Considerations on the learning curve for laparoscopic colorectal surgery: a view from the bottom

Those who have surmounted the learning curve for laparoscopic colorectal resection state that considerable numbers of highly selected cases should comprise a department's early experience to ensure reliability of technique before routine implementation. The objective of this study was to determine how this advice may interrupt case flow.

Details on all colorectal operations performed in a single institution over a 4-year period were gleaned from a prospectively maintained database. Patient profiles were scrutinised to identify how the application of various published exclusion criteria would impact upon the theoretical completion rates of our proposed learning curve.

In total, 317 colorectal resections were performed; 259 operations were for adenocarcinoma (including 100 rectal tumours) while 58 were for benign disease. Of those with malignancy, 25(10%) were obese, 61(24%) had previous intra-abdominal surgery, while 52(20%) were aged over 80 years and 60(23%) were ASA (3/4). Strictest exclusion criteria would halve the number of cases to be commenced laparoscopically. A specialist registrar rotating through the department would have case exposure cut from a mean of 33 to 11 in 6 months under this regimen. Prioritising benign cases in the initial experience as has been recommended by certain groups would mean that, at most, 1.2 cases would be performed every 4 weeks during the learning period.

Although our caseload seems sufficient to allow the acquisition of expertise in a timely fashion, procedural flow would be markedly interrupted by stringent pre-selection. A low threshold for initiating the procedure laparoscopically seems a pragmatic way of ensuring departmental confidence through familiarity.