[Manually assisted laparoscopic surgery--realistic evolution of the minimally invasive therapy concept? Initial experiences with the "Endohand"]

Hand-assisted laparoscopic sigmoid resection for diverticular disease: 100 consecutive cases

BACKGROUND

Hand-assisted laparoscopic surgery (HALS) has been proposed as a useful alternative to conventional laparoscopic and open surgery. As compared with conventional laparoscopic surgery, it offers the advantages of tactile feedback, better exposure, and a shorter learning curve. There is increasing evidence that HALS retains the advantages of minimal-access surgery. The aim of this study was to analyze the feasibility as well as the short- and medium-term outcomes of HALS sigmoid resection for diverticular disease.

METHODS

The study included 100 consecutive patients between July 1999 and August 2004. Data were prospectively recorded. Follow-up evaluation was performed by standardized telephone interview after a mean postoperative period of 19 months (range, 2-55 months).

RESULTS

Two major intraoperative complications occurred: splenic laceration requiring splenectomy and ureteral injury requiring suture. There were only three conversions: one case of pararectal incision and two cases of extended lower Pfannestiel incision. There was no single case of conversion to midline laparotomy. One patient died postoperatively of myocardial infarction. The postoperative complications included intraabdominal hematoma (2%), anastomotic leakage (3%), wound infection (11%) and bladder dysfunction (1%). The reoperation rate was 5%. The median hospital stay was 8 days. In terms of satisfaction with the results, 97% of patients would choose HALS again.

CONCLUSIONS

When used for diverticular disease, HALS sigmoid resection has a low intra- and postoperative complication rate. The satisfaction rate among patients is high. Even in technically difficult cases, conversion to midline laparotomy can be avoided.

Hand-assisted laparoscopic surgery using Gelport

INTRODUCTION

Minimally invasive surgery has revolutionized general surgery during the past 10 years. However, for more advanced surgical procedures, the acceptance of the minimally invasive approach has been slower than expected. Advanced laparoscopic surgery is complex and time-consuming. The major drawbacks of laparoscopic surgery are two-dimensional view, lack of depth perception and loss of tactile sensation. This has led to the innovation of hand-assisted laparoscopic surgery (HALS). The objective of the present study was to determine that safety of HALS.

MATERIALS AND METHODS

We preformed 18 HALS procedures in our department between July 2003 and January 2005 on patients who had given their informed consent for the use of Gelport. Out of these, 15 were colectomy, 2 nephrectomy and 1 splenectomy. Out of the 18 patients, 13 were males and 5 were females with the age group ranging from 44 to 72 years.

RESULTS

Hand-assisted laparoscopic surgery could be completed in 17 patients maintaining all the oncological principals of surgery. The mean operating times were 120 min for right haemicolectomy, 135 min for left colectomy, 150 min for splenectomy, and 150 min for nephrectomy. The patient undergoing radical nephrectomy by HALS had to be converted to open surgery. As the tumour was large and adherent to the spleen and posterior peritoneal wall. Postoperative recovery was excellent with an average hospital stay of 5 days. Histopathology report showed wide clearance and till date we have a good follow up of 30-380 days.

CONCLUSION

Hand-assisted laparoscopic surgery allows tactile sensation and depth perception thereby may simplify the complex procedures. This may result in reduction of operating time and conversion rates at the same time maintaining all the oncological principles. Hand-assisted laparoscopic surgery strikes a perfect balance between an extended open laparotomy incision and an excessively tedious laparoscopic exercise. Hand assistance is an initial tool for the trainee laparoscopic surgeon or a last resort for the experienced laparoscopic surgeon.

Cost-effectiveness of minimally invasive-intervention in aortofemoral revascularization

Minimally invasive surgical procedures have become popular recently because they offer several advantages over conventional operative techniques. A person undergoing a minimally invasive procedure usually experiences less pain, is discharged earlier from hospital, returns to work sooner and has a less obtrusive post-operative scar. Excluding highly technical techniques (e.g. laparoscopic surgery), operations performed using mini-laparotomy are usually more cost-effective than conventional procedures, largely because they are less expensive to perform. Our paper investigates cost-effectiveness and other parameters relating to minimally invasive aortofemoral revascularization procedures performed at our clinic. We compared 20 similar cases, half where revascularization was undertaken using mini-laparotomy and half where conventional laparotomy was selected. From our findings we conclude that mini-laparotomy is safe and reliable for aortobifemoral bypass procedures and has several advantages over traditional techniques; namely, shorter operating time, earlier resumption of intestinal function, shorter duration of in-patient stay and reduced costs.

A new minimally invasive method of aortofemoral revascularization

In recent years, minimal invasive surgical applications have been used in every field of surgery and became a routine application for some kinds of operations. Mini-laparotomy has been limited to abdominal incisions between 3 and 10 cm long. Four aortobifemoral and one aortofemoral bypass cases that were performed with mini-laparotomy incision between January 1997 and February 1998 are presented. In all cases, revascularization of lower extremities was performed successfully without enlarging the incision. The average operation time was shorter and the number of transfused blood units was significantly lower in that group when compared to the conventional laparotomy group of 12 cases. In all cases, bowel sounds appeared in 2 to 8 hours and at the end of 24 hours, oral nutrition was started. The mean discharge time from the hospital was 4.7 days. With the advantages of less operation time, optimal aortic exposure, ability in safe cross-clamping, less postoperative pain, less scar tissue occurrence, early resumption of intestinal functions, early mobilization and shorter hospitalization time, the mini-laparotomy technique is a safe reliable method for use in aortobifemoral bypass operations.

Aortobifemoral Bypass Surgery Using Mini-Laparotomy Technique

We describe 4 cases of aortobifemoral bypass performed using a mini-laparotomy incision (6 to 8 cm) between January 1997 and February 1998. Revascularization of the lower extremities was carried out successfully without the need to enlarge the incision. The mean aortic cross-clamp time was 12.7 ± 3.4 minutes and the mean duration of the operation was 93.7 ± 30.9 minutes. In all cases, bowel sounds appeared at 2 to 8 hours postoperatively and oral nutrition was started after 24 hours. The mean hospital stay was 4.7 days. With the advantages of short operation time, optimal aortic exposure, easy and safe aortic cross-clamping, limited postoperative pain and scar tissue, early mobilization and resumption of intestinal functions, and short hospitalization, we believe that the mini-laparotomy technique is safe and effective for aortobifemoral bypass operations.