The learning curve is too long, unlike the laparoscopic chole.

It is highly dependant on the country and context. E.g:

1. The two large known trials in UK and USA respectively were performed too early in the learning curve, in the mid-90s to demonstrate any clinically significant advantage such that it wasn't introduced as the norm in colorectal training programmes at the time.

2. In colorectal resections, unlike cholecystectomies even in the best of hands leaks do occur, which results in major co-morbidity, if not mortality such that it is imperative to ensure trainees remain competent in performing open resections and dealing with ischaemia and leaks etc. i.e. whereas a major complication rate of 1 in 250 (0.4%) in lap choles is acceptable; a leak rate of between 2-5% is clinically unacceptable though currently unavoidable. Such that if someone's laparoscopic complication rate doesn't match this, it is unethical for them to recommend the procedure to their patients, unless the patient is referred on to another, which is not common practice in most practices that do not offer a holistic-care public service.

3. There is no doubt, as mentioned above, the learning curve is longer, as it is a four-quadrant procedure rather than a single quadrant one; however, this is not a significant factor if one has been trained appropriately and adequately in both, open versus laparoscopic surgery.

4. A number of colleagues unfortunately are waiting for robotics to become the norm and thus for the cost to decrease, so it can be offered as a "novel" procedure, perhaps for competitive gain. The learning curve here is not as steep, and I concur with Steve Wexner that it is currently a technique that benefits the surgeon. To extrapolate, if trainees are adept resectionists, and are trained equally in open and laparoscopic surgery, then most of us believe it "takes off" appropriately. However, it is essential to ensure patient selection is made on an individual physiological basis. This has been highlighted by the recent trial on wounds that demonstrates the advantage of transverse incisions for specimen retrieval compared to vertical midline incisions - but only in the patients selected appropriately!

5. At the end of the day, as mentioned in a number of previous posts (sorry for the repetition, but I feel we often forget this), a technique is just that - a mere technique. There is no doubt that if added to one's armamentarium, laparoscopic resections can be beneficial - if we choose our patients correctly, for saving some time in hospital for some does not equate to poor results for others i.e. unlike lap choles we must never forget due to the nature of bowel surgery, there will always be a conversion rate. The only way for each of us to know what is the correct procedure for each of us to offer to our patients is by studying our long-term results for every patient we manage. (Incomplete data such as 30-day mortality for lap vs open do not suffice). To demonstrate advantage such that lap resections is the default, one would need to demonstrate a survival benefit for cancer resections, over 5 years, for all resections one performs, even to demonstrate the cost-benefit analysis, as cost includes cost of life!

6. The upshot? The surgery is great; colorectal surgery is risky, irrespective of technique - as surgeons, we don't want to add to the risk! (Just to be clear, I enjoy performing/training in laparoscopy!)

numbers needed to learna and maintain competency is important for good outcomes

over the years even in developed countries the following have improved uptake of lap colorectal

colorectal as a speciality

national training and accreditation programmes eg lapco

public private partnership or industry support to help initial process via animal lab, cadaver lab training programme, outreach preceptorship programme, immersion programmes

but most important firuptake is including it as part of curriculum in specialist registrar programmes, Welsh lap colorectal programme for trainees

in india, problem is localy advanced cancers in young patients and poor biology tutors like signet, however we do have industry supported fellows after finishing their mch surgical oncology , when they are already competent in open surgery . Over the next five years uptake will increase.

Thanks,very lucid answers

Esteemed Presanna, PSARP - posterior sagittal anorectoplasty , still reserves the mystery behind muscle complex conservative dissection without iatrogenia even in open surgery, much more to discover in laparoscopy of how to avoid section of muscular complex of anal sphincter either by Pena or de Vries procedure to imperforate anus in pediatric surgery .

Thankyou