Can community surgeons perform laparoscopic colorectal surgery with outcomes equivalent to tertiary care centers?

BACKGROUND: Laparoscopic colorectal surgery (LCS) performed in tertiary care centers has been well studied. It has been shown to provide improved short-term outcomes and comparable long-term outcomes to the conventional open approach. However, LCS performed in a community hospital setting has not been well studied. In a previous paper, we presented the short-term outcomes of 100 LCS performed by two community surgeons with no formal training in LCS. In this follow-up study, we present both short- and longer-term outcomes for 250 patients who underwent LCS. METHODS: This is a prospective study of 250 consecutive patients who underwent LCS at the North Bay District Hospital (a 200-bed community hospital located 350 km away from the nearest tertiary care center). RESULTS: Between October 2000 and October 2006, 250 consecutive patients (130 women and 120 men, mean age of 64.4 +/- 13.7 years) underwent LCS for benign (N = 129) and malignant (N = 121) disease. Median operating time was 215.0 min (58.0-475.0 min) and the conversion rate was 7.2%. The intraoperative complication rate was 2.8%. There were 20 (8.0%) major postoperative complications and 42 (16.8%) minor postoperative complications. There was no intraoperative mortality. There were six 30-day mortalities due to ischemic bowel (1), stroke (1), myocardial infarction (3), and pneumonia (1). The median length of stay was 4.0 days (2.0-55.0 days). Disease-free survival for stages I-IV colorectal cancer (CRC) was 100, 97.2, 71.4, and 10% for a mean follow-up time of 36.9, 29.3, 27.9, and 21.1 months, respectively. The mean number of resected lymph nodes was 11.5 +/- 8.6. CONCLUSION: We note that both our short and longer-term outcomes are similar to tertiary care centers. We therefore conclude that LCS can be performed in a community hospital setting with both short- and longer-term outcomes similar to tertiary care centers.

The role of telementoring and telerobotic assistance in the provision of laparoscopic colorectal surgery in rural areas.

PURPOSE: The aim of this study was to assess whether telementoring and telerobotic assistance would improve the range and quality of laparoscopic colorectal surgery being performed by community surgeons. METHODS: We present a series of 18 patients who underwent telementored or telerobotically assisted laparoscopic colorectal surgery in two community hospitals between December 2002 and December 2003. Four community surgeons with no formal advanced laparoscopic fellowship were remotely mentored and assisted by an expert surgeon from a tertiary care center. Telementoring was achieved with real-time two-way audio-video communications over bandwidths of 384 kbps-1.2 mbps and included one redo ileocolic resection, two right hemicolectomies, two sigmoid resections, three low anterior resections, one subtotal colectomy, one reversal of a Hartmann operation, and one abdominoperineal resection. A Zeus TS microjoint system (Computer Motion Inc, Santa Barbara CA) was used to provide telepresence for the telerobotically assisted laparoscopic procedures, which included three right hemicolectomies, three sigmoid resections, and one low anterior resection. RESULTS: There were no major intraoperative complications. There were two minor intraoperative complications involving serosal tears of the colon from the robotic graspers. In the telementored cases, there were two postoperative complications requiring reoperation (intra-abdominal bleeding and small bowel obstruction). Two telementored procedures were converted because of the mentee's inability to find the appropriate planes of dissection. One telerobotically assisted procedure was completed laparoscopically by the local surgeon with aid of telementoring because of inadequate robotic arm position. The median length of hospital stay for this series was 4 days. The surgeons considered telementoring useful in all cases (median score 4 out of 5). The use of remote telerobotic assistance was also considered a significant enabling tool. CONCLUSIONS: Telementoring and remote telerobotic assistance are excellent tools for supporting community surgeons and providing patients better access to advanced surgical care.