must adapt”
port site recurrence
Port site recurrence
  • 1-21% incidence
  • 3 of 14 patients
  • ASCRS registry 1.1%
  • Incidence in open wounds = 1%
  • Not a problem
slide71
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
slide72
Learning Curve:
    • Right sided lesions: 55 cases
    • Left sided lesions: 62 Cases
slide73
Two surgeons
    • 721 laparoscopic colorectal procedures
  • Learning Curve: 70-80 Procedures
    • Operating time
    • Conversion rates
slide75
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
financial support
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
financial support77
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