Laparoscopic training must advance

So why is there still an insufficient number of surgeons trained in this technique? How can access and patient choice be improved, and why should Trust boards be concerned? LOUISE FRAMPTON reports.

Robin Kennedy, consultant colorectal surgeon, St Mark’s Hospital, Harrow, is at the forefront of efforts to advance training in laparoscopic surgery. He is also a champion of the Enhanced Recovery Partnership Programme. In his view, both of these approaches are crucial to improving patient outcomes and he is keen to encourage increased adoption throughout the UK. Robin Kennedy teaches around six UK trainees per year in laparoscopic techniques, as well as overseas trainees – along with a number of outside consultants from within a 50- mile radius, who visit St Mark’s as part of the National Training Programme for Laparoscopic Colorectal Surgery. The programme has been developed by the Department of Health to train NHS consultant colorectal surgeons in England with the aim of giving all suitable patients with colorectal cancer access to a fully trained laparoscopic colorectal surgeon. The programme was devised in 2007 to implement the 2006 NICE guidelines which state that laparoscopic (including laparoscopically assisted) resection is recommended as an alternative to open resection for individuals with colorectal cancer in whom both laparoscopic and open surgery are considered suitable. Training centres in around 15 hospitals have now been established throughout the UK, as part of the programme, with the aim of helping consultant surgeons to safely implement laparoscopic techniques at their own organisations and to overcome geographic variations in access. “Retraining on this scale has not been performed anywhere else in the world, so the UK is leading the way – the national training programme is really very exciting,” Robin Kennedy enthused. “This could potentially transform colorectal surgery if surgeons engage with this initiative. Prior to this, consultant surgeons have not been retrained in new techniques, in this way, as the profession has never seen such a major change in practice.” As part of the programme, consultants are asked to come to St Mark’s and perform around 20 procedures, on their own patients, to enable them to safely introduce the skills into their own hospitals. However, as these are difficult techniques, Robin Kennedy also provides an opinion on whether or not the surgeons should continue with the approach at the end of their training. “Currently, within the NHS, there is no formal surgical opinion on professional competence – we are undertaking a research project to develop and validate this. Most chief executives would be very happy to have a group of expert surgeons who would provide an opinion on whether they feel a surgeon should take on this complicated technique,” he commented. Robin Kennedy also acknowledged the challenges ahead and pointed out the need to address public awareness, increase participation in training, as well as overcome reluctance to embrace change: “The NICE appraisal was very clear that patients should be able to make an informed choice between open or laparoscopic procedures following discussion with their surgeon. However, GPs are often unaware of which approach individual centres or surgeons are going to use, making informed choice difficult, while surgeons may not always be clear about what can be performed laparoscopically.” He added that there is a lot of work to be done to encourage surgeons to participate in the programme and said that a “postcode lottery” continues to operate as to whether patients are offered a choice of traditional “open” or a laparoscopic approach. “If you look at the figures, 80% of patients are not receiving laparoscopic surgery. This may be due to the fact that surgeons are very busy, so haven’t had the time to be retrained and – until recently – the resources have not been available,” he commented. “However, in spite of efforts of engagement with the training programme that I would have liked to have seen, which is very disappointing.” When asked why he believed this was the case, be replied: “It is natural for many people not to want to change the way they have worked for many years – many surgeons find it challenging, they think their patients may not want to travel, or their chief executives may not want to lose money as the tariff for the patient goes to the training centre. “Laparoscopic surgery also costs more in terms of the disposable equipment used, but it is certainly cost neutral – if not cost saving – if other factors are taken into consideration. At worst, this is simply a cost neutral change, which offers a considerably improved outcome. We must do everything we can to enable adoption – it is a real shame that patients cannot benefit from laparoscopic colorectal surgery as it transforms recovery,” he continued.

Benefits of laparoscopic surgery