Laparoscopic appendicectomy: a training model for laparoscopic right hemicolectomy
Objective. Analyse the outcome of laparoscopic appendicectomy (LA) and right hemicolectomy (LRHC) and see if the surgical approach to the former can be applied to right hemicolectomy.
Methods. A prospective electronic laparoscopic database identified 330 appendicectomies and 78 right hemicolectomies (using this approach) between 1996 and 2005.
Results. 330 patients (188 males: median age 38yrs, range17-74yrs) underwent LA. 270 (82%) were performed by trainees (higher surgical trainee 71%, basic surgical trainee 12%). The median operative time for trainees was 35 minutes (14-75min) with a conversion rate 2%. There were no intra-operative complications. The post-operative complication rate excluding minor wound infection (5.5%) was 1.5%. There were no deaths. The median hospital stay was 2 days (1-15 days). The 30-day readmission rate was 1%. 78 patients (23–93years) underwent LRHC during 2004/5; trainees performed parts there of in the majority or all of the surgery in 25 cases. The median operation time was 55 minutes: trainees 115 (65-145 minutes). There was one conversion. The median hospital stay was 4 days (2-23 days) falling to 3 for the last 20 operations (1-8 days). There were two re-admissions for wound sepsis and small bowel obstruction and 3 deaths (3.8%): anastomotic leak (1), C difficile infection leading to renal failure (1), duodenal perforation (1).
Conclusion. Laparoscopic appendicectomy is a safe, predictable, easily learnt operation and an ideal model for learning the skills and principles required for more advanced laparoscopic colorectal interventions and in particular, right hemicolectomy.
Keywords. Laparoscopic appendicectomy, right hemicolectomy, training
The uptake of laparoscopic colorectal surgery has been lamentably slow in the UK with only 45 surgeons offering the technique in selected individuals1; 22% of these surgeons received no formal training and 60% perform fewer than 10 procedures per annum. Whilst there are many reasons, an important consideration is that unlike cholecystectomy for upper GI trainees, there isn’t as yet a routinely used high volume training operation for colorectal consultants and trainees to develop the necessary skill mix to perform these operations safely and with a measure of predictably.
The Associations of Laparoscopic and Colorectal Surgeons of GB and Ireland advocates2 a preceptorship programme for training established colorectal surgeons. This comprises observation of ten resections, either through attending a recognised course or personalised visits to an established surgeon with an experience of more than 100 cases. The ‘trainee’ is then preceptored in their own hospital through 2-4 cases. The consensus working party suggest that these surgeons then undertake 20 straightforward resections before contemplating more complex interventions. Colectomy however, is widely acknowledged as having the longest laparoscopic learning curve3. American surgeons have, based upon the COST trial, been advised to only attempt laparoscopic resection in curative colonic cancer after they have performed 20 successful resections for benign or metastatic disease4.
Appendicectomy has for a long time been regarded the traditional training model for open gastrointestinal surgery. Whilst the published evidence comparing laparoscopic and open appendicectomy is contradictory, our unit’s early experience5 has shown the technique to be safe, be associated with low morbidity and more importantly take no longer than an open procedure. Once the surgeon is competent in the technique, we believe that right hemicolectomy, the traditional training model for resectional colorectal surgery, is its logical extension.
We have audited our combined experience of appendicectomy and right hemicolectomy where we have utilised a very similar operative approach to see if the former has any role in teaching/learning advanced laparoscopic colorectal surgery.
A prospective electronic database of all patients who underwent laparoscopic surgery at our institution between 1996 and 2004 was analysed to study the efficacy of laparoscopic appendicectomy and its usefulness for training. We also analysed our two-year experience of right hemicolectomy using similar port site placement.
Surgery is performed in a supine position with the bladder drained by ‘in out’ catheterisation. The surgeon and cameraman stand on the patients left. All trainees are taught to obtain a pneumoperitoneum under direct vision. A 30-degree laparoscope is introduced through the 12mm umbilical port; 5mm ports are inserted 1-2cm above each pubic tubercle, the right for appendix manipulation and the left for tissue dissection. Abdominal viscera and small bowel are examined and any free pus aspirated. Appendicectomy begins with diathermy coagulation and dissection of the mesoappendix as near to the appendix as possible and continued to its base. Retrocaecal appendices require mobilisation of the caecum using medial retraction and lateral division of the peritoneum. Mobilised appendices are divided between endo-loop ligatures. A 5mm laparoscope allows the appendix to be extracted through the umbilical port. Perforated appendices are removed utilising retrieval bags.
We now utilise the same patient position and port placements for right hemicolectomy; a 12mm left sided supra-pubic port is used for Hem-o-Lock (Pilling Weck, High Wycombe, UK) clip ligation prior to division of the ileocolic and right colic vessels. The supra-pubic ports are placed in more cranial positions when operating on patients with larger/longer abdomens. In general, we advocate a medial to lateral dissection approach using the Harmonic Scalpel (Ethicon Endosurgery) with early and high division of the ileo-colic vessels. This approach is particularly useful when confronted with short thickened or obese mesentry. However, when dealing with larger tumours’or where the tumour is tethered to the abdominal wall we start laterally. We have also employed this approach to good effect in patients’ with either small volume peritoneal cavities, lots of small bowel, distended or obstructed small bowel where it can be difficult to display the ileocolic vessels. Mobilised specimens are removed through an appropriately sized umbilical incision (usually 3-4cms). We also use the umbilical port for performing intra-operative liver ultrasound. All ports are irrigated with aqueous Iodine.
330 patients (188 males: median age 38yrs, range17-74yrs) underwent laparoscopic appendicectomy. 270 (82%) were performed by trainees (higher surgical trainee 71%, basic surgical trainee 12%). The median operating time was 35 minutes (range 14-75min) with an open conversion rate of 2%. There were no intra-operative complications. Negative findings were seen in 15%; normal appendices were not removed. The post-operative complication rate excluding minor wound infections (5.5%) was 1.5%. The most major complication, a secondary bleed from the appendicular artery required a laparotomy and a peritoneal lavage at 7 days for sepsis: the patient had undergone a laparoscopic lavage three days earlier. The median hospital stay was 2 days (range 1-15 days). There were four re-admissions within 30-days: retro-peritoneal haematoma, temperature, small bowel obstruction (2) – all settled with conservative therapy.
78 patients (23 – 93years), BMI range 21-45 underwent right hemicolectomy utilising the above port placement during the last two-year period of the study; trainees performed parts of in the majority, or all of the surgery in 25 cases. The median operation time was 55 minutes rising to 85 minutes for trainees (65-125 mins). The median hospital stay was 4 days (2-23 days). This has fallen to 3 days for the last 20 operations (1-8 days). There was one early conversion for a fixed Crohn’s mass of the ascending colon and two re-admissions within 30 days; wound infection and a small bowel adhesive obstruction (post Crohn’s resection) at one week. This patient developed an anastomotic leak on day 17 and required a laparotomy and end ileostomy with mucus fistula. There was one serious intra-operative complication directly attributable to the technique, a duodenal perforation. Although recognised and repaired the patient went on to develope peritonitis and multiorgan failure 36hrs later. An additional pin-point duodenal perforation was, with some difficulty eventualy identified at laparotomy. Two octogenarians died from none reversible acute renal failure secondary to clostridium difficille colitis and an anastomotic leak. The latter patient refused intervention. A diabetic was re-admitted 7 weeks later with fulminate urinary tract sepsis and died; postmortem examination was normal.
Laparoscopic resection of colorectal cancer is safe and feasible and improves short-term outcomes,6. Long term survival will determine its eventual role. Unfortunately there are limited training opportunities for UK surgeons to acquire the necessary skills. We believe that if we are to rectify the situation we need to urgently address the question of laparoscopic training in general for colorectal trainees. Most SpRs in colorectal surgery will at best have only spent one year in upper GI training and at maximum performed only 60 cholecystectomies. There is as yet no mention of laparoscopic skills in published training programmes. We believe that the humble appendicectomy may be the way forward.
Unlike cholecystectomy, many surgeons continue to have doubts about the merits of laparoscopic appendicectomy arguing that it is an easy open operation and can be performed by junior surgeons. Laparoscopic surgery they argue takes longer toperform, requires more experienced staff, equipment and is more expensive. We have shown that laparoscopic appendicectomy is a safe, predictable, effective operation that can be easily learnt by trainee surgeons of all grades and is now accepted as the norm in our institution. We consider it to be the perfect model for teaching equipment set-up, trouble shooting, hand-eye co-ordination, manual dexterity and safe laparoscopy. The operative technique described makes laparoscopic right hemicolectomy a natural progression.
The first component of safe laparoscopy is abdominal access using open cannulation. This is particularly useful when patients have undergone previous intra-abdominal procedures. It is also surprisingly quick. Trainees then go to learn how to avoid, recognise and manage complications and more importantly, how to conduct a systematic laparoscopy for acute abdominal pain. It is always necessary to place at least one additional trocar to manipulate, palpate and move viscera. Where this is placed depends on the pathology encountered. All ports need to be placed ergometricaly to allow easy movement of the instrumentation and prevent fencing. Laparoscopic appendicectomy is probably the first time that trainees will have undertaken multi-quadrant operating.
Although a 0-degree laparoscope can be used a 30O scope allows more flexibility in obtaining complete views of all structures. Like everything else in surgery it takes time to master and to correctly interpret the image. The two-dimensional flat video display also makes it difficult to judge depth. The visual field is smaller and the necessity to work with screen images demands a lot of mental skill. Once a trocar is inserted, it serves as a fulcrum and steadying point where a small movement at the proximal end produces a large movement distally. The normal axis is also inverted, in that to go left the trocar must be moved right and to go down it must be moved up; to turn it in circles one goes in the usual direction, but the instrument is 180 degrees from where one might suppose. The surgeon is thus effectively operating in a mirror! This shift is a critical one and requires lot and lots of training and practice. In simple terms the surgeon needs to retrain their brain so that all movements become instinctive. Whilst a few fortunate individuals are naturals, with proper training and supervision most surgeons are able to adapt.
Appendicectomy also allows the trainee to learn and master the skills of intra-corporeal and extra-corporeal knot tying, the application of pre-tied suture loops, safe bowel manipulation, division and ligation of a mesentry and retrieval of a potentially infected specimen. As right colon mobilisation is integral retro-caecal appendicectomy we believe right hemicolectomy to be the natural progression of this operation. Trainees also need to be taught to avoid, recognise and manage potential complications ie. bowel trauma and bleeding from the mesoappendix, omental vessels or retro-peritoneum. Suction, adequate lighting and pressure all aid in identifying the bleeding site but this needs to be learnt. Occasionally, an additional trocar may be needed to allow retraction or grasping of a bleeding vessel. Our experience suggests that it is seldom necessary to convert to an open procedure.
The method we have adopted for right hemicolectomy is a direct follow-on from appendicectomy and is far simpler than other published approaches. It is also reproducible, easily taught and learnt. Our current SpRs and laparoscopic fellows become comfortable after around 10 appendicectomies and quickly adapt to undertaking the more advanced resection. The hardest part is the controlled specimen removal through a small incision.
The UK preceptorship programme has been driven by the paucity of hands on training for established consultants who wish to take up the technique. Although we accept that preceptorship is an improvement on the current void it cannot be compared to what can be achieved through a traditional surgical apprenticeship spread over a six-month period. The senior author has successfully preceptored two individuals, both of whom were able to quickly transfer their laparoscopic skills sharpened through learning and offering routine laparoscopic appendicectomy and inguinal herniorraphy to the more advanced colonic resection. Conversely, we have also been able to guide established consultants without much in the way of laparoscopic skills through straightforward colonic resections. These surgeons have then found their skills and abilities to concentrate and make decisions lacking when attempting independent procedures.
Clinical governance would dictate that if we have learnt anything form what happened with the introduction of cholecystectomy, caution needs to exercised in advocating laproscopic colorectal resection by surgeons who do not have the neccessary skill mix, cognitive and manual dexterity. We believe that a graduated step-wise approach from cholecystectomy through to appendicectomy then right hemicolectomy is the logical and safe way forward. The biggest issue is of course training the existing consultant body. We would suggest that if they really wanted to learn laparoscopic colectomy then they would see sense in our argument and make it work for themselves ie make themselves available and find either an upper GI colleague or a capable SpR to teach them.
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