Laparoscopic colorectal surgery and community hospitals.

(Dr. McKinley replies) We are pleased that our article “Can community surgeons perform laparoscopic colorectal surgery with outcomes similar to tertiary care centers”1 has been read with interest, and we thank Professor Rulli and colleagues for their comments. We are happy to respond. Dr. Rulli and colleagues are quite right that there are several studies in the literature that support our conclusions.2 They also point out that our paper is self-referential and suggests our conclusions may be potentially dangerous. We specifically made our conclusions self-referential, for the very concern he is expressing. We feel we have demonstrated that it is possible for community surgeons with no formal training in advanced laparoscopy to transition themselves from an open to a laparoscopic approach when performing colorectal surgery. Our statement that, “it is possible,” was the only conclusion we could justifiably make. Whether all community surgeons with no formal training in advanced laparoscopy can or should transition themselves is a question beyond the scope of our paper. The statement, “transition themselves,” in no way suggests that we practise in a vacuum. No surgeon is an island, and we are grateful to the many colleagues we have had an opportunity to learn from. These include our teachers and mentors during our surgical fellowship, the many excellent courses we were able to attend and our long collaboration and friendship with The Centre for Minimal Access Surgery, directed by Dr. Mehran Anvari. We are happy to briefly comment on other issues that are critical to our safe transition. In our series, the learning curve appeared to be the first 40 cases and was defined by a significant increase in wound infection and in the conversion rate, as well as by the use of patient selection. Our learning curve was not defined by an increased intraoperative or postoperative complication rate. As well, operating times and length of stays were not increased during the learning curve. We also note that the complication rates during our learning curve were similar to those reported by tertiary care centres for entire case series. Thus, we conclude that it is possible for community surgeons to transition themselves from an open to a laparoscopic approach safely and efficiently. We believe the the following factors are important in minimizing morbidity during our learning curve: careful patient selection; maintenance of a patient database; course attendance; 2-surgeon approach; dedicated nursing; and appropriate capitalization of the operating room. During this series, we evaluated the feasibility and use of mentoring, telementoring and telerobotic assisting as part of a larger multicentre study.3–7 During our colorectal series, this included 1 mentored procedure (case 41), 4 telementored procedures (cases 63, 66, 71 and 83) and 4 telerobotic assisted procedures (cases 70, 77, 82 and 87). Although we did not evaluate these techniques during our learning curve, we believe that they would be important enabling tools for community surgeons during their learning curves. Dr. Rulli and colleagues also raise the important issue of colorectal case volumes. He suggests that 100 cases over 3 years may not be enough to support a laparoscopic colorectal surgical program. The first point we would the Society of American Gastrointestinal and Endoscopic Surgeons (Las Vegas, 2007) our experience with 250 laparoscopic colorectal procedures. Our mean follow-up was 36 months, and both our short-term outcomes and our longer-term oncologic outcomes are equivalent to tertiary care centres. We therefore believe that we have created a laparoscopic colorectal surgery program with outcomes similar to tertiary care centres. Dr. Rulli and colleagues are quite right that many reports in the literature would suggest that our volumes are less than optimal, but several points need to be stated. First, may of these series involve tertiary care open colorectal surgeons transitioning themselves to a laparoscopic approach, and often these surgeons have no other laparoscopic practice. Conversely, community surgeons often have a large laparoscopic surgical practice outside their colorectal work. We respectfully suggest that the literature from academic centres may not be an appropriate yardstick when attempting to gain insight into community surgeons' practices. During the 3 years of our colorectal case series, we performed 2 Heller myotomies, 85 antireflux procedures, 3 splenectomies, 4 gastrectomies, 100 colorectal procedures, 22 ventral hernia repairs, 20 inguinal hernia repairs, 305 laparoscopic cholecystectomies and 100 laparoscopic appendectomies. Laparoscopy begets laparoscopy, and it may be that community surgeons with good outcome laparoscopic practices may be uniquely suited to adopting laparoscopic colorectal techniques. For similar reasons, the classical learning curve data published for transition from open to laparoscopic cholecystectomy may not be fruitful in understanding the transition to advanced laparoscopy from basic laparoscopy. We hope that we have sufficiently addressed the comments of Dr. Rulli and colleagues.