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Standardization of laparoscopic total mesorectal excision for rectal cancer: a structured international expert
Danilo Miskovic1, Jake Foster, Ayman Agha
1*John Goligher Department of Colorectal Surgery, St. James's University Hospital, Leeds, United Kingdom †Department of Surgery and Cancer, Imperial College London, United Kingdom ‡Department of Surgery, University Medical Centre of Regensburg, Regensburg, Germany §Division of Colorectal Surgery, Case Western Reserve University, Cleveland, Ohio ¶Department of Surgery, Yeovil District Hospital, Yeovil, United Kingdom ‖Department of Surgery, Keio University, Tokyo, Japan **N. N. Petrov Institute of Oncology, Saint Petersburg, Russia ††Department of Surgery, Korea University, Seoul, Korea ‡‡Department of Surgery, The University of Hong Kong, Hong Kong §§Division of Colorectal Surgery, Lankenau Medical Center, Wynnewood, PA ¶¶Department of Surgical Science, University of Torino, Torino, Italy ‖‖Colorectal Department, Beaujon Hospital, Assistance Publique-Hôpitaux de Paris and University Paris VII, France ***Colorectal Surgery Department, British Hospital of Buenos Aires, Buenos Aires, Argentina ††† Department of Colorectal Surgery, Digestive Disease Center, Cleveland Clinic Florida, Weston ‡‡‡Minimally Invasive Colorectal Unit, The Queen Alexandra Hospital, Portsmouth, United Kingdom.
Objective:
To establish a structured international expert consensus on a detailed technical description of the laparoscopic total mesorectal excision (TME).
Background:
Laparoscopic TME is a common surgical approach for the treatment of rectal cancer, but there is little agreement on technical details and standards.
Methods:
Sixty leading surgical experts from 5 different world regions with a median overall experience of 250 laparoscopic TME participated in this study. Four stages of mixed quantitative and qualitative consensus-finding methods were applied. (1) Semistructured expert interviews were independently analyzed by 2 assessors. (2) Consensus on the interview data was reached using reiterating questionnaires (Delphi method). (3) This was further refined in an interactive workshop. (4) Based on this meeting, a comprehensive text was drafted and final approval was sought by all experts.
Findings:
Three theme categories were identified in 9 detailed interviews (anatomical landmarks, description of tissue retraction, and operating strategies). Following 2 rounds of a 54-item questionnaire, 29 items achieved very high agreement (A* ≥90%), 14 with good agreement (≥80%), 13 with moderate agreement (≥50%), and 18 with little or no agreement (<50%). In the workshop, areas of agreement were consolidated and conclusions were sought for those with less agreement. The final document was approved after 2 further rounds of surveys by all respondents.
Conclusions:
This detailed and agreed technical description of laparoscopic TME may have implications on training, assessment, quality control, and future research.
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