Does case selection and outcome following laparoscopic colorectal resection change after initial learning curve? Analysis of 235 consecutive elective laparoscopic colorectal resections

Abstract

INTRODUCTION:Laparoscopic colorectal surgery is being widely practiced with an excellent short-term and equal long-term results for colorectal diseases including cancer. However, it is widely believed that as the experience of the surgeon/unit improves the results get better. This study aims to assess the pattern of case selection and short-term results of laparoscopic colorectal surgery in a high volume centre in two different time frames.MATERIALS AND METHODS:This study was done from the prospective data of 265 elective laparoscopic colorectal resections performed in a single unit from December 2005 to April 2011. The group was subdivided into initial 132 patients (Group 1) from December 2005 to December 2008 and next 133 patients (Group 2) between December 2008 and April 2011 who underwent laparoscopic colorectal resections for cancer. The groups were compared for intraoperative and perioperative parameters, type of surgery, and the stage of the disease.RESULTS:The age of patients was similar in Groups 1 and 2 (57.7 and 56.9, respectively). Patients with co-morbid illness were significantly more in Group 2 than in Group 1 (63.2% vs. 32.5%, respectively, P≤0.001). There were significantly more cases of right colonic cancers in Group 1 than in Group 2 (21.9% vs. 11.3%, respectively, P<0.02) and less number of low rectal lesions (20.4% vs. 33.8%, respectively, P≤0.02). The conversion rates were 3.7% and 2.2% in Groups 1 and 2, respectively. The operating time and blood loss were significantly more in Group 1 than in Group 2. The ICU stay was significantly different in Groups 1 and 2 (31.2± 19.1 vs. 24.7± 18.7 h, P≤0.005). The time for removal of the nasogastric tube was significantly earlier (P=0.005) in Group 2 compared to Group 1 (1.37± 1.1 vs. 2.63±1.01 days). The time to pass first flatus, resumption of oral liquids, semisolid diet, and complications were similar in both groups. The hospital stay was more in Group 1 than in Group 2 ( P≤0.01). The numbers of lymph nodes retrieved was similar in both groups. The T stage of the disease in Groups 1 and 2 were similar, however, the number of T4 lesions was significantly more in Group 2 (8.3% vs. 18.7%, respectively, P<0.01).CONCLUSION:This study shows that with increasing experience, laparoscopic colorectal surgery can be practiced safely with minimal conversion rates and morbidity. As the units experience improves, there is a trend towards selecting advanced cases and performing complex laparoscopic colorectal procedures. With increasing experience, there is a trend towards better short-term outcome after laparoscopic colorectal surgeries.

Comparison of Open Colorectal Surgeries versus Laparoscopic and Lap Assisted Colorectal Surgeries for Short Term Outcomes in Colorectal Malignancy

“…Bedirli et al noted 19 lymph nodes in laparoscopic as compared to 23 lymph nodes in open surgeries (10) . The number of resected lymph nodes is seen to increase with experience of surgeon (16,17) . In our study, patients in both groups had adequate margin and nodal clearance.…”

Laparoscopic Colorectal Surgery: An Update (with Special Reference to Indian Scenario)

“…This first report from India concluded that radical surgery for rectosigmoid colorectal tumours could be performed laparoscopically in selected patients. The same team further reported their own series of 265 patients and concluded that as the unit's experience improved, there was a trend towards selecting difficult cases and performing complex laparoscopic colorectal resections [11].…”

“…Nine RCTs which were quoted by Paolo Millo et al, [9], non-randomized control trials of Palanivelu C et al, [12] which showed 7days of hospital stay and Prakash K et al, [11] who found 8.6±2.4 days of hospital stay, reported a shorter length of stay after laparoscopic resections, with one trial reporting a difference of five days in favour of the laparoscopic technique.…”

“…The short and long term results of multicentre randomized trials done, like COST [5], CLASSIC [6], COLOR [7], retrospective analysis done of 102 patients, prospective database of 265 patients (Prakash K et al,) [10,11], prospective non-randomized trial (Palanivelu C et al,) [12] and Cochrane review, Kuhry E et al, [15] did not reveal any differences in radicality of tumour resection between laparoscopic and open colorectal surgery groups.…”

In Laparoscopic Myomectomy, Does a Caseload of 100 Patients During the Learning Curve Produce a Significant Improvement in Performance Measures?

“…If this is indeed true, the development of formal patient selection criteria for use in training may aid in reducing the length of learning curve. Based on other laparoscopic procedures, it is also expected that the surgeons transition from simple cases to performing simple and technically complex cases [25]. Indicators of technical difficulty of cases such as number, size, and weight of myomas did not change between Group A and Group B, suggesting that the complexity of cases undertaken did not change over time.…”