Multidimensional Analysis of the Learning Curve of Laparoscopic Colorectal Surgery in a Regional Hospital. The Implementation of a Standardised Surgical Procedure Counterbalances the Lack of Experience.

Abstract

Background: Although in the last few years a larger proportion of colorectal surgeries have been performed laparoscopically, a steep learning curve prevents us from considering laparoscopic colorectal surgery as the gold standard technique for treating disease entities in the colon and rectum. The purpose of this single center study is to determine, using various parameters and following a well structured and standardised surgical procedure, the adequate number of cases after which a single surgeon qualified in open surgery but with no previous experience of laparoscopic colorectal surgery and without supervision, can acquire proficiency in this technique.Methods: From 2012 to 2019, 112 patients with pathology in the rectum and colon underwent a laparoscopic colorectal resection by a team led by the same surgeon. The patients were divided into two groups (Group A:50 – Group B:62) and their case records and histopathology reports were examined for predefined parameters, statistically analyzed and compared between groups.Results: There was no significant difference between groups in the distribution of conversions (p=0.635) and complications (p=0.637). Patients in both groups were operated for the same median number of lymph nodes (p=0.145) and stayed the same number of days in hospital (p=0.109). A statistically important difference was found in operation duration both in total (p=0.006) and for each different type of colectomy (sigmoidectomy: p=0.026, right colectomy: p=0.013, Extralevator abdominoperineal resection: p=0.050, low anterior resection: p=0.083).Conclusions: Taking into consideration all the parameters, it is our belief that a surgeon acquires proficiency in laparoscopic colorectal surgery after performing at least 50 diverse cases with a well structured and standardised surgical procedure.

A reliable framework for laparoscopic colorectal surgery based on well-structured and standardized surgical and post-operative protocols

“…In this study, a reduction in operative times was observed for both the specialized and non-specialized surgeons, being proportional to the number of operations performed by each of them. The operative time decreases with the surgeon's increasing experience, and it is a useful criterion for evaluating the learning curve [24]. At the same time, the specialized surgeon proved to have a greater reduction in operative times compared to the non-specialized surgeons.…”

“…At the same time, the specialized surgeon proved to have a greater reduction in operative times compared to the non-specialized surgeons. It has been previously showed that the surgeon's expertise is reversible proportional to the operative time indicating the point where the learning curve is completed by reaching a steady level of performance [24,38,39].…”

“…The surgical procedures were performed by a team of surgeons supervised by a specialized surgeon (M.C.) who has completed the learning curve in laparoscopic colorectal surgery [24]. A well-structured and standardized surgical procedure was implemented in all instances, strictly following oncological criteria, according to the principles of complete mesocolic excision (CME) and total mesorectal excision (TME) with central vascular ligation (CVL) [25][26][27].…”