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Dr. William Kelley, Jr.
Colectomy Editor's Commentary
Richmond Surgical Group
Tuckahoe Medical Center
Richmond, Virginia
This issue of Laparoscopy in Focus addresses one of the more controversial areas of minimally invasive surgery. During their early experiences with laparoscopic colon resection, many surgeons became frustrated and reverted to the open technique, citing excessive operative time, excessive cost, and uncertain patient benefits as criticisms of laparoscopic colon resection for benign disease. The learning curve for laparoscopic colon surgery is extremely operator-dependent and quite steep. This was especially true when most surgeons began their early attempts at colon resection, with only cholecystectomy, appendectomy and a few hernia cases as their background experience. While some deliberate and persistent surgeons reported conversion rates below 10%, many others converted 30%-70% of their initial cases.
The surgeons interviewed in this issue have pointed out that continued experience eventually brings operative times and the global costs down to levels that are competitive with those for open surgery performed for benign indications. Adequate laparoscopic cancer operations require considerably more experience, however, and are much more tedious than traditional colorectal cancer surgery. An experienced surgeon performing laparoscopic antireflux surgery can expect to require 8-10 operations before colon surgery becomes routine, 20-25 procedures before the operative time becomes reasonable, and 30-40 cases before the times approach those for open surgery. As times improve and the surgeon becomes more efficient with instrument utilization and develops packaged kits for disposable instruments, the costs approach-and sometimes fall below-those for traditional open surgery. Cancer operations also become routine for the committed laparoscopic surgeon, but most surgeons will admit that the operative times are longer for those procedures in unselected patients.
The most important reservations about laparoscopic colorectal surgery are now being addressed in an organized fashion by registries, such as the ASCRS registry, and by randomized trials such as those being conducted by Dr. Zucker and the NCI. Preliminary results have suggested that patient recuperation is enhanced by the laparoscopic technique and that laparoscopic colon surgery is safe in experienced hands. The question of laparoscopic surgery for colorectal cancer is still debated, and the results from randomized series will not be available for at least another 5 years. At this point in time, surgeons should be circumspect about curative laparoscopic colorectal surgery. Patients must be adequately informed about the concerns and controversies in this area. As this issue has emphasized, it is very important for responsible surgeons to share their experiences, and surgeons who are performing curative minimally invasive surgery for colorectal cancer are strongly advised to participate in organized registries and trials. Nowhere in laparoscopic surgery is the training, experience and judgment of the individual surgeon more important than in colorectal surgery. Training and animal models are stressed by Dr. Whelan, and surgeon experience and the learning curve have been stressed by all interviewees. In addition, preceptorship and proctoring of early cases should be emphasized.
There are now many surgeons experienced in laparoscopic colorectal surgery in most areas of the country. The surgeon beginning his or her experience with minimally invasive colorectal surgery is strongly advised, in the best interests of the patient, to obtain an experienced proctor for his or her early cases.
