Don’t Fear the Learning Curve for Robotic Colorectal Surgery: A Young Surgeon’s Experience

Imad Qayyum, MD, David Mateo de Acosta, MD, Brant Clatterbuck, David L Crawford, MD, FACS, Steven S Tsoraides, MD. University of Illinois College of Medicine, Peoria

INTRODUCTION – Many reports have documented the learning curve for robotic colorectal surgery. Little exists describing the experience of a junior surgeon recently out of training.

METHODS AND PROCEDURES – A retrospective review of consecutive robotic colorectal resections performed by a single surgeon during the first two years of practice (October 2011 – October 2013) was performed. A total of 50 cases were performed using the robot. After exclusion of rectopexy and right-sided procedures, 45 cases were reviewed including sigmoid & anterior resection, low anterior resection, and abdominal perineal resection. NCCN guidelines were followed in the management of all malignancies.

The surgeon’s exposure to robotics during training included 9 console cases during general surgery residency, and additional cases as first assistant. Nine assistant cases were experienced during colorectal residency.

The initial 10 cases in the series were performed utilizing an experienced senior partner as the first assistant. The subsequent cases were typically performed with a surgical resident or surgical technologist as first assistant. On occasion, an attending surgeon performed a procedure in combination with the junior surgeon. Cases were routinely executed in a total robotic fashion. A transition occurred to a two-dock technique from a single-dock technique during the study phase. The splenic flexure is routinely mobilized during low anterior resections and most anterior/sigmoid resections.

Patients were selected based on surgeon preference. The robotic approach is the preferred approach for rectal surgery and all included cases were considered elective. Very few elective open rectal cases were scheduled during the study period.

RESULTS – Total operative time for included cases was 313 min, with a mean docking time of 36 min and mean console time of 148 min. When comparing the first half of cases to the second half with a paired t-test, calculated p values suggested no significant difference was found: Total mean operative time 324 min vs. 302 min. Mean docking time 36 min vs. 36 min. Mean console time 139 min vs. 157 min. Mean lymph node retrieval across the series was 14.5 nodes: 16.2 nodes vs. 12.9 nodes, with this difference being statistically insignificant. Conversion to open surgery occurred in 1 case due to extensive adhesions and bulky tumor size. Addition of a hand port or mini-laparotomy was planned in 3 cases and added at the time of surgery in an additional 6 cases. There were 6 patients with postoperative complication of significance. There was no 30-day mortality.

CONCLUSION – Junior colorectal surgeons can perform total Robotic Colorectal Resection with comparable efficiency to published data. This is especially relevant in light of our total robotic experience in contrast to other reported “hybrid” techniques. Although more extensive data are required, our experience shows that a junior surgeon may not encounter a steep learning curve in adopting robotics. Our times compare favorably to previously published data and our lymph node retrieval within resected specimens is appropriate. Earlier exposure to robotics during training and early assistance from experienced senior surgeons may be the key to this success.

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