Evaluating the degree of difficulty of laparoscopic colorectal surgery

Objective: To quantify the degree of overall difficulty and the difficulty of each of the individual steps involved in the performance of laparoscopic colorectal procedures. The data should serve as a guide to surgeons in the early stages of their experience in laparoscopic colorectal surgery as to which procedures and steps to embark on first, to allow them to build experience in a stepwise fashion. Methods: A mail-in survey of 35 experienced laparoscopic colorectal surgeons was conducted. Using a scale of 1 to 6, the surgeons were asked to rate the overall degree of difficulty of each of 12 laparoscopic colorectal procedures. Each procedure was then broken down into its key components (exposure, isolation of the vascular pedicle, dissection of the specimen, and anastomosis), and the raters were asked to individually grade each of these components for each intervention. An overall difficulty score was created for each procedure, as well as an individual difficulty score for each step. Results: The response rate was 80%, representing a collective experience of approximately 6335 laparoscopic colorectal interventions. On the overall difficulty score, sigmoid colectomy achieved the lowest composite score of 2.0, while reversal of the Hartmann procedure scored the highest at 4.5. Analyzing the individual step complexity rating, mobilization of the splenic flexure scored highest, ahead of rectal mobilization. Vascular dissection scored significantly higher for right colectomy than for sigmoid resection, as did intracorporeal vs extracorporeal anastomosis for right colectomy. Conclusions: The learning curve for laparoscopic colorectal surgery is steep. This survey can help surgeons in the early part of this curve in their initial choice of procedure and allow them to build experience in a stepwise manner. This will help to identify achievable goals and develop strategies for reducing operating times and improving patient outcome by selecting appropriate cases at the outset.