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

INTRODUCTION: 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.
METHODS: 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.
RESULTS: 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.
CONCLUSION: 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.