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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” - PowerPoint PPT Presentation
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Laparoscopic colorectal surgery- getting startedPeter SagarThe General Infirmary at LeedsLeeds, UK
Laparoscopic Colorectal Surgery: Getting Started
InnovatorsEarly AdoptersEarly MajorityLate MajorityLaggardsUptake Of a New Surgical Procedure
Laparoscopic Colorectal Surgery: Getting Started
Early adopters versus the laggards
Laparoscopic Colorectal Surgery: Getting Started
Why Not?
Its too hard
It takes too long
I cant spare the time to learn
I cant train my registrars
Its 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: 200/54045 surgeons performing lap colorectal surgeryMainly right hemi-colectomy & stoma formation
Laparoscopic Colorectal Surgery: Getting Started
Where do we stand now?
Laparoscopic Colorectal Surgery: Getting Started
So, whats 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 SurgeryClinical EffectivenessShorter length of stayFewer complicationsLess blood loss & use of blood productsLess pain & analgesiaQuicker return to normal activitiesBetter cosmesisIncidence of port site metastases is 1%Equivalent to open surgery
Laparoscopic Colorectal Surgery: Getting Started
Evidence to Support Laparoscopic Colorectal SurgeryCost EffectivenessOperating costs are higherLonger operating timeCapital and recurring costs are higher
Higher costs appear to be offset byFewer complications, especially wound related problemsShorter hospital stayLess use of analgesiaLess use of blood products
Overall costs to society are comparable
Laparoscopic Colorectal Surgery: Getting Started
Evidence to Support Laparoscopic Colorectal SurgeryDisease Free Survival: Comparative Randomised StudiesBarcelona (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 la66 surgeons at 48 institutionsR & L colon ca onlyPrimary end point tumour recurrence
N Engl J Med 2004; 350: 2050-9
Laparoscopic Colorectal Surgery: Getting Started
COST TRIAL
Recurrence at 3 years16% laparoscopic vs 18% open
Survival at 3 years86% 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 trialConclusion
...the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.
N Engl J Med 2004; 350: 2050-9
Laparoscopic Colorectal Surgery: Getting Started
COST trial
872 patients 428 open, 435 lap la66 surgeons at 48 institutionsR & L colon ca onlyPrimary end point tumour recurrence
N Engl J Med 2004; 350: 2050-9
Laparoscopic Colorectal Surgery: Getting Started
CLASICC trial
794 patients526 laparoscopic, 268 open32 surgeons (83% of patients recruited from surgeons >20 patients)Colon and rectal cancer
Lancet 2005; 365:1718-1726
Laparoscopic Colorectal Surgery: Getting Started
CLASICC trial- uniqueness
Central pathology analysisPathological endpointsInclusion of rectal cancer cases
Laparoscopic Colorectal Surgery: Getting Started
CLASICC trial- primary endpoints
CRM, longitudinal and high tie margins30-day mortalityLocal recurrenceDisease-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 randomised111 lap, 108 openImproved 3 yr survival and lower rates of recurrence But....
Lacy et al Lancet 2002; 359: 2224-9
Laparoscopic Colorectal Surgery: Getting Started
The infamous Spanish trial
Morbidity; 11% LR vs 29% ORLocal complication rate; 10% LR vs 34% ORTotal complication rate; 13% LR vs 34% OR
Laparoscopic Colorectal Surgery: Getting Started
GuidelinesNICE Guidelines
ASCRS
Laparoscopic Colorectal Surgery: Getting Started
Laparoscopic Colorectal Surgery: Getting Started
NICE guidelines laparoscopic colorectal cancer - August 2006Laparoscopic 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 & CompetencySpR TrainingSkills CentresMasterclasses & SymposiaLaparoscopic Colorectal FellowshipPreceptorship
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 FellowFellow Logbook 5 MthsPROCEDUREPrimary OperatorAssistingLaparoscopy3Lap Appendicectomy14Lap Ileocaecetomy51Lap Right Hemi-Colectomy4Lap Anterior Resection131Lap (Sub)Total Colectomy6Lap Colectomy/Ileo-anal Pouch13Lap Panproctocolectomy1Lap AP Resection11Lap Sacrocolporectopexy11Lap Cholecystectomy6
TOTAL654
Laparoscopic Colorectal Surgery: Getting Started
Laparoscopic Colorectal Surgery: Getting Started
Laparoscopic Colorectal Surgery: Getting Started
Preceptorship
Training consultants
Preceptorships - 2-4 cases
Consultants should have seen >10 live resectionsCoursesPersonal 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, whats the problem?
Lack of Local Support
Lack of Cases
Lack of Theatre Time
Cost/Funding
Laparoscopic Colorectal Surgery: Getting Started
Local SupportMedical Director AuditConsultant ColleaguesCase volumeCancer casesNursing & Anaesthetic StaffOperating TimeTheatre 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 +/- 437Open 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
N Engl J Med 2004; 350: 2091
Laparoscopic Colorectal Surgery: Getting Started
How do we change attitudes?
New techniques & equipmentEducational programsTeaching 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 recurrence1-21% incidence3 of 14 patients
ASCRS registry 1.1%Incidence in open wounds = 1%
Not a problem
Laparoscopic Colorectal Surgery: Getting Started
Laparoscopic Colorectal Cancer Resections19902003
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 ConversionBMIASA gradeType of resectionIntra-abdominal abscess/fistulaSurgeons experience
Laparoscopic Colorectal Surgery: Getting Started
Learning Curve:Right sided lesions:55 casesLeft sided lesions: 62 Cases
Laparoscopic Colorectal Surgery: Getting Started
Two surgeons721 laparoscopic colorectal procedures
Learning Curve: 70-80 ProceduresOperating timeConversion rates
Laparoscopic Colorectal Surgery: Getting Started
Laparoscopic Colorectal Surgery: Getting Started
Risk Factors for Recurrence: Lap RepairInexperienced SurgeonSurgeons age: > 45 years
Odds of Recurrence for older inexperienced surgeon1.72 times that of younger inexperienced surgeon: Lap repairOpen repair: Only very inexperienced had increased recurrence rates
Laparoscopic Colorectal Surgery: Getting Started
Financial SupportStepwise increase useItem per item basis
Submit a formal business planDiscuss with Clinical & Business Manager
Outline case for laparoscopic surgeryPotential annual case load and expected growth with timeCost Implications and potential cost savingsIdentify standard/basic disposables set
Generic business Plan
Laparoscopic Colorectal Surgery: Getting Started
Financial SupportStepwise increase useItem per item basis
Submit a formal business planDiscuss with Clinical & Business Manager
Outline case for laparoscopic surgeryPotential annual case load and expected growth with timeCost Implications and potential cost savingsIdentify standard/basic disposables set
Generic business Plan