Zusammenfassung
Die laparoskopische kolorektale Chirurgie hat sich seit der Erstbeschreibung 1990
zunehmend verbreitet. Im Gegensatz zu einer Vielzahl von Untersuchungen zur Lernkurve
in der laparoskopischen Kolonchirurgie fehlen derartige Arbeiten zur laparoskopischen
Rektumchirurgie nahezu vollständig. In der vorliegenden Arbeit wird die Lernkurve
eines Chirurgen in der laparoskopischen Rektumchirurgie aufgezeigt. Basierend auf
den Daten einer prospektiven Beobachtungsstudie von 180 Patienten, kann festgestellt
werden, dass von einem in der offenen kolorektalen Chirurgie erfahrenen Operateur,
mit Anfangserfahrung in der laparoskopischen Chirurgie und nach entsprechender
Vorbereitung und gleichzeitigem Interesse an der minimalinvasiven Chirurgie ca.
35 laparoskopische Rektumresektionen und 200 laparoskopische Kolonresektionen notwendig
sind, bis Selektionsrate, Operationszeit, allgemeine und chirurgische Komplikationen
ein Plateau erreicht haben. Eine der operativen Erfahrung angepasste Selektion ist
Voraussetzung für eine niedrige Konversions- und Komplikationsrate sowie mit der offenen
Chirurgie vergleichbaren onkologischen Langzeitergebnissen. Die Lernkurve ist allerdings
von sehr vielen Faktoren abhängig, die wir teilweise gar nicht kennen. Sie ist sicherlich
interindividuell unterschiedlich lang. Jeder Chirurg sollte kritisch seine laparoskopische
Erfahrung beurteilen und dementsprechend selektieren. Eine Supervision durch in
der laparoskopischen kolorektalen Chirurgie erfahrene Operateure verhindert die mit
der Lernkurve verbundenen Nachteile für den Patienten. Die Ausbildung in der laparoskopischen
kolorektalen Chirurgie sollte nur in Zentren mit der entsprechenden Fallzahl und Kontinuität der
Ausbilder erfolgen. Die Bemühungen der CAMIC in der Etablierung von Referenz- und
Kompetenzzentren sind daher nur zu unterstützen.
Abstract
Laparoscopic colorectal surgery has become increasingly more common since first being
described in a publication in 1990. Despite a multitude of studies about the learning
curve in laparoscopic colon surgery, there are almost no such studies with regard
to laparoscopic rectum surgery. This paper aims to describe a surgeon's learning curve
with regard to laparoscopic rectum surgery. Based on data collected in a prospective
observational study of 180 patients, it can be established that a surgeon experienced
in open colorectal surgery, with basic experience in laparoscopic surgery, after suitable
preparation and having a personal interest in minimally invasive surgery, needs to
perform about 35 laparoscopic rectum resections within 200 laparoscopic colon resections
until selection rate, operating time and rates of general and surgical complications
reach a plateau. A selection of cases suited to a surgeon's personal level of operating
experience, is a prerequisite for a low rate of conversions and complications and
for oncological long-term results comparable to those achieved through open surgery.
However, the learning curve is dependent on a multitude of factors that are partly
unknown at this point. Its duration most certainly varies between individual surgeons.
Every surgeon is required to critically evaluate his or her own laparoscopic experience
and select cases accordingly. Supervision by surgeons more experienced in laparoscopic
colorectal surgery prevents disadvantages for patients in the early phases of the
surgeon's learning curve. Training in laparoscopic colorectal surgery should take
place only in institutions with a sufficient number of cases treated and a continuity
in experienced teachers. CAMIC's efforts in establishing centres of competence and
reference are therefore to be commended and supported.
Schlüsselwörter
laparoskopische Rektumchirurgie - Lernkurve - Team
Key words
laparoscopic rectum surgery - learning curve - team
Literatur
- 1
Braga M, Vignali A, Zuliani W et al.
Laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome.
Ann Surg.
2002;
236
759-766
- 2
Clinical Outcomes of Surgical Therapy Study Group .
A comparison of laparoscopically assisted and open colectomy for colon cancer.
N Engl J Med.
2004;
350
2050-2059
- 3
Guillou P J, Quirke P, Thorpe H et al.
Short term endpoints of conventional versus laparoscopic assisted surgery in patients
with colorectal cancer. (MRC CLASSIC trial): multicentre, randomised controlled trial.
Lancet.
2005;
365
1718-1726
- 4
Lacy A M, Garcia-Valdecasas J C, Delgado S et al.
Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic
colon cancer: a randomised trial.
Lancet.
2002;
359
2224-2229
- 5
Leung K L, Kwok S P, Lam S C et al.
Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial.
Lancet.
2004;
363
1187-1192
- 6
Veldkamp R, Kuhry E, Hop W C et al.
Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of
a randomized trial.
Lancet Oncol.
2005;
6
477-484
- 7
Veldkamp R, Kuhry E, Hop W C et al.
Colon cancer Laparoscopic or Open Resection Study Group (COLOR) Laparoscopic surgery
versus open surgery for colon cancer: short-term outcomes of a randomised trial.
Lancet Oncol.
2005;
6
477-484
- 8
Köckerling F, Reymond M A, Schneider C et al.
Prospective multicenter study of the quality of oncologic resections in patients undergoing
laparoscopic colorectal surgery for cancer.
Dis Colon Rectum.
1998;
41
963-970
- 9
Marusch F, Gastinger I, Schneider C et al.
Experience as a factor influencing the indications for laparoscopic colorectal surgery
and the results.
Surg Endosc.
2001;
15
116-120
- 10
Larach S W, Patankar S K, Ferrara A et al.
Complications of laparoscopic colorectal surgery: analysis and comparison of early
vs. later experience.
Dis Colon Rectum.
1997;
40
592-596
- 11
Bärlehner E, Benhidjeb T, Anders S et al.
Laparoscopic resection for rectal cancer: outcomes in 194 patients and review of the
literature.
Surg Endosc.
2005;
19
757-766
- 12
Dulucq J L, Wintringer P, Stabilini C et al.
Laparoscopic rectal resection with anal sphincter preservation for rectal cancer:
long-term outcome.
Surg Endosc.
2005;
19
1468-1474
- 13
Ito M, Sugito M, Kobayashi A et al.
Influence of learning curve on short-term results after laparoscopic resection for
rectal cancer.
Surg Endosc.
2009;
23
403-408
- 14
Kim S H, Park I J, Joh Y G et al.
Laparoscopic resection for rectal cancer: a prospective analysis of thirty-month follow-up
outcomes in 312 patients.
Surg Endosc.
2006;
20
1197-2002
- 15
Pugliese R, Di Lemia S, Sansonna F et al.
Results of laparoscopic anterior resection for rectal adenocarcinoma: retrospective
analysis of 157 patients.
Am J Surg.
2008;
195
233-238
- 16
Schlachta C M, Mamazza J, Seshadri P A et al.
Defining a learning curve for laparoscopic colorectal resections.
Dis Colon Rectum.
2001;
44
217-222
- 17
Agachan F, Joo J S, Sher M et al.
Laparoscopic colorectal surgery. Do we get faster?.
Surg Endosc.
1997;
11
331-335
- 18
Agachan F, Joo J S, Weiss E G et al.
Intraoperative laparoscopic complications: are we getting better?.
Dis Colon Rectum.
1996;
39
14-19
- 19
Chen W, Sailhamer E, Berger D L et al.
Operative time is a poor surrogate for the learning curve in laparoscopic colorectal
surgery.
Surg Endosc.
2007;
21
238-243
- 20
Darzi A, Smith S, Taffinder N et al.
Assessing operative skill. Needs to become more objective.
BMJ.
1999;
318
887-888
- 21
Dincler S, Koller M T, Steurer J et al.
Multidimensional analysis of learning curves in laparoscopic sigmoid resection: eight-year
results.
Dis Colon Rectum.
2003;
46
1371-1378
- 22
Park I J, Choi G S, Lim K H et al.
Multidimensional analysis of the learning curve for laparoscopic colorectal surgery:
lessons from 1 000 cases of laparoscopic colorectal surgery.
Surg Endosc.
2009;
23
839-846
- 23
Senagore A J, Luchtefeld M A, Mackeigan J M.
What is the learning curve for laparoscopic colectomy?.
Am Surg.
1995;
61
681-685
- 24
Simons A J, Anthone G J, Ortega A E et al.
Laparoscopic-assisted colectomy learning curve.
Dis Colon Rectum.
1995;
38
600-603
- 25
Staudacher C, Di Palo S, Tamburini A et al.
Total mesorectal excision (TME) with laparoscopic approach: 226 consecutive cases.
Surg Oncol.
2007;
16 (Suppl 1)
113-116
- 26
Tekkis P P, Senagore A J, Delaney C P et al.
Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of
right-sided and left-sided resections.
Ann Surg.
2005;
242
83-91
- 27
Voitk A J, Tsao S G, ignatius S.
The tail of the learning curve for laparoscopic cholecystectomy.
Am Surg.
2001;
182
250-253
- 28
Wishner J D, Baker Jr J W, Hoffman G C et al.
Laparoscopic-assisted colectomy. The learning curve.
Surg Endosc.
1995;
9
1179-1183
- 29
Menke H, Klein A, Böttger T et al.
Pulmonale Komplikationen nach abdominellen Operationen, Identifikation verschiedener
Risikofaktoren.
Chirurg.
1992;
6
54-58
- 30
Marusch F, Gastinger I, Schneider C et al.
Importance of conversion for results obtained with laparoscopic colorectal surgery.
Dis Colon Rectum.
2001;
44
207-214
- 31
Morino M, Parini U, Giraudo G et al.
Laparoscopic total mesorectal excision: a consecutive series of 100 patients.
Ann Surg.
2003;
237
335-342
- 32
Bennett C L, Stryker S J, Ferreira M R et al.
The learning curve for laparoscopic colorectal surgery. Preliminary results from a
prospective analysis of 1 194 laparoscopic-assisted colectomies.
Arch Surg.
1997;
132
41-44
- 33
Buchanan G N, Malik A, Parvaiz A et al.
Laparoscopic resection for colorectal cancer.
Br J Surg.
2008;
95
893-902
- 34
Böttger T, Terzic A, Müller M.
Die laparoskopische Pankreaslinksresektion.
Zentralbl Chir.
2006;
131
1-6
- 35
Böttger T, Terzic A, Müller M.
Die laparoskopische Semifundoplikatio nach Dor zur Behandlung der gastroösophagealen
Refluxerkrankung.
Zentralbl Chir.
2006;
131
376-382
- 36
Böttger T, Hermeneit S, Müller M et al.
Laparoskopische Leberresektion – eine Überblick über die aktuelle Studienlage und
eigene Erfahrungen.
Chir Praxis.
2009;
71
399-413
- 37
Böttger T, Hermeneit S, Müller M et al.
Intrathorakale thorakoskopische Anastomose nach minimalinvasiver Ösophagusresektion.
Zentralbl Chir.
2009;
134
90-93
- 38
Böttger T, Terzic A, Müller M.
Laparoscopic, thoracoscopic esophageal resection.
Surg Endosc.
2007;
21
1695-1700
- 39
Böttger T, Hermeneit S, Müller M et al.
Modifiable surgical and anesthesiologic risk factors for the development of cardiac
and pulmonary complications after laparoscopic colorectal surgery.
Surg Endosc.
2009;
23
2016-2025
- 40
Moorthy K, Shaul T, Foley R J.
Factors that predict conversion in patients undergoing laparoscopic surgery for Crohn's
disease.
Am J Surg.
2004;
187
47-51
- 41
Agha A, Fürst A, Iesalnieks I et al.
Conversion rate in 300 laparoscopic rectal resections and its influence on morbidity
and oncological outcome.
Int J Colorectal Dis.
2008;
23
409-417
- 42
Maeda T, Tan K Y, Konishi F et al.
Trainee surgeons do not cause more conversions in laparoscopic colorectal surgery
if they are well supervised.
World J Surg.
2009;
33
2439-2443
- 43
Leroy J, Jamali F, Forbes L et al.
Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term
outcomes.
Surg Endosc.
2004;
18
281-289
- 44
Scheidbach H, Schneider C, Konradt J et al.
Laparoscopic abdominoperineal resection and anterior resection with curative intent
for carcinoma of the rectum.
Surg Endosc.
2002;
16
7-13
Prof. T. C. Böttger
Euromed Clinic
Europa-Allee 1
90763 Fürth
Deutschland
Phone: +49 / (0)9 11 / 9 71 40
Fax: +49 / (0)9 11 / 9 71 45 55
Email: thomasboettger@gmx.de
