Robotic colorectal surgery

Incorporating a Detailed Case Log System to Standardize Robotic Colon and Rectal Surgery Resident Training and Performance Evaluation

OBJECTIVE

This study was designed to evaluate a novel case log used as part of a standardized robotic colon and rectal surgery resident training program.

DESIGN

This observational study describes a detailed procedure log developed to standardize training of residents in robotic colorectal surgery. The procedure log tracks resident total case numbers and execution of specific steps of eleven colorectal procedures. Case log data were accumulated and analyzed to assess resident progress.

SETTING/PARTICIPANTS

The study includes colon and rectal surgery residents during the 2016-2017 academic year. The national Colon and Rectal Surgery Robotic Training Program was developed and implemented during the 2010-2011 academic year in response to increasing adoption of robotic-assisted colorectal surgery. This program evolved to include online modules, dry lab exercises, simulation and cadaveric courses.

RESULTS

Forty of 93 residents in 54 colon and rectal surgery programs participated in the case log system and the comprehensive training program. Residents participated as console surgeon in an average of 28 cases (range 1-115). Sixty-five percent of participating residents performed ≥20 complex colorectal cases as console surgeon. Of the 1080 operations entered, the three most frequently performed procedures were low anterior resections (n = 360, 33.3%), sigmoid resections (n = 172, 15.9%), and right colectomies with intracorporeal anastomosis (n = 138, 12.8%). Residents with 10 or more robotic cases had a 27% increase in cases as console surgeon and a 28% decrease in cases completed as bedside assistant. Experience and progression to the console varied by resident and by program.

CONCLUSION

This detailed standardized case log system provides comprehensive assessment of resident experience that allows preparation for a robotic colon and rectal surgery practice after fellowship. As adoption of the robotic approach for colon and rectal cases continues to increase, novel methods that evaluate teaching methods and resident progress warrant further study.

Is right colectomy a complete learning procedure for a robotic surgical program?

This study analyses the utility of right colectomy as a learning procedure at the beginning of a robotic surgical program. The hypothesis is that right colectomy contains all the technical steps necessary to acquire basic abilities in robotics surgery. The first 23 consecutive robotic right colectomy performed at the beginning of a robotic program were analysed. All surgical times were recorded in the operating room and second checked on a dedicated video-database. Specific robotic times were analysed using CUSUM method to evaluate the learning curve. CUSUM-derived learning phases were compared. Fourteen males and nine females with a mean age of 68.7 (46-84) underwent robotic right colectomy. The mean overall time was 265.3 min (180-320 min), docking time was 7 min (5-12 min), console time was 205.9 min (145-260 min), and anastomotic time was 43.6 (25-60 min). CUSUM analyses identified two learning phases: "starting phase" and "consolidation phase". Interphase comparison confirmed the significant (p < 0.05) differences between the two phases. Robotic technology facilitates the training process in minimally invasive colorectal surgery. At the beginning of the learning curve, right colectomy could represent a complete procedure to be proficient in robotic colorectal surgery.

Recent surgical advances in colorectal cancer excision: toward optimal outcomes

Colorectal cancer is the third most common cancer affecting both males and females in the western world. Despite all the developments in the current treatment of colorectal cancer, it is still continuing to be an important factor of patient morbidity and mortality worldwide. Surgery is the mainstay of treatment for colorectal cancer. Over the last decade, there have been major changes and developments in the surgical treatment. Understanding the importance of the anatomy, technological advances in minimally invasive surgery and effects of chemoradiotherapy have changed the approaches to colorectal cancer treatment. Today, novel treatment strategies must be targeted not only minimally invasive approaches, but also aiming to increase patients’ quality of life without compromising the oncological principles.

Developing a robotic colorectal cancer surgery program: understanding institutional and individual learning curves

IMPORTANCE

Robotic colorectal resection continues to gain in popularity. However, limited data are available regarding how surgeons gain competency and institutions develop programs.

OBJECTIVE

To determine the number of cases required for establishing a robotic colorectal cancer surgery program.

DESIGN

Retrospective review.

SETTING

Cancer center.

PATIENTS

We reviewed 418 robotic-assisted resections for colorectal adenocarcinoma from January 1, 2009, to December 31, 2014, by surgeons at a single institution. The individual surgeon's and institutional learning curve were examined. The earliest adopter, Surgeon 1, had the highest volume. Surgeons 2-4 were later adopters. Surgeon 5 joined the group with robotic experience.

INTERVENTIONS

A cumulative summation technique (CUSUM) was used to construct learning curves and define the number of cases required for the initial learning phase. Perioperative variables were analyzed across learning phases.

MAIN OUTCOME MEASURE

Case numbers for each stage of the learning curve.

RESULTS

The earliest adopter, Surgeon 1, performed 203 cases. CUSUM analysis of surgeons' experience defined three learning phases, the first requiring 74 cases. Later adopters required 23-30 cases for their initial learning phase. For Surgeon 1, operative time decreased from 250 to 213.6 min from phase 1-3 (P = 0.008), with no significant changes in intraoperative complication or leak rate. For Surgeons 2-4, operative time decreased from 418 to 361.9 min across the two phases (P = 0.004). Their intraoperative complication rate decreased from 7.8 to 0 % (P = 0.03); the leak rate was not significantly different (9.1 vs. 1.5 %, P = 0.07), though it may be underpowered given the small number of events.

CONCLUSIONS

Our data suggest that establishing a robotic colorectal cancer surgery program requires approximately 75 cases. Once a program is well established, the learning curve is shorter and surgeons require fewer cases (25-30) to reach proficiency. These data suggest that the institutional learning curve extends beyond a single surgeon's learning experience.

Colorectal cancer: all hands on deck

The past 50 years has seen substantial progress in our understanding of and in the management of colorectal cancer (CRC). Surveillance colonoscopy with resection of premalignant polyps has led to a decreased incidence of CRC even though compliance with the recommendations is suboptimal. Epidemiologic and genetic information allow us to identify individuals at risk for cancer and should allow us to prevent the disease in many individuals. Patients diagnosed with metastatic CRC live much longer than in the past, and some with metastatic disease are cured. This is attributed to many factors, including cross-sectional imaging that identifies metastases earlier, new surgical and radiation techniques, and numerous new chemotherapies. Higher resolution imaging modalities have improved the ability to find limited and resectable metastatic disease; surgical advances include laparoscopic-assisted procedures and safer and more extensive hepatic resection; and radiation techniques allow for higher dose and less morbidity. Biologic therapies have not yet been maximized, but we are learning when and where some should be used. Soon we expect to be staging patients by biologic and genetic characteristics rather than by gross pathology-treating patients based on biologic features but preferably identifying people at risk and preventing CRC altogether.

Surgical stress response after colorectal resection: a comparison of robotic, laparoscopic, and open surgery

BACKGROUND

The perioperative immune status of colorectal robotic surgery (RS), laparoscopic surgery (LS), and open surgery (OS) patients has not been compared. Our aim was to evaluate perioperative stress and immune response after RS, LS and OS.

METHODS

This prospective study included 46 colorectal surgery patients from the Department of Surgical Oncology of the University of Tokyo Hospital. Peripheral venous blood samples were obtained preoperatively and on postoperative days 1, 3, and 6. We evaluated expression of HLA-DR (marker of immune competence), C-reactive protein (CRP) levels, and lymphocyte subset counts (natural killers, cytotoxic T cells and helper T cells).

RESULTS

Fifteen, 23, and 8 patients underwent RS, LS and OS, respectively. HLA-DR expression was the lowest on day 1 and gradually increased on days 3 and 6 in all the groups. There was no significant difference in postoperative HLA-DR expression between the RS and LS group. However, on day 3, HLA-DR expression in the RS group was significantly higher than in the OS group (p = 0.04). On day 1, CRP levels in the LS group were significantly lower than in the RS group (p = 0.038). There were no significant perioperative changes in the lymphocyte subset cell count between the three groups.

CONCLUSIONS

Perioperative surgical stress, as evaluated by immunological parameters, was comparable between robotic and laparoscopic surgery and higher with open surgery. Robotic surgery may be an alternative to laparoscopic surgery, as a minimally invasive surgery option for colorectal cancer.

Outcomes in non-metastatic colorectal cancer

The measurement of outcomes in non-metastatic colon and rectal cancer patients is a multi-dimensional endeavor involving prediction tools, standard of care, and best treatment guidelines. Socioeconomic, demographic, and racial impacts on outcome must be carefully considered. Consideration must also be given to measures of cost, quality, and healthcare delivery in response to initiatives meant to optimize patient health while maintaining quality of life.