A1 *I 1- I_-I _ _ _1_ _bq 1'g~ ~ ~ ~ ~ IJA.W _
I
-
I
I
_ I I _l _
~~~~~~~~1il ___
Colectomy-The Innovation Continues
Laparoscopic
T
HIS MONTH'S EDITION of the Annals ofSurgery
highlights an article demonstrating the safety and efficacy of laparoscopic colectomy. Colon resection continues to be a very common operation in this country, with more than 200,000 done per year. Colon resection along with hernia repair and hysterectomy are the logical operations that will be pursued laparoscopically because they represent the majority of common surgical procedures done in this country. This editorial discusses laparoscopic colectomy, specifically with reference to safety, efficacy, laparoscopic education, and the role of university medical centers. Phillips et al. present 51 selected patients operated over an 18-month period with an average age of 65. They operated on patients with colon cancer, diverticulitis, polyps, Crohn's, and volvulus, initially selecting low-risk patients during their early experience. Several technical aspects appear to be important in this new surgical procedure, including localizing the lesion endoscopically and leaving the scope in during the operative procedure to check the anastomosis. The ureters are visualized, and the transilluminated blood supply to the colon is controlled with a combination of staples, clips, and sutures. The authors were able to remove the specimen by enlarging the umbilical incision, transanally, or by making a separate incision (laparoscopic facilitated or assisted). Anastomoses were either done transanally with a circular stapler, handsewn, with intracorporeal stapling, or laparoscopic assisted. This latter technique of exteriorizing the anastomosis and then completing it on the outside and then dropping it back in through a small incision is most useful for lesions above the peritoneal reflection. The results show conversion to open colectomy in four of 51 cases and facilitated operations in seven of 51. They required 1 unit of blood transfused and averaged 14 lymph nodes per specimen. The average operative time was 2.3 hours, and flatus was passed on the first postoperative day in 49 of 51 patients. Average time to discharge in those operated on electively was 3.9 days. Although no exact data are given, the authors suggest that the patients return to work in approximately 7 days. The total complication rate was 8%, with one death in a patient with pneumonia.
The authors have discussed each issue likely to draw criticism. The length of operation has been worrisome in prior reports, but their average operating time of 2.3 hours is encouraging and will likely decrease as operators gain experience, just as we saw with laparoscopic cholecystectomy. Critics worry that adequate node evaluation cannot be made laparoscopically, but this paper documents an average node harvest of 14 during these resections, with a range of eight to 22. The complication rate seems to be appropriately low and certainly consistent with prior experience with open colectomies. Again, it should be noted that these are selected patients and the complication rate may increase as the cases become more complex. With 49 of 51 patients passing flatus by postoperative day 1, it is easy to understand why patients are discharged so quickly from the hospital. Although some surgeons argue that patients with conventional colon resections can be fed on the first or second postoperative day, this is certainly not the national experience. Most recent series of open colon resections continue to report hospitalization of 6 to 8 days. There is no documentation that patients can return to work in 7 to 10 days after laparoscopic colectomy, but it does not require a "leap of faith" to imagine that most patients will return to work far sooner than they would have with open colon resections. The current controversial issue concerning colon resection may not be its efficacy but its safety and our ability to again teach an entire nation of general surgeons a new operation. As demonstrated by our experience with laparoscopic cholecystectomy, the learning curve is real. Bile duct injuries tend to occur on the first several laparoscopic cholecystectomies that any given surgeon does, and it likely will be true that ureter injuries and colon leaks after laparoscopic colectomy will occur during a surgeon's early experience. Our patients and state legislatures will undoubtedly be asking how we can avoid some of the calamity that is likely to occur with the early laparoscopic colon experience. This is clearly a pressing issue because laparoscopic colectomy is technically more difficult than laparoscopic cholecystectomy. Potentially lethal complications such as anastomotic leak, abscess, fistula, intraoperative bleeding, ureter injury, and inadequate cancer
701
702
PAPPAS
operations will be carefully followed as we proceed with this new operation. Although states such as New York are starting legislation to regulate the teaching and educational process for laparoscopic cholecystectomy, they do not adequately address issues for new operations. The logical questions are: (1) do appropriate guidelines for training and practice currently exist for new operations? and (2) what is the role of the academic departments of surgery in providing education to community-based surgeons? Currently, guidelines for training and standards of practice and granting of privileges have been completely outlined by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the other surgical societies. Surgical Residents that are completing their training after 1991 are required to have experience in laparoscopic surgery during their residency and should be credentialed to perform laparoscopic operations. Individual operations may be begun by these surgeons in practice as they have always done with open procedures, at their discretion. The issue of training surgeons that have already completed their residency program is more difficult. SAGES defines the criteria for being credentialed in laparoscopic surgery as requiring (1) completion of a General Surgery Training Program; (2) demonstrated proficiency in laparoscopic surgery procedures and appropriate clinical judgment, which has been documented and demonstrated; (3) credentialing in diagnostic laparoscopy; (4) training by a surgeon experienced in laparoscopic surgery or completion of a university-sponsored or academic societysponsored course that should include clinical and handson experience; and (5) observation of laparoscopic surgical procedures by an experienced surgeon. Completion of a course must include written documentation of the experience obtained either by observing or hands-on laboratory work. SAGES specifically comments on new procedures, noting that a background in laparoscopic surgery is required before proceeding with new innovative procedures, and it behooves the laparoscopic surgeon to recognize when additional training is necessary. SAGES suggests proctoring as an excellent way to document a surgeon's experience. Academic departments of surgery should lead the way in the educational process of retraining America's general
Ann. Surg. * December 1992
surgeons. In the past, universities have offered CME credits for didactic courses and obviously have continued to train residents in clinical training. Unfortunately, prior university-sponsored courses have had little hands-on training and little technique-oriented teaching. University departments of surgery have just begun to enter this new role of teaching technical aspects of surgery to the community. This is a logical extension of the university efforts because it relies on the university's expertise in didactic teaching, facilities for animal work, and experienced surgical educators, all of which can be incorporated into existing systems of continuing medical education. Courses sponsored by the university departments of surgery have a theoretical advantage over non-university-based courses based on their long experience of educating surgical residents. In principal, a university-based laparoscopic educational center should offer frequent courses with easy access for community surgeons. They should be inexpensive and offer didactic elements, hands-on teaching in animal laboratories, plus clinical experience watching laparoscopic surgery on patients. These can be incorporated into existing continuing medical education systems at universities. The courses can and should be sponsored by private industry. This implies the development of a new relationship between industry and university-based academic surgery. This new relationship must maintain academic and educational freedom, and guarantees of that freedom must be clearly defined in any written agreement between academia and industry. In summary, laparoscopic colectomy is progress through a series of technical advances that will continue to appear in the laparoscopic literature and carry general surgery into the next century. It behooves all of us in academic surgery to begin formalized educational processes, not only for our residents but for our colleagues in private practice to officially establish technical laparoscopic surgical education at university medical centers, thereby answering critics who are worried about the continuing innovation that is laparoscopic surgery.
THEODORE N. PAPPAS, M.D. Durham, North Carolina
I
-
I
I
_ I I _l _
~~~~~~~~1il ___
Colectomy-The Innovation Continues
Laparoscopic
T
HIS MONTH'S EDITION of the Annals ofSurgery
highlights an article demonstrating the safety and efficacy of laparoscopic colectomy. Colon resection continues to be a very common operation in this country, with more than 200,000 done per year. Colon resection along with hernia repair and hysterectomy are the logical operations that will be pursued laparoscopically because they represent the majority of common surgical procedures done in this country. This editorial discusses laparoscopic colectomy, specifically with reference to safety, efficacy, laparoscopic education, and the role of university medical centers. Phillips et al. present 51 selected patients operated over an 18-month period with an average age of 65. They operated on patients with colon cancer, diverticulitis, polyps, Crohn's, and volvulus, initially selecting low-risk patients during their early experience. Several technical aspects appear to be important in this new surgical procedure, including localizing the lesion endoscopically and leaving the scope in during the operative procedure to check the anastomosis. The ureters are visualized, and the transilluminated blood supply to the colon is controlled with a combination of staples, clips, and sutures. The authors were able to remove the specimen by enlarging the umbilical incision, transanally, or by making a separate incision (laparoscopic facilitated or assisted). Anastomoses were either done transanally with a circular stapler, handsewn, with intracorporeal stapling, or laparoscopic assisted. This latter technique of exteriorizing the anastomosis and then completing it on the outside and then dropping it back in through a small incision is most useful for lesions above the peritoneal reflection. The results show conversion to open colectomy in four of 51 cases and facilitated operations in seven of 51. They required 1 unit of blood transfused and averaged 14 lymph nodes per specimen. The average operative time was 2.3 hours, and flatus was passed on the first postoperative day in 49 of 51 patients. Average time to discharge in those operated on electively was 3.9 days. Although no exact data are given, the authors suggest that the patients return to work in approximately 7 days. The total complication rate was 8%, with one death in a patient with pneumonia.
The authors have discussed each issue likely to draw criticism. The length of operation has been worrisome in prior reports, but their average operating time of 2.3 hours is encouraging and will likely decrease as operators gain experience, just as we saw with laparoscopic cholecystectomy. Critics worry that adequate node evaluation cannot be made laparoscopically, but this paper documents an average node harvest of 14 during these resections, with a range of eight to 22. The complication rate seems to be appropriately low and certainly consistent with prior experience with open colectomies. Again, it should be noted that these are selected patients and the complication rate may increase as the cases become more complex. With 49 of 51 patients passing flatus by postoperative day 1, it is easy to understand why patients are discharged so quickly from the hospital. Although some surgeons argue that patients with conventional colon resections can be fed on the first or second postoperative day, this is certainly not the national experience. Most recent series of open colon resections continue to report hospitalization of 6 to 8 days. There is no documentation that patients can return to work in 7 to 10 days after laparoscopic colectomy, but it does not require a "leap of faith" to imagine that most patients will return to work far sooner than they would have with open colon resections. The current controversial issue concerning colon resection may not be its efficacy but its safety and our ability to again teach an entire nation of general surgeons a new operation. As demonstrated by our experience with laparoscopic cholecystectomy, the learning curve is real. Bile duct injuries tend to occur on the first several laparoscopic cholecystectomies that any given surgeon does, and it likely will be true that ureter injuries and colon leaks after laparoscopic colectomy will occur during a surgeon's early experience. Our patients and state legislatures will undoubtedly be asking how we can avoid some of the calamity that is likely to occur with the early laparoscopic colon experience. This is clearly a pressing issue because laparoscopic colectomy is technically more difficult than laparoscopic cholecystectomy. Potentially lethal complications such as anastomotic leak, abscess, fistula, intraoperative bleeding, ureter injury, and inadequate cancer
701
702
PAPPAS
operations will be carefully followed as we proceed with this new operation. Although states such as New York are starting legislation to regulate the teaching and educational process for laparoscopic cholecystectomy, they do not adequately address issues for new operations. The logical questions are: (1) do appropriate guidelines for training and practice currently exist for new operations? and (2) what is the role of the academic departments of surgery in providing education to community-based surgeons? Currently, guidelines for training and standards of practice and granting of privileges have been completely outlined by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the other surgical societies. Surgical Residents that are completing their training after 1991 are required to have experience in laparoscopic surgery during their residency and should be credentialed to perform laparoscopic operations. Individual operations may be begun by these surgeons in practice as they have always done with open procedures, at their discretion. The issue of training surgeons that have already completed their residency program is more difficult. SAGES defines the criteria for being credentialed in laparoscopic surgery as requiring (1) completion of a General Surgery Training Program; (2) demonstrated proficiency in laparoscopic surgery procedures and appropriate clinical judgment, which has been documented and demonstrated; (3) credentialing in diagnostic laparoscopy; (4) training by a surgeon experienced in laparoscopic surgery or completion of a university-sponsored or academic societysponsored course that should include clinical and handson experience; and (5) observation of laparoscopic surgical procedures by an experienced surgeon. Completion of a course must include written documentation of the experience obtained either by observing or hands-on laboratory work. SAGES specifically comments on new procedures, noting that a background in laparoscopic surgery is required before proceeding with new innovative procedures, and it behooves the laparoscopic surgeon to recognize when additional training is necessary. SAGES suggests proctoring as an excellent way to document a surgeon's experience. Academic departments of surgery should lead the way in the educational process of retraining America's general
Ann. Surg. * December 1992
surgeons. In the past, universities have offered CME credits for didactic courses and obviously have continued to train residents in clinical training. Unfortunately, prior university-sponsored courses have had little hands-on training and little technique-oriented teaching. University departments of surgery have just begun to enter this new role of teaching technical aspects of surgery to the community. This is a logical extension of the university efforts because it relies on the university's expertise in didactic teaching, facilities for animal work, and experienced surgical educators, all of which can be incorporated into existing systems of continuing medical education. Courses sponsored by the university departments of surgery have a theoretical advantage over non-university-based courses based on their long experience of educating surgical residents. In principal, a university-based laparoscopic educational center should offer frequent courses with easy access for community surgeons. They should be inexpensive and offer didactic elements, hands-on teaching in animal laboratories, plus clinical experience watching laparoscopic surgery on patients. These can be incorporated into existing continuing medical education systems at universities. The courses can and should be sponsored by private industry. This implies the development of a new relationship between industry and university-based academic surgery. This new relationship must maintain academic and educational freedom, and guarantees of that freedom must be clearly defined in any written agreement between academia and industry. In summary, laparoscopic colectomy is progress through a series of technical advances that will continue to appear in the laparoscopic literature and carry general surgery into the next century. It behooves all of us in academic surgery to begin formalized educational processes, not only for our residents but for our colleagues in private practice to officially establish technical laparoscopic surgical education at university medical centers, thereby answering critics who are worried about the continuing innovation that is laparoscopic surgery.
THEODORE N. PAPPAS, M.D. Durham, North Carolina
