Hand-assisted laparoscopic sigmoidectomy for diverticulitis

Hand-Assisted Laparoscopic Approach in Colon Surgery

BACKGROUND

This study sought to compare outcomes of patients who underwent hand-assisted laparoscopic (HAL) colectomy with open and laparoscopic colectomy (LP).

STUDY DESIGN

The NSQIP databases were used to examine the clinical data of patients who underwent elective colectomy during 2012-2013. Multivariate regression analysis was performed to compare the three surgical approaches.

RESULTS

We sampled a total of 21,090 patients who underwent colectomy. Of these, 7480 (35.5 %) had open colectomy (OC), 8751 (41.5 %) had a laparoscopic colectomy, 2860 (13.6 %) had a HAL colectomy, and 1999 (9.5 %) had an open procedure converted from LC or HAL. Multivariate regression analysis revealed HAL colectomy had a similar mortality (AOR 0.53, P = 0.07) and a lower morbidity (AOR 0.37, P < 0.01) compared to OC. LC had lower mortality (AOR 0.58, P = 0.02) and morbidity (AOR 0.43, P < 0.01) compared to OC. Mortality of patients who underwent HAL was not significantly different from LC (AOR 0.90, P = 0.79); however, morbidity of such patients was significantly higher than for patients who underwent LC (AOR 1.29, P < 0.01).

CONCLUSIONS

HAL colectomy is a safe approach with significant advantages compared to open colectomy. Although the morbidity of patients who underwent HAL is higher than patients who underwent LC, the morbidity rate is still lower than OC.

Hand-Assisted Laparoscopic Approach in Colon Surgery

BACKGROUND

This study sought to compare outcomes of patients who underwent hand-assisted laparoscopic (HAL) colectomy with open and laparoscopic colectomy (LP).

STUDY DESIGN

The NSQIP databases were used to examine the clinical data of patients who underwent elective colectomy during 2012-2013. Multivariate regression analysis was performed to compare the three surgical approaches.

RESULTS

We sampled a total of 21,090 patients who underwent colectomy. Of these, 7480 (35.5 %) had open colectomy (OC), 8751 (41.5 %) had a laparoscopic colectomy, 2860 (13.6 %) had a HAL colectomy, and 1999 (9.5 %) had an open procedure converted from LC or HAL. Multivariate regression analysis revealed HAL colectomy had a similar mortality (AOR 0.53, P = 0.07) and a lower morbidity (AOR 0.37, P < 0.01) compared to OC. LC had lower mortality (AOR 0.58, P = 0.02) and morbidity (AOR 0.43, P < 0.01) compared to OC. Mortality of patients who underwent HAL was not significantly different from LC (AOR 0.90, P = 0.79); however, morbidity of such patients was significantly higher than for patients who underwent LC (AOR 1.29, P < 0.01).

CONCLUSIONS

HAL colectomy is a safe approach with significant advantages compared to open colectomy. Although the morbidity of patients who underwent HAL is higher than patients who underwent LC, the morbidity rate is still lower than OC.

Hand-assisted laparoscopic total colorectal resection for familial adenomatous polyposis with coexisting rectal cancer

When familial adenomatous polyposis (FAP) is diagnosed in a patient, prophylactic surgery must be performed whether colorectal cancer is present or not. Operations for FAP have been performed through a large median abdominal incision or an additional perineal incision, depending on the coexistence of rectal cancer. Recently, we reported a technique of laparoscopic rectal amputation without abdominal skin incision for patients with rectal cancer to minimize postoperative cardiac and respiratory complications [6]. In this article, we report a case of laparoscopically assisted proctocolectomy with ileostomy through a minimal abdominal and perineal skin incision performed by a hand-assisted procedure. The purpose of combining the perineal and laparoscopic approaches is to minimize the skin incision, while retaining a rate of cure and safety equivalent to those of conventional rectal amputation, by using the advantages of laparoscopic procedures, and to facilitate postoperative recovery and improve the quality of life for relatively young patients with FAP.

Hospital discharge criteria following colorectal surgery: a systematic review

AIM

The aim of this study was to identify and synthesize the hospital discharge criteria that have been used in the colorectal surgery literature.

METHODS

A systematic literature search was conducted using eight bibliographic databases. Searches were limited to English language journal articles published between January 1996 and October 2009. Primary research applying hospital discharge criteria following colorectal surgery was included. Study selection was made independently by two reviewers. Discharge criteria were extracted from each included study.

RESULTS

The 156 studies identified by the search strategy described 70 different sets of criteria to indicate readiness for discharge. The majority of studies applied a combination of three or four criteria; those most frequently cited were tolerance of oral intake (80%), return of bowel function (70%), adequate pain control (44%) and adequate mobility (35%). End-points employed to determine the achievement of criteria were generally poorly defined.

CONCLUSION

A variety of hospital discharge criteria were applied in the colorectal surgery literature. Development of standardized criteria will allow more accurate comparison of results between studies assessing hospital length of stay or other discharge-related outcome measures.

Hand-assisted laparoscopic colorectal surgery: initial experience of a single surgeon

BACKGROUND/AIM

As totally laparoscopic colorectal surgery is considered challenging and technically demanding with a long steep learning curve, we adopted hand-assisted laparoscopic colorectal surgery as a bridge to totally laparoscopic assisted colorectal surgery. This prospective study aims to highlight the initial experience of a single surgeon with this technique.

MATERIALS AND METHODS

A prospective analysis of the first 25 cases of hand-assisted laparoscopic colorectal resections which were performed by a single surgeon over a 15-month period. There were 15 males and 10 females with a mean age of 55.5 (range 20-82) years.

RESULTS

The indication in majority of cases was cancer (76%). The procedures consisted of 18 (72%) various colectomies and 7 (28%) anterior resections. The operative time ranged between 110-400 (mean 180) min. There was one conversion (4%) and the mean operative blood loss was 80 (range 60-165) ml. The number of lymph nodes retrieved in the cancer cases was 5-31 (mean 15) nodes. The mean length of hospital stay was five (range 3-10) days. The total number of short-term complications was six (24%) and there was one death due to anastomatic leak and multiorgan failure. Long-term complications after a maximum follow up of 30 months were two incisional hernias at the hand port site, but none of the patients developed adhesive small bowel obstruction or late anastomotic stricture. Currently all our colorectal procedures are conducted laparoscopically.

CONCLUSION

Hand-assisted laparoscopic colorectal procedures are easy to learn as a good bridge to master totally laparoscopic colorectal surgery.

Controversy of hand-assisted laparoscopic colorectal surgery

Laparoscopically assisted colorectal procedures are time-consuming and technically demanding and hence have a long steep learning curve. In the technical demand, surgeons need to handle a long mobile organ, the colon, and have to operate on multiple abdominal quadrants, most of the time with the need to secure multiple mesenteric vessels. Therefore, a new surgical innovation called hand-assisted laparoscopic surgery (HALS) was introduced in the mid 1990s as a useful alternative to totally laparoscopic procedures. This hybrid operation allows the surgeon to introduce the non-dominant hand into the abdominal cavity through a special hand port while maintaining the pneumoperitoneum. A hand in the abdomen can restore the tactile sensation which is usually lacking in laparoscopic procedures. It also improves the eye-to-hand coordination, allows the hand to be used for blunt dissection or retraction and also permits rapid control of unexpected bleeding. All of those factors can contribute tremendously to reducing the operative time. Moreover, this procedure is also considered as a hybrid procedure that combines the advantages of both minimally invasive and conventional open surgery. Nevertheless, the exact role of HALS in colorectal surgery has not been well defined during the advanced totally laparoscopic procedures. This article reviews the current status of hand-assisted laparoscopic colorectal surgery as a minimally invasive procedure in the era of laparoscopic surgery.

Hand-assisted laparoscopic versus open approach in colorectal surgery: a systematic review

AIM

This systematic review was performed to answer the question whether hand-assisted laparoscopic surgery (HALS) can preserve the advantages of laparoscopic compared with open surgery in colorectal disease.

METHOD

Eligible studies were identified from electronic databases (Medline, Embase Cochrane) and cross-reference search. The database search, quality assessment and data extraction were independently performed by two reviewers. Outcome criteria were operative time, number of trocars used, conversion rate, incision length, blood loss, time to passage of flatus, use of analgesia, postoperative morbidity, in-hospital mortality, length of hospital stay, number of lymph nodes and costs.

RESULTS

Out of 162 publications seven publications were selected for comprehensive review. Three randomized controlled trials (RCT) and four non-RCTs, comprising 571 patients, met the inclusion criteria. Because of heterogeneity, the data could not be pooled. The operative time was significantly longer in HALS in four of the seven studies (addition in median operative time of 13-81 min). The conversion rate varied from 0 to 10%. Two of the four reporting studies demonstrated a significantly shorter time to passage of flatus in HALS (averagely one day in advance). Length of hospital stay was significantly shorter in HALS in four of the seven studies (average gain between 2 and 4 days).

CONCLUSIONS

Hand-assisted laparoscopic surgery has the advantages of laparoscopic surgery over open surgery while reducing some of the disadvantages of laparoscopic surgery (shorter operative time, lower conversion rates). Especially for indications in which an incision to extract the resection specimen is required, HALS provides an excellent treatment option.

Colonoscopy assisted laparoscopic sigmoidectomy: a case report

INTRODUCTION

We report a case of colonoscopy-assisted laparoscopic sigmoidectomy used for the management of sigmoid volvulus.

CASE PRESENTATION

We report a 68-year-old female who underwent colonoscopy assisted laparoscopic sigmoidectomy. In this procedure, an anvil is inserted into the anus with colonoscopic assistance. An anastomosis is established without removing the colon from the abdominal cavity, and the maximum incision size is approximately 2 cm, similar to that in laparoscopic cholecystectomy. The risk of infection is lower compared with pure laparoscopic surgery, in which an incision is made for extracting the tissue specimen without opening the colon within the abdominal cavity to maintain anastomosis. The patient was discharged 1 week after surgery without complications.

CONCLUSIONS

We believe that this new technique is a feasible approach for the treatment of benign lesions, particularly sigmoid volvulus, which is generally large enough to allow insertion of the anvil.

Hand-assisted laparoscopic versus open right colectomy: a randomized controlled trial

OBJECTIVE

Laparoscopic colectomy has been proved to be both technically and oncologically feasible. However, the approach has been criticized for its procedural complexity and long operative time as a result of the loss of tactile feedback and absence of depth perception. The advent of hand-access devices offered a potential solution to these problems. This randomized controlled trial aims to compare hand-assisted laparoscopic colectomy (HALC) with open colectomy (OC) in the management of right-sided colonic cancer.

METHODS

Adult patients with nonmetastatic carcinoma of cancer or ascending colon were recruited. Patients were excluded if they presented with surgical emergencies, had synchronous tumors on work-up, or when the tumor was larger than 6.5 cm in any dimension or preoperative imaging. Recruited patients were randomized to undergo either HALC or OC by the same surgical team. Outcome measures included operative time, blood loss, postoperative pain score and analgesic requirement, length of hospital stay, postoperative complications, as well as disease recurrence and patient survival.

RESULTS

Eighty-one patients (HALC = 41, OC = 40) were successfully recruited. The 2 groups were matched for age, gender distribution, body mass index, and comorbidities. No significant difference was observed between the 2 groups in the distribution of tumors and the final histopathological staging. HALC took significantly longer than OC (110 min vs. 97.5 minutes, P = 0.003) but resulted in significantly less blood loss (35 mL vs. 50 mL, P = 0.005). Patients after HALC experienced significantly less pain, required significantly less parenteral and enteral analgesia, recovered faster, and was associated with a shorter length of stay (7 days vs. 9 days, P = 0.004). With median follow-up of 28 to 30 months, no difference was observed in terms of disease recurrence, and the 5-year survival rates remained similar (83% vs. 74%, P = 0.90).

CONCLUSION

HALC retained the same short-term benefits of the pure laparoscopic approach. The technique is associated with a slightly increased but acceptable operative time. Aside as a useful adjunct in complex laparoscopic procedures, the hand-assisted laparoscopic technique is also a useful, if not more effective, alternative for patients with right-sided colonic cancer.

Laparoscopic hand-assisted extended right hemicolectomy for cancer management

Laparoscopic extended right hemicolectomy for cancer management is an uncommon operation because it is difficult to divide the middle colic vessels laparoscopically in an oncologic resection. Furthermore, some surgeons believe a left hemicolectomy is an adequate alternative. This study aimed to evaluate the feasibility of performing a laparoscopic hand-assisted extended right hemicolectomy for cancer located between the distal transverse colon and the proximal descending colon. The technique was described and demonstrated with a video presentation. The clinical outcome was recorded for four consecutive patients.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (doi: 10.1007/s00464-006-9128-1) contains supplementary material, which is available to authorized users.

Current Status of Hand-Assisted Laparoscopic Colorectal Surgery: A Review

PURPOSE

Hand-assisted laparoscopic colorectal surgery has continued to develop since the mid-1990s. There have been a number of publications regarding its use and efficacy as a technique. We studied these reports to assess the current status of hand-assisted laparoscopic colorectal surgery.

MATERIALS AND METHODS

We searched for articles on hand-assisted laparoscopic colorectal surgery archived in MEDLINE, PubMed, and the Cochrane database of systematic reviews.

RESULTS

We found a total of 36 papers. These included nine descriptive studies, three nonrandomized trials, and four randomized trials.

CONCLUSION

Most authors found hand-assisted laparoscopic colorectal surgery to be a very useful and promising technique. Suitable hand-insertion ports and laparoscopic instruments are crucial. Controlled trials demonstrate that the early benefits of the laparoscopic approach are realized and there may be a shorter learning curve.

Laparoscopic colon surgery: past, present and future

Since its first described case in 1991, laparoscopic colon surgery has lagged behind minimally invasive surgical methods for solid intra-abdominal organs in terms of acceptability, dissemination, and ease of learning. In colon cancer, initial concerns over port site metastases and adequacy of oncologic resection have considerably dampened early enthusiasm for this procedure. Only recently, with the publication of several large, randomized controlled trials, has the incidence of port site metastases been shown to be equivalent to that of open resection. Laparoscopic surgery for colon cancer has also been demonstrated to be at least equivalent to traditional laparotomy in terms of adequacy of oncologic resection, disease recurrence, and long-term survival. In addition, numerous reports have validated short-term benefits following laparoscopic resection for cancer, including shorter hospital stay, shorter time to recovery of bowel function, and decreased analgesic requirements, as well as other postoperative variables. In benign colonic disease, much less high-quality literature exists supporting the use of laparoscopic methods. Two recent randomized controlled trials have demonstrated some short-term benefits to laparoscopic ileocolic resection for CD, in addition to evident cosmetic advantages. On the other hand, the current evidence on laparoscopic surgery for UC does not support its routine use among nonexpert surgeons outside of specialized centers. Laparoscopic colonic resection for diverticular disease appears to provide several short-term benefits, although these advantages may not translate to cases of complicated diverticulitis. Despite the increasing acceptability of minimally invasive methods for the management of benign and malignant colonic pathologies, laparoscopic colon resection remains a prohibitively difficult technique to master. Numerous technological innovations have been introduced onto the market in an effort to decrease the steep learning curve associated with laparoscopic colon surgery. Good evidence exists supporting the use of second-generation, sleeveless, hand-assist devices in this context. Similarly, new hemostatic devices such as the ultrasonic scalpel and the electrothermal bipolar vessel sealer may be particularly helpful for extensive colonic mobilizations, in which several vascular pedicles must be taken. The precise role of these hemostatic technologies has yet to be established, particularly in comparison with stapling devices and significantly cheaper laparoscopic clips. Finally, recent advances in camera systems are promising to improve the ease with which difficult colonic dissections can be performed.

A critical analysis of laparoscopic colectomy at a single institution: lessons learned after 1000 cases

BACKGROUND

A critical outcome analysis of a large, single-institution experience provides a better frame of reference for an assessment of the role of laparoscopic colectomy for colorectal pathology.

METHODS

Review of a prospectively gathered database was performed of a consecutive series of laparoscopic colectomy patients who were operated on by 2 surgeons at a single institution (tertiary referral center) using standardized techniques and care plans. Patients were assessed for operative indications, type of resection, operative time, conversion, complications, duration of stay, and readmission within 30 days.

RESULTS

One thousand consecutive patients undergoing laparoscopic colectomy from January 1999 thru June 2004 were analyzed. The types of resections were right colectomy = 314, left/sigmoid colectomy/anterior resection = 435, total colectomy = 61, total proctocolectomy = 14, and other = 176. The indications for surgery were diverticular disease = 285, colorectal neoplasia = 285, inflammatory bowel disease = 172, rectal prolapse = 81, and other = 177. The conversion rate was 11.4%. The mean operative time was 112 +/- 45 minutes for all resections. The mean duration of hospitalization for all patients was 3.7 +/- 3.8. The overall complication rate was 9.9%, with the most frequent complications being ileus 2.8%, pulmonary 1.6%, cardiac 1.4%, and wound infection 2.6%. The 30-day readmission rate was 9.1%, and the most frequent reasons for readmission were ileus/small-bowel obstruction, intra-abdominal infection, and anastomotic leak.

CONCLUSIONS

This largest single-institution experience with laparoscopic colectomy confirms the benefits of a standardized approach including shorter hospital rehabilitation and low rates of cardiopulmonary and wound complications. Efforts must be directed at improving access to training in laparoscopic colectomy techniques so that patients can benefit from this new technology.

Hand-assisted laparoscopic colectomy: rational evolution for diverticulitis

Laparoscopic technique has proved to be a revolutionary advance in the surgical treatment of disease. However, limits exist regarding its application to colorectal resection as evidenced by the higher conversion rate and longer learning curve seen with colectomy. Conversion remains a complex issue related to multiple factors. One of the factors, inflammatory disease such as diverticulitis, exposes limitations of laparoscopic technique, specifically the absence of tactile sensation and use of one's hand as a surgical instrument. Nonetheless, the clinical benefits of smaller incisions, decreased pain, decreased ileus, and reduced hospitalization and disability make laparoscopic colectomy a compelling surgical option for the treatment of diverticulitis. Hand-assisted technique offers surgeons a practical and rational innovation for conventional laparoscopic colectomy and offers promise for improved feasibility and efficacy for the treatment of diverticulitis.

Hand-assisted laparoscopic sigmoid colectomy: helping hand or hindrance?

BACKGROUND

Hand-assisted laparoscopic colectomy has been introduced as an alternative to the standard laparoscopic technique, but it has not yet been established whether it offers the same benefits. Therefore, we compared the outcome of patients undergoing hand-assisted laparoscopic sigmoid resection (HALSR) to that of those undergoing laparoscopic sigmoid resection (LSR).

METHODS

The study population comprised a sequential series of consecutive patients undergoing elective laparoscopic sigmoid/left colectomy. Values are reported as mean (range).

RESULTS

There were 85 LSR patients and 66 HALSR patients, with no differences in patient demographics or diagnoses. There were slight differences in operative time favoring HALSR (LSR 205 min (90-380) vs HALSR 189 min (120-290); p = 0.07), and the extraction incision was larger in the HALSR group (LSR 6.2 cm (3-25) vs HALSR 8.1 cm (7-12); p < 0.01). There was no difference in time for return of bowel function (LSR 2.8 days (1-15) vs HALSR 2.5 days (1-8); p = 0.31) or length of hospital stay (LSR 5.0 days (2-17) vs HALSR 5.2 days (3-22); p = 0.73). Complications were similar in the two groups (LSR 23% vs HALSR 21%), but there were fewer conversions in the hand-assisted group (HALSR 0% vs LSR 13%; p < 0.01).

CONCLUSIONS

Hand-assisted laparoscopic sigmoid resection yields the same outcomes as standard laparoscopic techniques, but with fewer conversions. Hand-assistance is a helpful innovation that may expand the application of laparoscopic colectomy.

Colovesical fistula: not a contraindication to elective laparoscopic colectomy

PURPOSE

Traditionally, diverticular fistula was thought to be a contraindication for laparoscopic colectomy. The advent of hand-assisted laparoscopy has allowed repair of a diverticular fistula to be technically feasible laparoscopically. We present our experience with laparoscopic colectomy in patients with diverticular fistulas.

METHODS

Patients with colovesical or colovaginal fistulas secondary to diverticular disease were consecutively entered into a database over a five-year period. All operations were electively performed by a single group of colorectal surgeons. Patient demographics, American Society of Anesthesiologists classification, type of surgery, operating time, hospital length of stay, and early and late complications were recovered by chart review. These results were then compared to results from a group of patients who had undergone elective laparoscopic colectomy for recurrent diverticulitis during the same period by the same group of surgeons.

RESULTS

Altogether, 40 consecutive operations for diverticular fistulas were performed, 36 of which were started laparoscopically (90 percent). The average patient age was 65 years and the average American Society of Anesthesiologists class was 2. Patient demographics were similar among the group with recurrent diverticulitis (n = 149). The average hospital stay was 6.2 days for the fistula group and 4.4 days in the recurrent diverticulitis group. The average operating time was 220 minutes for the fistula group vs. 176 minutes for the uncomplicated group (P < 0.002). The conversion rate was significantly higher in the fistula group (25 percent vs. 5 percent, P < 0.001). There were no postoperative anastomotic leaks or bleeding episodes requiring reoperation in the fistula group.

CONCLUSIONS

Diverticular fistula should no longer be considered a contraindication for laparoscopic colectomy. These cases are more complex, as evidenced by the longer operating times and higher conversion rates when compared with resections for uncomplicated recurrent diverticulitis. Although the length of hospital stay was longer for patients who underwent laparoscopic colectomy for diverticular fistula, those whose operations were completed laparoscopically had the same outcome as patients with uncomplicated disease. We anticipate that minimally invasive surgery will become the standard of care for colovesical fistula, as it now is for uncomplicated diverticular disease.

The utility of hand-assisted laparoscopy in ovarian cancer

INTRODUCTION

The traditional approach to patients with ovarian cancer is cytoreductive surgery and surgical staging through a vertical midline laparotomy. While laparoscopy has become an integral part of gynecologic surgery, debulking procedures have not been feasible to date with standard minimally invasive techniques.

METHODS AND MATERIALS

Twenty-five patients with ovarian carcinoma underwent surgical staging and cytoreduction using hand-assisted laparoscopy. We review the surgical technique and clinical outcomes.

RESULTS

Twenty-five patients were managed during this study time frame with hand-assisted laparoscopy. Six patients had apparent advanced stage ovarian cancer at the time of referral, and 17 patients had apparent early-stage ovarian cancer. Of the 19 patients with presumed early-stage disease, 5 patients were upstaged based on retroperitoneal lymph node involvement, 3 with disease to other pelvic structures, and 2 patients had microscopic disease in the omentum. Twenty-two patients had their surgeries completed via hand-assisted laparoscopy, and three cases required conversion to laparotomy for completion of debulking surgery. Complication rates were low with three complications requiring reoperation or hospitalization. The mean hospital stay was 1.8 days for the 22 patients who had a successful hand-assisted laparoscopic evaluation. Operating times were variable and ranged from 81 to 365 min.

CONCLUSION

Hand-assisted laparoscopy may be employed in the initial management of early and advanced stage ovarian carcinoma. This approach allows for thorough evaluation of peritoneal and retroperitoneal structures and surgical cytoreduction while retaining the advantages of minimally invasive surgery.

Hand-assisted laparoscopic surgery (HALS): a report of 150 procedures

BACKGROUND

This study was performed to evaluate the (long-term) morbidity associated with hand-assisted laparoscopic surgery (HALS) for various indications.

METHODS

HALS procedures for various indications were evaluated prospectively from 1995 to 2002. The primary outcome parameters were postsurgical complications and the development of incisional hernias.

RESULTS

Twenty-six splenectomies, 51 hand-assisted laparoscopic donor nephrectomies (HLDN), 34 segmental bowel resections, 29 proctocolectomies, and 10 emergency colectomies were evaluated. A Küstner or Pfannenstiel incision was used for handport placement. Minor complications (i.e., wound complications, urinary tract infection) occurred in 15%, 12%, 26%, 7%, and 33% of the patients after, respectively, splenectomy, HLDN, bowel resection, proctocolectomy, and emergency colectomy. Major complications (i.e., hemorrhage, anastomotic leakage) occurred in 15% and 12% of the patients after, respectively, bowel resection and proctocolectomy. Incisional hernias occurred in six patients (4%), all after a wound complication in the Küstner incision.

CONCLUSION

HALS is fast, safe, and feasible for various indications, especially HLDN and (procto-)colectomies. Little advantage can be expected when HALS is applied in splenectomy and segmental bowel (sigmoid) resection.

Hand-Assisted Laparoscopic Colectomy: A Single-Institution Experience

The purpose of this study was to examine the results of a single institution experience with hand-assisted laparoscopic colon resection for benign disease. We conducted a retrospective study of consecutive cases performed by experienced laparoscopic surgeons at a single institution. From August 1999 to June 2001, 37 patients underwent hand-assisted laparoscopic colon resection. Seventeen patients were male, and 20 were female. Median patient age was 58 years (range 20–80). Indications for surgery were: polyp (13), uncomplicated diverticular disease (eight), complicated diverticular disease (i.e., colovesicular fistula, phlegmon, etc.) (seven), chronic constipation (four), rectal prolapse (two), ulcerative colitis (one), endometriosis (one), and fecal incontinence (one). Procedures performed were: sigmoidectomy (14), right colectomy (nine), low anterior resection (seven), subtotal colectomy (five), cecectomy (one), and transverse colectomy (one). Variables examined were: conversion to open procedure, operative time, blood loss, time to return of flatus, length of postoperative hospital stay, and complications. There were no deaths. One case was converted to celiotomy (unable to rule out malignancy). The median operative time was 122 minutes (range 32–240) with a median operative blood loss of 132 mL (range 0–300). Return of flatus was noted (median) at postoperative day 3 (range 1–5), and the median length of stay after operation was 4 days (range 2–8). One patient developed a superficial wound infection, and there was one pelvic abscess (drained percutaneously). One patient developed urinary retention. There were no reoperations. In this single-institution experience hand-assisted laparoscopic elective colectomy for benign disease was successful in both straightforward and complicated cases. A low conversion rate to celiotomy and favorable operative times compared with published “pure” laparoscopic results suggest a flatter learning curve for handoscopy while retaining the benefits of “minimally invasive” surgery such as early return of flatus and short postoperative hospital stay. For these reasons hand-assisted laparoscopy should be considered an acceptable technique in elective colon resection for benign disease.

Care of the laparoscopic colectomy patient

Laparoscopic bowel surgery has demonstrated patient care benefits of decreased duration of hospital stay, smaller incisions, lower risk of cardiopulmonary complications, and reduced risk of small-bowel obstruction. Resection of complicated diverticular disease and inflammatory bowel disease can be technically challenging and may be associated with higher conversion rates. The applicability of these techniques to colon cancer is supported by a growing body of evidence that demonstrates similar survival and recurrence rates obtained by open resection and the exaggeration of the risk of port site recurrences. Laparoscopic colorectal surgery has also challenged much of the standard postoperative care plans used for colectomy. Optimal postoperative care of the laparoscopic colectomy patient requires an appreciation of the faster recovery enjoyed by these patients and the fact that ambulation and dietary advancement need to be accelerated. Coordination between the surgical team and the postoperative care team is essential to obtain all the benefits associated with this new approach to the management of colorectal disease.

Hand assisted laparoscopic donor nephrectomy: a comparison with the open approach

PURPOSE

Hand assisted laparoscopy combines aspects of open and laparoscopic surgery. A hand in the abdomen may facilitate laparoscopic live donor nephrectomy, allowing more urologists to participate. We report and compare our initial series of hand assisted laparoscopy donor nephrectomy with nephrectomy performed by standard open methods.

MATERIALS AND METHODS

In the last 18 months 60 patients at 2 institutions underwent hand assisted laparoscopy donor nephrectomy. This cohort was compared to a contemporary group of 31 patients who underwent open donor nephrectomy via a flank incision at our 2 institutions. Demographic and outcome data were compared retrospectively in a nonrandomized fashion in the 2 groups.

RESULTS

Demographic data on patient age, male-to-female ratio and body mass index were similar in the 2 groups. Operative time, transfusion rate, time to oral intake and complications were also similar. However, estimated blood loss, change in hematocrit preoperatively to postoperatively, hospitalization, parenteral and oral narcotic requirement, and donor convalescence were significantly less in the hand assisted laparoscopy versus open groups. In terms of allograft function, nadir creatinine, time to nadir creatinine, creatinine clearance at 6, 12, and 18 months, delayed graft function, episodes of acute rejection and ureteral stricture were similar in the groups.

CONCLUSIONS

Hand assisted laparoscopy is safe, efficacious and reproducible for living related donor nephrectomy. Compared with the open technique hand assisted laparoscopy provides the donor with significantly decreased postoperative morbidity, while enabling excellent allograft function. Further randomized prospective studies are warranted.

Surgical aspects and future developments of laparoscopy

Laparoscopy has revolutionized surgery and in the process influenced the practice of anesthesiology. This article reviews several minimal access procedures that have been accepted into practice, are gaining acceptance, or remain investigational. Absolute contraindications to laparoscopy have been emphasized. As the threshold for primary care physicians to refer sicker and sicker patients for surgery decreases, it is crucial for the anesthesiologist to understand physiologic stresses of pneumoperitoneum and the nuances of laparoscopic surgery. The anesthesiologist also can be recruited to adjust insufflation pressures, tweak images on monitors, rotate and position the patient, or pass balloons and bougies. With patient and surgeon expectation of no pain or nausea and early discharge, anesthetic choices become vital for the ultimate success of the procedure.

Laparoscopic elective treatment of diverticular disease. A comparison between laparoscopic-assisted and resection-facilitated techniques

BACKGROUND

Because of the presence of significant inflammatory reaction, elective surgical laparoscopic-assisted treatment of complicated diverticular disease can be difficult, leading to a high conversion and complication rate. Laparoscopic alternatives to this assisted approach consist of the hand-assisted method and the more conventional facilitated laparoscopic sigmoid resection. Facilitated laparoscopic sigmoid resection implies laparoscopic mobilization of the sigmoid as much as possible and splenic flexure when called for. Through a Pfannenstiel incision, the difficult steps of the operation-such as the dissection of the inflammatory process and taking down the fistula, but also resection and manual anastomosis-can be performed. In this study, we compare the operating time, conversion rate, complications, and costs of both assisted and resection-facilitated techniques.

METHODS

We compared two consecutive series of 35 patients with diverticular disease who underwent a sigmoid resection by laparoscopy. Both groups were comparable in terms of age, gender, and kind of complicated diverticular disease.

RESULTS

The operating time, conversion rate, and costs were all less in the laparoscopic-facilitated group. The fact that there were no conversions in this group is the most important finding of this study. Not only was it possible to convert from the assisted laparoscopic approach to laparotomy (five patients of 35), it was also possible to convert from the assisted to the facilitated form (seven of 35 patients).

CONCLUSIONS

Laparoscopic-facilitated sigmoid resection is a feasible intervention for all forms of complicated diverticular disease and yields marked reductions in operating time, conversion rate, and operative and general costs.

Hand-assisted laparoscopic surgery (HALS) with the HandPort system: initial experience with 68 patients

OBJECTIVE

To evaluate the feasibility and potential benefits of hand-assisted laparoscopic surgery with the HandPort System, a new device.

SUMMARY BACKGROUND DATA

In hand-assisted laparoscopic surgery, the surgeon inserts a hand into the abdomen while pneumoperitoneum is maintained. The hand assists laparoscopic instruments and is helpful in complex laparoscopic cases.

METHODS

A prospective nonrandomized study was initiated with the participation of 10 laparoscopic surgical centers. Surgeons were free to test the device in any situation where they expected a potential advantage over conventional laparoscopy.

RESULTS

Sixty-eight patients were entered in the study. Operations included colorectal procedures (sigmoidectomy, right colectomy, resection rectopexy), splenectomy for splenomegaly, living-related donor nephrectomy, gastric banding for morbid obesity, partial gastrectomy, and various other procedures. Mean incision size for the HandPort was 7.4 cm. Most surgeons (78%) preferred to insert their nondominant hand into the abdomen. Pneumoperitoneum was generally maintained at 14 mmHg, and only one patient required conversion to open surgery as a result of an unmanageable air leak. Hand fatigue during surgery was noted in 20.6%.

CONCLUSIONS

The hand-assisted technique appeared to be useful in minimally invasive colorectal surgery, splenectomy for splenomegaly, living-related donor nephrectomy, and procedures considered too complex for a laparoscopic approach. This approach provides excellent means to explore, to retract safely, and to apply immediate hemostasis when needed. Although the data presented here reflect the authors' initial experience, they compare favorably with series of similar procedures performed purely laparoscopically.

Extending the limits: minimally invasive surgery

Minimally invasive technology is being applied to an increasing number of surgical procedures. It remains to be seen which techniques will eventually become a 'gold standard' as has the laparoscopic cholecystectomy, and which will fall by the wayside. In the meantime, anesthesiologists must be aware of the unique requirements and complications of laparoscopic surgery.