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Laparoscopic Colorectal Surgery Laparoscopic colorectal surgery getting started Peter Sagar The General

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Laparoscopic Colorectal Surgery Laparoscopic colorectal surgery getting started Peter Sagar The General Powered By Docstoc
					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


                                                                 Laggards



                                                 Late Majority




                                     Early Majority



                           Early Adopters
          Innovators
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                         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
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:       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: 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

				
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