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09-01-2012 | Surgery | Article

Colorectal resection HALS proficiency reached after 100 cases


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MedWire News: A surgeon may perform over 100 colorectal resections before they become proficient at hand-assisted laparoscopic surgery (HALS), suggest research published in the Archives of Surgery.

"This… depicts the experience of the surgeons who adopted HALS as the primary modality of minimally invasive surgery after fellowship," say Robert Cima (Mayo Clinic, Rochester, Minnesota, USA) and co-authors.

They say their findings suggest that proficiency takes significantly longer to achieve than technical competency, which is believed to occur after fewer procedures.

The study followed-up two surgeons and used Change-Point Analysis to determine the number of cases before the surgeons progressed from being in the "learning" period to the "skilled" period.

Over 6 years, surgeons A and B performed 397 and 322 HALS colorectal resections, respectively, with the change point occurring after 108 and 105 cases, respectively.

Analysis showed that patients operated on before and after the surgeons progressed to the skilled period did not differ in terms of age, gender, body mass index, history of abdominal surgery, comorbidity, or American Society of Anesthesiologists class.

The mean operative time fell significantly from 263 minutes during the learning period to 185 minutes in the skilled period. The operative time fell significantly for both surgeons and for select procedures, specifically sigmoid colectomy (63 minutes), anterior resection (70 minutes), subtotal colectomy (75 minutes), and total proctocolectomy with ileal reservoir (80 minutes).

There was no significant difference in rates of intraoperative complications or conversion to open surgery during the learning and skilled periods.

However, patients operated on during the learning period showed significantly higher morbidity (33.8 vs 24.9%) than patients operated on during the skilled phase, and experienced a significantly higher risk for infectious complications (12.7 vs 6.9%) and readmission (10.3 vs 5.5%). Length of hospital stay also fell significantly, from 7.0 to 6.4 days.

"The current recommendation for graduates in colon and rectal surgery is 75 complex laparoscopic procedures (including general surgery and colon and rectal surgery training)," write Cima et al.

"Our data suggest, however, that for colorectal surgeons going into practice after their fellowship, additional cases will be required until proficiency and optimal outcomes are attained."

MedWire ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2012

By Lynda Williams

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