Laparoscopic colorectal surgery in learning curve: Role of implementation of a standardized technique and recovery protocol. A cohort study

Abstract

BackgroundDespite the proven benefits, laparoscopic colorectal surgery is still under utilized among surgeons. A steep learning is one of the causes of its limited adoption. Aim of the study is to determine the feasibility and morbidity rate after laparoscopic colorectal surgery in a single institution, “learning curve” experience, implementing a well standardized operative technique and recovery protocol.MethodsThe first 50 patients treated laparoscopically were included. All the procedures were performed by a trainee surgeon, supervised by a consultant surgeon, according to the principle of complete mesocolic excision with central vascular ligation or TME. Patients underwent a fast track recovery programme. Recovery parameters, short-term outcomes, morbidity and mortality have been assessed.ResultsType of resections: 20 left side resections, 8 right side resections, 14 low anterior resection/TME, 5 total colectomy and IRA, 3 total panproctocolectomy and pouch. Mean operative time: 227 min; mean number of lymph-nodes: 18.7. Conversion rate: 8%. Mean time to flatus: 1.3 days; Mean time to solid stool: 2.3 days. Mean length of hospital stay: 7.2 days. Overall morbidity: 24%; major morbidity (Dindo–Clavien III): 4%. No anastomotic leak, no mortality, no 30-days readmission.ConclusionProper laparoscopic colorectal surgery is safe and leads to excellent results in terms of recovery and short term outcomes, even in a learning curve setting. Key factors for better outcomes and shortening the learning curve seem to be the adoption of a standardized technique and training model along with the strict supervision of an expert colorectal surgeon.

Pressurized IntraPeritoneal Aerosol Chemotherapy – Practical aspects

“…Standardization has been shown in various fields to decrease learning curve and to improve performance. 17,18 In analogy to aviation, a strict safety protocol was developed by the German pioneer group. 1 Safety checklists have been shown to decrease avoidable errors.…”

Quantitative Assessment of Visceral Obesity and Postoperative Colon Cancer Outcomes

“…The observed poor outcomes among viscerally obese patients may in part, be attributable to the technical challenges arising from excess intraabdominal fat encountered during operation 16, 23 . Of note, in this study, surgical approach (open vs. laparoscopic) was not a predictor of increased complications among visceral obesity groups whether categorized by BMI, V/S or VFA as compared to non-obese counterparts (Supplemental Table 2).…”

“…The Clavien-Dindo scale includes: Grade 1 (deviation from normal postoperative course without the need for pharmacological, surgical endoscopic or radiological interventions), Grade II (requiring pharmacological, blood transfusion and total parenteral nutrition), Grade III (requiring surgical, endoscopic or radiological intervention) and Grade IV (life threatening complications requiring intensive care unit management) and Grade V (death of a patient). Patients who had at least one complication were included and those who had more than one complication were classified using the highest grade of reported complication 22, 23 .…”

Short-Term Postoperative Outcome of Laparoscopic Total Mesorectal Excision in Rectal Carcinoma

“…The mean operating time was 224 minutes in our study, which is acceptable but slightly more than other studies showing results of laparoscopic TME. 10 Per operative bleeding in APR group was more due to perineal dissection, which remains same in open surgery. So no additional bleeding was encountered due to adopting laparoscopic technique.…”