Evaluation of the Single-Port Laparoscopic Right Hemicolectomy Learning Curve

doi:10.4236/ss.2013.410085

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Surgical Science, 2013, 4, 433-437

http://dx.doi.org/10.4236/ss.2013.410085 Published Online October 2013 (http://www.scirp.org/journal/ss)

Evaluation of the Sin gle-P ort Laparoscopic Right

Hemicolectomy Learning Curve*

Virgilio V. George#, Michael J. Guzman, Joshua A. Waters, Andrea L. Jester,

Don J. Selzer, Bruce W. Robb

Department of Surgery, Indiana University School of Medicine, Indianapolis, USA

Email: #[email protected]

Received June 17, 2013; revised July 16, 2013; accepted July 24, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: The use of single-port laparoscopy has gained po pularity within recent years. Part of the appeal in learn-

ing this approach is that it draws heavily from concepts mastered through conventional laparoscopy. Various studies

have shown the efficacy and feasibility of the single-port laparoscopic approach, but there are few that examine the

learning curve in adop ting this new technique. Objective: Our goal was to better define the learning curve in perform-

ing a single-port laparoscopic right hemicolectomy. Design: A review of prospectively gathered operative data was

performed to analyze the results of single-port laparoscopic right hemicolectomies performed within our institution by

experienced laparo scopic surgeons. The first 100 cases were divided in to quintiles. Comparisons were made among the

cohorts regarding patient demographics, operative time, length of stay, conversions, and complications. Results: There

was no difference among quintiles with regard to age, sex, BMI, or ASA class. Operative time, conversions, length of

stay, and number of complications did not significantly vary among each group of patients. There was a significant dif-

ference in estimated blood loss and length of stay between the fifth cohort and the others due to one patient’s poor out-

come. Conclusions: The single-port laparoscopic right hemicolectomy learning curve for surgeons already skilled in

laparoscopy is short. Th ere are few differences in various outcome measures among groups at any stage in the learning

curve. The skills utilized to perform conventional laparoscopic colorectal surgery readily translate to the single-port

approach and result in proficiency from nearly the start.

Keywords: Single-Port; Laparoscopy; Learning Curv e; Colectomy

1. Introduction

New surgical techniques are constantly being developed

around the world. Some interventions never gain traction,

while others become an important part of a surgeon’s

skill set. Single-port laparoscopy is one approach that has

steadily gained popularity across various surgical disci-

plines and is a frequent topic of investigation. It would

appear that single-port laparoscopy will remain a part of

surgical therapy for some time.

As the field of single-port laparoscopy grows, the

trend in publications changes with it. To date, there have

been a number of studies from the general, urologic, and

gynecologic surgery literature looking at the feasibility

and safety of the single-port laparoscopic approach to

various surgeries [1-5]. Although the technique may vary,

it would appear that nearly any surgery that can be done

laparoscopically can also be done using a single-port

approach.

Colon and rectal surgery is no stranger to this trend

and in recent years it has seen a vast increase in publica-

tions about the use of single-port laparoscopy. Our group

has published the largest series of single-port laparo-

scopic right hemicolectomies to d a te [6].

When learning any new procedure, there is a learning

curve that each person must complete in order to become

proficient. There has been some data addressing the

learning curve for single-port laparoscopic cholecystec-

tomy, gastric band placement, and nephrectomy [7-9].

However, there have been no studies looking at the

learning curve for performing any single-port laparo-

scopic colorectal surgeries. In this study, we aim to de-

fine the learning curve for single-port laparoscopic right

hemicolectomy (SPLRH).

*Selected for podium presentation at the American Society of Colon

and Rectal Surgeons annual scientific meeting San Antonio, TX June

2-6, 2012.

#Corresponding author.

V. V. GEORGE ET AL.

434

2. Materials and Methods

2.1. Patient Selection

All study participants were selected based on the guide-

lines and regulations set by the Indiana University

School of Medicine Institutiona l Review Board.

This series represents a retrospective analysis of pro-

spectively gathered data from a consecutive series of

patients undergoing planned SPLRH in a single colorec-

tal surgery group between January 2008 and November

2010. The primary inclu sion criterion was planned sing le

port laparoscopic approach in the setting of a right

hemicolectomy. Patients were included in this series re-

gardless of operative indication, urgency of operation, or

ultimate approach (i.e. co nv ersion to open ) . Patients were

then divided into quintiles of twenty consecutive cases

for the purpose of statistical analysis.

2.2. Measurements and Endpoints Assessed

The data collected and analyzed in this series fall into

three groups: patient demographics, operative measure-

ments, and short term outcomes. Patient specific data

included: gender, age, body mass index (BMI), and

American Society of Anesthesiology (ASA) classifica-

tion as a surrogate of patient comorbidity. The operative

measurements used in our study were: operative time,

conversions to either multi-port laparoscopy or open

surgery, and the estimated blood loss (EBL). Short term

outcome measurements were total length of stay (LOS)

and number of complications. The different complica-

tions measured within our study included superficial

wound infection, abdominal abscess, anastomotic leak,

renal failure defined by increase in creatininegreater than

or equal to 1 mg/dL above baseline, post-o perative ileus,

post-operative bleeding (regardless of intervention), and

30 day mortality.

2.3. Operative Technique

The operative technique used by the surgeons within our

institution h as prev iously b een describ ed by W aters et al.

[6,10]. Briefly, a vertical incision was made in the fascia

large enough to accommodate the single-port trocar. A

standard 5-mm 30˚ laparoscope was then inserted (or

rarely a 10-mm laparoscope), followed by 25-mm work-

ing ports with non-articulating instruments. The ileocolic

pedicle was then elevated in order to dissect the colon off

its retroperitoneal attachments and duodenum in a medial

to lateral fashion. Once this was complete, the ileocolic

vessels were divided using an energy device. The hepatic

flexure and the lateral attachments were then tak en down

from superior to inferior. Fascial incisions were enlarged

as necessary to exteriorize the specimen for division and

anastomosis. After inspecting the anastomosis intracor-

poreally, the fascia was closed in either a running or fig-

ure-of-eight fas hi on.

2.4. Data Analysis and Presentation

All data was compiled, analyzed, and formatted into fig-

ures using GraphPad Prism (La Jolla, CA). Continuous

variables were compared using one-way analysis of vari-

ance (ANOVA). This data was described using means

with ranges where appropriate. Categorical data was

compared using a Chi-square test and presented as pro-

portions or number of instances where appropriate. Prob-

ability values less than or equal to 0.05 were considered

statistically significant. Data tables were made using Mi-

crosoft Word 2010 (Redmond, WA).

3. Results

During our study period, a total of 100 patients under-

went SPLRH by our group of surgeons. The patient

demographics for all patients included in our study are

outlined in Table 1. As outlined in the table, there was

no statistical difference between quintiles with reg ards to

patient gender, age, ASA classification, or BMI. When

considering the entire study population, 61% were male,

the mean age was 64 years, the mean ASA class was 3,

and mean BMI was 28.

Operative measurements are described in Table 2.

Operative times are reported as mean time in minutes

with range, and mean time of operation throughout the

study period was 114 minutes with a range from 64 - 270

minutes. Conversion to either multi-port laparoscopy or

open was made at the discretion of each surgeon. Indica-

tions for conversion varied from failure to progress, dis-

covery of more invasive cancer than anticipated pre-

operatively, and inability to control bleeding. Estimated

blood loss is displayed in more detail in Figure 1. The

fifth quintile had a significantly higher mean blood loss

(228 mL) compared to the other groups. This quintile

contained one patient who was a particularly high outlier

in operative measures and short term outcomes.

Short term outcomes are displayed in Table 3. The

mean LOS for the entire population was 5.6 days with a

Table 1. Patient demographics.

Patient

group % maleAge (mean

years,

range)

ASA class

(mean,

range)

BMI (mean,

range)

1 - 20 55 65 (39 - 90) 3 (1 - 3) 28 (20 - 39)

21 - 40 65 65 (25 - 85) 3 (2 - 4) 27 (21 - 46)

41 - 60 55 67 (26 - 86) 3 (2 - 4) 26 (18 - 36)

61 - 80 70 64 (30 - 85) 3 (2 - 4) 29 (19 - 41)

81 - 10065 56 (28 - 83) 3 (2 - 4) 30 (18 - 43)

V. V. GEORGE ET AL. 435

Table 2. Operative measures.

Patient

group Mean operative

time (min) Operative time

ranges (min) Conversions

1 - 20 109 71 - 212 1 open

21 - 40 119 83 - 194 2 lap, 1 open

41 - 60 108 64 - 177 1 open

61 - 80 112 67 - 190 0

81 - 100 127 86 - 270 1 open

Table 3. Short term outcomes.

Patient

group Mean length of

stay (days) Length of stay

range (days) Complications

(#)

1 - 20 6 2 - 24 4

21 - 40 4 2 - 11 3

41 - 60 5 2 - 10 1

61 - 80 5 2 - 26 3

81 - 100 7* 2 - 48 2

*p < 0.05.

Figure 1. Estimated blood loss (mean ± range) by 20 patient

cohorts. *Significantly different from other groups (p <

0.05).

range from 2 - 48 days. Here again, the high outlier in the

fifth quintile made it significantly different from the

other groups. This patient had the longest stay out of the

entire population and eventually died due to multi-system

organ failure. When comparing the number of complica-

tions between each quintile, there was no difference be-

tween groups and overall rate of morbidity was 13%.

4. Discussion

Single-port laparoscopy is becoming a popular option in

the field of colorectal surgery. However, because it is a

relatively new approach many surgeons do not have any

formal training in performing these operations. Those

who are taking it upon themselves to learn th is new tech-

nique do not yet know the number of cases it takes to

become proficient in safely performing a SPLRH, and

our study sought to evaluate the learning curve for this

operation. We have found that the learning curve is quite

short and almost non-existent fo r those already skilled in

conventional laparoscopic surgery and more specifically,

right hemicolectomy.

When examining the patients included in this study it

is important to note that our population is a fairly accu-

rate representation of a typical surgeon’s patient mix, as

we did not select out patients that are particularly slender,

young, or healthy. In fact, the average patient who un-

derwent SPLRH in our series was overweight (mean

BMI 28), older (mean age 64), and with significant co-

morbid conditions (mean ASA 3). This makes our results

easier to reproduce by the average colorectal surgeon in

practice.

Our group has been slowly expanding inclusion crite-

ria for those who are offered a SPLRH as experience

grows and currently any patient who would be an appro-

priate candidate for conventional laparoscopy is also

considered appropriate for the single-port approach, and

they are offered that option as well. It is likely that as th e

general public becomes more aware of single-port

laparoscopy the demand for it will increase based on its

potential benefits whether perceived or truly present.

With respect to operative times, we did not find any

significant change in the duration of operation between

quintiles. These times are also similar to those for per-

forming a conventional laparoscopic right hemicolec-

tomy. While this could mean that we have not yet started

the drastic improvement phase of the typical learning

curve, we think that is unlikely. All surgeons within our

group have significant experience with conventional

laparoscopy from formal fellowship training and years of

practice as attending surg eons. While it is possible that at

some point SPLRH could be performed faster than con-

ventional laparoscopy, our operative times are already

similar to other groups with right hemicolectomy [11]. It

is likely that the skills already estab lished with multi-port

laparoscopic right hemicolectomy readily translate the

single-port approach. This may be due in part to our use

of standard laparoscopic instruments and cameras, which

eliminates the learning of new specialized and more

complicated instrumentation.

Conversions from the single-port approach to either a

multi-port approach or open technique did not change

significantly throughout our study period. Interestingly,

the only two conversions to conventional laparoscopy

took place within the second quintile by a single surgeon

who did so because of failure to progress within the op-

eration from difficult dissection. The conversions to open

surgery were done because of difficult dissection, where

it was believed that additional trocars would not signifi-

cantly improve the chance of completing the operation

laparoscopically and in the final instance, significant

V. V. GEORGE ET AL.

436

bleeding was encountered that required direct visualiza-

tion for control. However, our overall conversion rate

was in line with other reported experiences [11]. Addi-

tionally, we believe that conversion of the procedure

from a single-port approach should not be deemed a fail-

ure as much as it represents better judgment on the part

of the surgeon to change direction when the individual

scenario requires it.

Measurement of blood loss during an operation can be

interpreted in various ways. A large amount of blood loss

to one surgeon may mean that the surgery was particu-

larly difficult and that it may be expected that the patient

has a higher risk of having a post-operative complication,

but another surgeon may see that same blood loss and

interpret it as poor performance of the operating surgeon .

With that in mind, there was no diff erence in mean blood

loss across the quintiles until the final group. As previ-

ously mentioned, this was due to on e particular patien t in

that group who had a significant blood loss due to injury

to the middle colic vein. Interestingly, as the series went

on, there was an increase in the range of blood loss.

Our short term outcomes with regard to length of stay

and peri-operative morbidity did not change through the

progression of cases. Rather, both remained consistent

with other reported series of both single-port and multi-

port laparoscopic colectomies [10,12-14]. This suggests

that the key to determining patient recovery may not lie

within the approach between single or multi-port laparo-

scopy, and instead hinders on the nature of the operation

itself and/or inherent patient factors. Importantly, the use

of the single-port approach did not negatively impact the

rates of post-operative morbidity.

When examining the data presented here, it is impor-

tant to take into account a few limitations of this study.

These cases were performed by multiple surgeons in a

group. However, one surgeon either performed or as-

sisted in the majority of the cases ex amined in this series,

and all of our surgeons have similar training, experience

with colorectal surgery, and method to performing a

SPLRH, reducing the inter-surgeon variability. We did

look at the data from a single surgeon’s perspective but

did not find significant difference between his and the

rest of the group’s measures. Another limitation is that

the role of residents and fellows cannot be quantified

within the data. However, as would be expected, there is

a graded role of involvement over time with experience

by both the trainee and staff surgeon.

The introduction of new surgical techniques requires

completing a number of procedures before becoming

proficient. With the increasing presence of single-port

laparoscopy within surgical practice, it is important to

understand how long it takes a surgeon to become facile

with this evolving approach. Prior studies have already

examined the learning curve for various single-port

laparoscopic operations [7-9], and have concluded that

the learning curve is fairly short for those already ex-

perienced in their field. However, this is the first report

examining the learning curve with regards to colorectal

surgery. Whether this approach will become a part of an

average colorectal surgeon’s practice has yet to be de-

termined, and further investigations to understand its

potential long term benefits an d hazards are needed.

5. Conclusion

The learning curve for SPLRH is short for colorectal

surgeons who already experienced with conventional lap-

aroscopic operations. Surgeons who desire to start offer-

ing their patients a single-port approach to right hemi-

colectomy can do so without significant increase in op-

erative time, length of stay, or per-operative morbidity.

Surgeons will need to become facile with SPLRH to keep

up with patients’ increasing awareness and desire for this

approach.

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