title: Technical difficulty grade score for the laparoscopic approach of rectal cancer: a single institution pilot study.
abstract: BACKGROUND
  We aimed to categorize laparoscopic rectal resections according to technical difficulty to standardize learning purposes and stratify results, making future studies more comparable.
  
  
  METHODS
  Fifty patients undergoing a laparoscopic total mesorectal excision were prospectively followed. Four preoperatively known facts (gender, body mass index (BMI), tumor localization, and preoperative radiation therapy) were compared to four operative outcomes (operation time, blood loss, a visual analogue score (VAS) for difficulty rewarded by the surgeon, and oncological radicality of the procedure).
  
  
  RESULTS
  Operating time for male and female patients was 257 vs. 245 min (P=0.229), blood loss was 300 vs. 300 ml (P=0.309), the VAS was 8 vs. 6 (P<0.001), and radicality was 93% vs. 91% (P=0.806). Operating time was 215, 250, and 305 min for high, mid, and low tumors (Spearman -0.44; P=0.02), respectively. Blood loss was 105, 300, and 600 ml (Spearman -0.38; P=0.01). Lower tumors were rewarded a higher VAS (Spearman -0.57; P<0.001) and were less often radically resected (Spearman 0.32; P=0.026). Operating time for irradiated and nonirradiated patients was 277 vs. 225 min (P=0.008), blood loss was 500 vs. 150 ml (P=0.006), the VAS was 7 vs. 5 (P<0.001), and radicality was 79% vs. 100% (P=0.046). Operating time was 240 min for BMI 25-30 and 253 min for BMI>30 (Spearman 0.13; P=0.391). Blood loss was 150 ml for BMI 25-30 and 500 ml for BMI>30 (Spearman 0.38; P=0.01). Higher BMIs were rewarded a higher VAS (Spearman 0.06; P=0.704). BMI had no correlation to radicality of the procedure (Spearman -0.12; P=0.402). There was an association between technical difficulty score and operation time (P=0.007), blood loss (P<0.001), VAS (P<0.001), and radicality of surgery (P=0.043).
  
  
  CONCLUSIONS
  Laparoscopic surgery in male, irradiated, and obese patients with lower tumors seemed more difficult. A categorization according to technical difficulty, to preoperatively predict difficulty of the procedure, was found feasible.
authors.affiliation: Department of Surgery, Vrije Universiteit Medical Center, Postbus 7057, 1007 MB, Amsterdam, The Netherlands.
authors.forename: A A F A
authors.initials: AA
authors.lastname: Veenhof
authors.forename: A F
authors.initials: AF
authors.lastname: Engel
authors.forename: D L
authors.initials: DL
authors.lastname: van der Peet
authors.forename: C
authors.initials: C
authors.lastname: Sietses
authors.forename: W J H J
authors.initials: WJ
authors.lastname: Meijerink
authors.forename: E S M
authors.initials: ES
authors.lastname: de Lange-de Klerk
authors.forename: M A
authors.initials: MA
authors.lastname: Cuesta
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical; D015992:Body Mass Index; D002983:Clinical Competence / Q000592:standards*; D013505:Digestive System Surgical Procedures / Q000193:education / Q000592:standards*; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000592:standards*; D007858:Learning; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009765:Obesity / Q000150:complications; D018579:Patient Selection; D010865:Pilot Projects; D011446:Prospective Studies; D018714:Radiotherapy, Adjuvant; D012004:Rectal Neoplasms / Q000150:complications / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome