Hand-assisted Laparoscopic Group Research Articles

Compared to preoperative plasma levels post-operative urokinase-type plasminogen activator-1 levels are persistently elevated for 6 weeks after minimally invasive colorectal resection.

Urokinase-type plasminogen activator-1 (uPA) is a serine protease that converts plasminogen to plasmin after binding to uPA receptor (uPAR). Plasmin catalyzes the regeneration of basement membrane, extracellular matrix, and other tissues. uPA alone and with plasmin leads to activation of angiogenic growth factors that impact tumor cell proliferation, adhesion, and migration. uPA over expression has been noted in colorectal cancer (CRC) and high tissue levels have been correlated with prognosis. uPA/uPAR promotes immune cell activation in healing surgical wounds and may alter perioperative uPA plasma levels. Postoperative (postop) plasma levels, if elevated, may impact the early growth of residual metastases. The impact of minimally invasive colorectal resection (MICR) surgery for CRC on plasma uPA levels is unknown. This study's aim was to measure plasma uPA levels during the first postop month. CRC patients undergoing MICR who enrolled in an Institutional Review Board (IRB) approved data/plasma bank for whom adequate plasma was available were included in the study. Patients who had chemotherapy or radiotherapy within 4 weeks, those who received blood transfusions perioperatively and immunosuppressed patients were excluded. Clinical and pathological data were prospectively collected as were blood samples preoperatively, postop day (POD) 1, 3 and at least 1 late time point between POD 7-41. Plasma was isolated and stored at -80 ℃. Late samples were bundled into 7-day blocks and considered as single time points. Total uPA levels (ng/mL) were analyzed in duplicate via enzyme-linked immunosorbent assay (ELISA) and results reported as mean ± standard deviation (SD). The Wilcoxon paired t-test was used for analysis. Ninety-three patients undergoing MICR for CRC [colonic 68%; rectal 32%; average age 65.6 years, laparoscopic 63%, hand-assisted minimally invasive surgery (MIS) 37%] who met criteria were studied. Cancer stage breakdown was; stage I, 30%, stage II, 29%, stage III, 34%, stage IV, 7%. The median preoperative (preop) uPA plasma level (ng/mL) was 529.8 [95% confidence interval (CI): 462.8, 601.1] (n=93). Significant elevations in median levels vs. preop were present during POD 3 (542.8, 95% CI: 518.8, 597.3, n=86, P=0.003), POD 7-13 (688.1, 95% CI: 591.7, 753.0, n=72, P<0.001), POD 14-20 (764.9, 95% CI: 704.1, 911.6, n=27, P<0.001), POD 21-27 (685.6, 95% CI: 443.8, 835.8, n=15, P<0.001), and on POD 28-41 (800.3, 95% CI: 626.9, 940.6, n=21, P<0.001). The colon cancer subgroup's preop and POD 14-20 median results were significantly higher than the corresponding rectal cancer results; otherwise, at the other 5 postop time points there were no significant differences between the rectal and colon cancer subgroups. In addition, no association was found between cancer stage and preop uPA levels and no significant differences were found in postop uPA levels between the hand-assisted laparoscopic group and the lap assisted subgroup at any of the postop time points. Persistently elevated plasma uPA levels at 5/6 postop time point (P<0.05), in combination with other previously demonstrated long duration proangiogenic plasma protein changes, may render the plasma proangiogenic within the period of the first month post-surgery and may promote angiogenesis within the residual tumor foci. The clinical significance pertaining to these changes, if any, is uncertain and remains to be proven.

Laparoscopic and Robotic Surgery for Rectal Cancer—Comparative Study Between Two Centres

We compared short-term and long-term surgical and oncological outcomes of robotic surgery versus hand-assisted laparoscopic surgery for rectal cancers patients. Study was conducted at the National Cancer Institute and Yonsei Cancer Centre from August 2006 to December 2012. We prospectively reviewed all patients who underwent RS and HALS for upper and middle third rectal cancers. Patients’ demographics, postoperative short-term and long-term outcomes were assessed. Baseline patients’ characteristics were similar in both groups. Average operative time was 321.3 ± 70 min for robotic surgery versus 106.0 ± 37 min for hand-assisted laparoscopic surgery, P < 0.001). Higher number of patients (n = 74, 94.9%) with tumour in the upper rectum was found in hand-assisted laparoscopic group (P < 0.01). Perioperative complications were more common in the robotic surgery group (9 vs. 5 patients). In all stages, 3-year overall survival was 86.9% in the hand-assisted laparoscopic group vs. 89.6% in the robotic group: 80.0% vs. 79.2 for stage I and 82.4% vs. 88.9 for stage II and III. The 3-year DFS was 83.6% in hand-assisted laparoscopic group vs. 83.2%—robotic surgery group considering all stages. Anastomotic leakage, bleeding, number of postoperative complications, overall survival and disease-free survival were similar and not much different between robotic and hand-assisted laparoscopic rectal cancer surgery.

2440 Efficacy of Hand Assisted Laparoscopic Adenomyomectomy with Manipulation of Uterine Artery Comparing with Classical Laparoscopic and Laparotomic Adenomyomectomy

Study Objective To assess the safety and benefit of Hand-assisted laparoscopic (HALS) adenomyomectomy compared with laparoscopic and laparotomic adenomyomectomy. Design Single-center, nonrandomized, comparative study. Setting University hospital, tertiary referral center. Patients or Participants 20 patients underwent HALS adenomyomectomy with bilateral uterine artery ligation (BUAL) or transient occlusion of uterine artery (TOUA). HALS group was compared with laparoscopic adenomyomectomy (n=82) and laparotomic adenomyomectomy (n=170) with or without BUAL/ TOUA between January 2016 and January 2019. Interventions HALS adenomyomectomy was performed via laparoscopic and/or extracorporeal approach through suprapubic incision (about 5cm). Other groups underwent laparoscopic adenomyomectomy or laparotomic adenomyomectomy alone. Measurements and Main Results HALS and laparotomic groups were comparable with average estimated blood loss (217.5±136.0 vs, 193.6±193.0 mL, p=0.858), weight of removed mass (89.0 ±75.2 vs 108.2±91.9 g, p=0.699), postoperative hospital day (HD) (4.6±1.1 vs 4.7±0.8 days, p=0.922). Laparoscopic group was lower in all of them (EBL 119.5±79.6 ml, mass weight 39.3±25.9 g, HD 3.6±0.8 days). The three groups did not differ significantly in transfusion rates, hemoglobin change, febrile morbidity, and perioperative complications. Additional procedures were more frequently performed in HALS (0.33±0.48) than other groups such as myomectomy, pelvic adhesiolyis, adnexa & pelvic endometriosis excision (vs. laparosopy 0.16±0.36, p=0.024; vs. laparotomy 0.15±0.36, p=0.017). The mean operating time was longer in HALS group (182.5±38.1 min), compared with other groups (vs. Laparoscopy 99.9±40.6min, p Conclusion HALS adenomyomectomy with BUAL/ TOUA allows for complete excision of adenomyosis via extracorporeal & intracorporeal procedures while retaining the advantages of minimally invasive surgery. Furthermore, this approach could easily perform the additional pelvic surgery for benign uterine and adnexal pathology without compromising surgical outcomes.

Feasibility of hand-assisted laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancy.

In light of the modern surgical trend towards minimally invasive surgery, we aim to assess the feasibility of hand-assisted laparoscopic (HAL) cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in peritoneal surface malignancy (PSM). Patients with PSM secondary to colorectal cancer or pseudomyxoma peritonei with peritoneal cancer index (PCI) of ≤ 10 were considered for HAL CRS and HIPEC. One patient had PCI of 15 but based on the disease distribution laparoscopic-assisted CRS and HIPEC was thought to be feasible, thus was also included. These patients were compared to matched controls who underwent open CRS and HIPEC for similar pathologies. Matching was performed on age and PCI to reflect a comparable complexity of the operation, and tumor grade for comparable risk of disease recurrence. Eleven patients were included in each group. In both groups, mean PCI was 4.1, mean age was 58.5years, and 81.8% were well-moderately differentiated tumors. Complete cytoreduction was achieved in all patients. Upon comparison, HAL patients had significantly less blood loss and 3-day shorter hospitalization. No difference was demonstrated in operative time, number of visceral resections, and rate of omentectomy/peritonectomy. Also, no difference was detected in morbidities and 30-day readmission rates. No intraperitoneal recurrences have been reported in the HAL group after a median follow-up of 11months. HAL CRS and HIPEC is a feasible procedure and can be considered for PSM with low PCI. It offers very acceptable and comparable short-term outcomes to the conventional open approach.

Hand-assisted living-donor nephrectomy: a retrospective comparison of two techniques

BackgroundLiving-donor nephrectomy (LDN) is challenging, as surgery is performed on healthy individuals. Minimally invasive techniques for LDN have become standard in most centers. Nevertheless, numerous techniques have been described with no consensus on which is the superior approach. Both hand-assisted retroperitoneoscopic (HARS) and hand-assisted laparoscopic (HALS) LDNs are performed at Zurich University Hospital. The aim of this study was to compare these two surgical techniques in terms of donor outcome and graft function.MethodRetrospective single-center analysis of 60 consecutive LDNs (HARS n = 30; HALS n = 30) from June 2010 to May 2012, including a one-year follow-up of the recipients.ResultsThere was no mortality in either group and little difference in the overall complication rates. Median warm ischemia time (WIT) was significantly shorter in the HARS group. The use of laxatives and the incidence of postoperative vomiting were significantly greater in the HALS group. There was no difference between right- and left-sided nephrectomies in terms of donor outcome and graft function.ConclusionsBoth techniques appear safe for both donors and donated organs. The HARS technique is associated with a shorter WIT and a reduced incidence of postoperative paralytic ileus. Therefore, we consider HARS LDN a valuable alternative to HALS LDN.

Hand-assisted laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis.

Introduction:In this study, we aimed to evaluate the feasibility and safety of undergoing restorative proctocolectomy through ileal pouch-anal anastomosis (RPC-IPAA) with hand-assisted laparoscopic (HALS) in patients with ulcerative colitis (UC).Patients and Methods:We reviewed 40 consecutive patients who underwent RPC-IPAA with HALS or open technique for treatment of UC between 2010 and 2013. Moreover, the intra-/post-operative outcomes were compared.Results:We found the median operative time was significantly longer in the HALS group while the blood loss was significantly less in patients with HALS than with open surgery. In the HALS group, the median duration of bed rest and the length of hospital stay were significantly shorter. Moreover, the rate of early post-operative complications in the HALS group was significantly less than that in the open surgery group, among which one patient died in the 30th day after surgery for the extensive use of steroids before the operation.Conclusion:These findings clearly show that HALS RPC is safe and less invasiveness. HALS can become a more comfortable and standardised procedure for UC with the adoption of evolving technologies.

Comparison of straight vs hand-assisted laparoscopic colectomy: an assessment from the NSQIP procedure-targeted cohort

BackgroundThe perioperative outcomes of patients who underwent straight laparoscopic (LAP) vs hand-assisted laparoscopic (HALS) surgery were compared using a recently released procedure-targeted database. MethodsThe 2012 colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program database was used and patients were classified into 2 groups according to the final surgical approach: LAP vs HALS. Demographics, comorbidities, and 30-day outcomes were compared. ResultsA total of 7,843 patients met the inclusion criteria. There were 4,656 (59%) patients in LAP colectomy and 3,187 (41%) in HALS colectomy groups. Groups were comparable in terms of preoperative characteristics and demographics. Mean operative time was slightly longer in LAP group (178 ± 86 vs 171 ± 84 minutes, P < .001). After covariate-adjustment analysis, the overall morbidity, superficial surgical site infection, and ileus rates remained slightly higher in HALS group. ConclusionsBoth straight laparoscopic and hand-assisted approaches are used in colorectal surgery and may complement each other in challenging cases. Implementing the best approach to decrease postoperative complication rates and increase use of minimally invasive techniques may play a role in improving patient care and overall quality.

Surgical Treatment of Diverticulitis: Hand-Assisted Laparoscopic Resection Is Predominantly Used for Complex Cases and Is Associated With Increased Postoperative Complications and Prolonged Hospitalization.

Introduction Laparoscopic (LAP) colectomy is now the "gold" standard for diverticulitis; the role of hand-assisted LAP (HAL) and Open methods today is unclear. This study assessed the elective use of these methods for diverticulitis. Methods A retrospective review of demographic, comorbidity (Carlson Comorbidity Index [CCI]), resection type, and short-term outcomes was carried out. Results There were 125 (44.5%) LAP, 125 (44.5%) HAL, and 31 (11%) Open cases (overall N = 281). The mean age, body mass index, and percentage of high-risk patients (CCI score >2) of the HAL group were greater (P < .05) than the LAP group (vs Open, P = ns). The Open group's mean age and percent with CCI >2 was greater when compared with the LAP group (P < .05). More Open (P < .05) and HAL patients had complex disease (Open, 63%; HAL, 40%, LAP, 22%) and were diverted (Open, 35%; HAL, 10%; LAP, 3%). Time to bowel movement was not different; however, there was a stepwise increase in median length of stay (LOS; days) from the LAP (5 days) to HAL (6 days) to Open group (7 days) (P < .05 for all). The LAP complication rate (22.4%) was lower (P < .05) than the HAL (42.4%) or Open groups' (45.2%) rates. The LAP surgical site infection rate (5.6%) was lower (P < .05) than the HAL (12.8%) or Open groups (19.6%). Conclusion The HAL and Open groups had more high risk, complex disease, diverted, and older patients than the LAP group; likewise, the overall complication rate and LOS was higher in the HAL and Open groups. Use of HAL methods likely contributed to the high minimally invasive surgery utilization rate (89%).

Comparison of open, laparoscopic, and hand‐assisted laparoscopic devascularization of the upper stomach and splenectomy for treatment of esophageal and gastric varices: A single‐center experience

Laparoscopic devascularization of the upper stomach and splenectomy (Dev+Sp), is technically difficult in patients with portal hypertension because of enlarged collateral vessels and spleen. This report presents the efficacy and safety of hand-assisted laparoscopic (HALS) Dev+Sp. Ten patients underwent HALS Dev+Sp as a treatment for esophagogastric varices between 2005 and 2012 (HALS group). A vessel-sealing system was used for devascularization of vessels. An autosuture device was applied to dissect the splenic hilum and the left gastric and enlarged short gastric vessels. The operative and postoperative data were compared between patients who previously underwent laparoscopic Dev+Sp (LAP group, n = 9) and conventional Dev+Sp (OP group, n = 10) between 2001 and 2008. The mean operative time was 328, 336, and 245 min (P < 0.05) and the mean blood loss was 1786, 981, and 250 mL (P < 0.05) in the OP, LAP, and HALS groups, respectively. Laparoscopic surgery was converted to HALS in one patient and to open surgery in three patients. There were no conversions in the HALS group. There was no significant difference in the cumulative recurrence rate and bleeding rate in the groups. HALS Dev+Sp is a feasible and effective surgery in patients with portal hypertension.

Analysis of postoperative complications and risk factors in patients with portal hypertension treated by laparoscopic splenectomy

Objective To investigate the postoperative complications after laparoscopic splenectomy for patients with portal hypertension,and analyze the risk factors for postoperative complications.Methods The clinical data of 65 patients with portal hypertension who received laparoscopic splenectomy at the West China Hospital from September 2003 to September 2012 were retrospectively analyzed.The postoperative complications were analyzed using the modified Clavien classification system,and the risk factors for postoperative complications were analyzed.The measurement data and the count data were analyzed using the t test,chi-square test or the Fisher exact probability.The univariate and multivariate analysis were done using the Logistic regression model.Results Twenty-nine patients received hand-assisted laparoscopic splenectomy and 36 received total laparoscopic splenectomy (2 patients were converted to open surgery due to intraoperative bleeding).Sixteen patients had 20 complications.The incidence of postoperative complications of the hand-assisted laparoscopic group was 10.3％ (3/29),which was significantly lower than 38.2％ (13/34) of the total laparoscopic group (x2 =3.90,P ＜ 0.05).According to the modified Clavien classification system,there were 4 patients with grade Ⅰ complication,2 patients with grade Ⅱ complication,8 patients with grade Ⅲ a complication,1 with grade Ⅲ b complication,1 with grade Ⅳa complication,and no Ⅳb or Ⅴ complication was observed.The duration of postoperative hospital stay was (8.4 ± 2.9) days.For patients with grade Ⅱ,Ⅲ and Ⅳ complications,the duration of postoperative hospital stay was (10.1 ± 3.3) days,which was significantly longer than (7.7 ± 2.5) days of patients with grade Ⅰ complication or without complications (t =4.30,P ＜ 0.05).The results of univariate analysis showed that ASA classification and application of hand-associated device were risk factors for postoperative complications (x2=21.60,5.10,P ＜0.05).The results of multivariate analysis showed that ASA grade Ⅲ and non-application of hand-assisted device were independent risk factors for postoperative complications (OR =23.60,4.60,P ＜ 0.05).The incidence of postoperative complications of patients with ASA grade Ⅲ were 17.00 times higher than patients with ASA grade Ⅱ,and the incidence of postoperative complications of patients who received total laparoscopic splenectomy was 5.00 times higher than those who received hand-assisted laparoscopic splenectomy.Conclusions The incidence of postoperative complications is higher in patients with portal hypertension,while the severity of the complications is under ASA grade Ⅲ.ASA classification and application of hand-assisted device are correlated with the incidence of postoperative complications. Key words: Portal hypertension ; Laparoscopy ; Splenectomy ; Complications

The rate for the use of hand-assisted laparoscopic methods is directly proportional to body mass index

Hand-assisted laparoscopic (HAL) colorectal resection remains controversial. Critics believe HAL methods lead to decreased use of laparoscopically assisted (LA) methods. Proponents believe selective HAL use increases minimally invasive surgery (MIS) use rates. This study assessed general and body mass index (BMI)-specific HAL and LA colorectal resection use by surgeons who embraced both methods. This study retrospectively investigated 1,122 patients who underwent colorectal resection during an 8-year period. Surgical method, type of colorectal resection, BMI, comorbidities, incision length, and short-term outcomes were collected. The surgical methods included LA (60 %), HAL (25 %), and open (OP 15 %) procedures. The HAL group mean BMI was higher than that of the LA group (P < 0.0001), and the HAL use rate varied directly with BMI. The HAL technique was used for 48 % of the rectal, 36 % of the sigmoid, and 4 % of the right colorectal resections. The incision length was directly proportional to BMI for all the methods. Although the HAL incision lengths were significantly longer than the LA incision lengths for a BMI lower than 40 kg/m(2), there was no difference when the BMI was 40 kg/m(2) or higher. The comorbidities were greater in the HAL group than in the LA sigmoid colorectal resection group (P = 0.001). The mean hospital length of stay (LOS) was similar for the HAL and LA patients but longer for the open surgery patients (P < 0.0001 vs HAL group). The major complications, reoperations, and 30-day mortality rates were low and comparable. The HAL methods were used primarily for sigmoid and rectal colorectal resections and for higher BMI patients with more comorbidities. The mean incision length difference between the HAL and LA methods was 3.9 cm, but neither the LOS nor the major postoperative complications differed significantly. Selective use of HAL together with LA methods led to a MIS use rate of 85 % and facilitated MIS for high BMI patients. Together, the methods are complementary and may increase the number of minimally invasive surgeries performed.

Hand-assisted laparoscopic versus laparotomy in total proctocolectomy with ileal pouch-anal anastomosis: a clinical controlled study

To compare the outcomes of total proctocolectomy with ileal pouch-anal anastomosis performed by hand-assisted laparoscopic(HALS) and laparotomy. Clinical data of 78 patients undergoing HALS(n=36) or laparotomy(n=42) from January 2009 to June 2011 were retrospectively studied. All the operations were performed by the same surgical group. Patients safety, postoperative recovery, complications were compared between the two groups. As compared to laparotomy group, HALS group had longer operative time[(300.3±56.4) min vs. (227.2±34.0) min, P=0.001], less intraoperative bleeding[(150.2±42.2) ml vs. (213.5±61.0) ml, P=0.043], shorter interval to first flatus[(2.4±0.9) d vs. (3.1±1.2) d, P=0.026], and shorter hospital stay[(9.3±2.6) d vs. (11.6±3.4) d, P=0.039]. There were no significant differences in the incidence of complications such as anastomotic separation, hemorrhage, wound infection, pelvic sepsis, and intestinal obstruction between the two groups(P>0.05). HALS is as safe as open approach for total proctocolectomy with ileal pouch-anal anastomosis, and short-term outcomes are better than laparotomy.

Decreased Expression of Hepatic Signaling Phosphoproteins After Laparoscopic and Hand-Assisted Surgery in a Porcine Model

Minimally-invasive surgery (MIS) is associated with a decreased activation of both systemic and peritoneal immunity compared with the open technique. However, hepatic response to laparoscopic (LAP) and hand-assisted laparoscopic (HAL) surgery has not been defined well. We postulated that both LAP and HAL approaches are associated with a diminished activation of hepatic inflammatory signaling pathways compared with the traditional open surgery. Eighteen pigs underwent a transabdominal nephrectomy via Open, HAL, or LAP approach. Liver samples were obtained 24 h postoperatively and spot frozen. Frozen tissue samples were then homogenized and the nuclear pellets were separated and stored. Nuclear extracts were analyzed for activation of three nuclear signaling phosphoproteins: nuclear factor-kappaB (NFκB)-p65, heat-shock protein 27 (HSP27), and p38 mitogen-activated protein kinases (p38MAPK) using a standard Bioplex technique. Statistical comparison was performed using ANOVA and Student's t-test. The average expression of HSP27 was significantly higher in the Open versus either the LAP or the HAL groups (P = 0.028 and P = 0.039). The average expression of NFκB-p65 was significantly higher in the Open versus either the LAP or the HAL groups (P = 0.032 and P = 0.049). The average expression of p38MAPK was significantly higher in the Open versus either the LAP or the HAL groups (P = 0.007 and P = 0.036). There was no significant difference in the expressions of HSP27 and NFκB-p65 between LAP and HAL groups (P = 0.38 and P = 0.20), however, detection of p38MAPK generated statistical difference between these two groups (P = 0.018). Hand-assisted laparoscopic surgery has been widely accepted as an effective alternative to traditional laparoscopic procedures. We demonstrated that both laparoscopic and hand-assisted approaches resulted in blunted hepatic stress manifested by diminished expression of hepatic HSP27, NFκB, and p38-MAPK. In addition, the hand-assisted approach was equal to the laparoscopic approach in two of the three phosphoproteins studied. It appears that the use of hand-assisted techniques did not abrogate immunologic benefits of pure laparoscopy. Overall, in addition to the clinical benefits of minimal access, both hand-assisted and pure laparoscopic techniques may also confer an immunologic advantage over laparotomy.

Hand-assisted laparoscopic versus laparoscopic-assisted right hemicolectomy: a clinical controlled study

To compare the outcomes of right hemicolectomy performed either by the hand-assisted laparoscopic(HALS) or conventional laparoscopic surgery(LAS). Ninety-five patients undergoing HALS(n=47) from March 2002 to November 2006 or by LAS (n=48) from January 2007 to December 2009 were retrospectively studied. All the operations were performed by the same surgical team. Patient safety, postoperative recovery, complications, oncologic outcomes, medical expenses, and the follow-up results were compared between the two groups. No severe complications or perioperative deaths were oberved. There were significant differences between the two groups in terms of intraoperative bleeding, operative time, and length of incision(all P<0.05). However, the conversion rate, intraoperative injuries, time to first bowel movement, postoperative bed-rest time, hospital stay, time to first oral intake, and the number of patients requiring postoperative analgesia were comparable between the two groups(P>0.05). Length of surgical specimen was (25.6±9.9) cm in the HALS group and was (26.8±7.9) cm in the LAS group, the diffenence was not statistically significant(P<0.05). The mean number of lymph nodes retrieved in HALS group was 18.2±12.1, which was significantly lower than that in LAS group(24.1±9.3, P<0.05). The medical expense of the LAS group was (28 049.8±7576.1) RMB, which was significantly higher than that of the HALS group(21 132.7±5323.4) RMB(P<0.05). A follow-up rate of 93.7% was achieved in the HALS group with 3 patients lost to follow-up. The follow-up duration ranged from 45.4 to 101.9 months with a median of 66.7 months. In LAS group, the follow-up rate was 96% with 2 patients lost to follow-up and the follow-up duration ranged from 12.4 to 45.7 months with a median of 21.6 months. There was no significant difference in 3-year disease-free survival(91.3% vs. 87.9%, P>0.05) between the two groups. HALS and LAS can achieve similar minimal invasiveness efficacy and oncologic outcomes for right hemicolectomy.

Single-Incision Laparoscopic Right Colectomy: A Case-Matched Comparison with Standard Laparoscopic and Hand-Assisted Laparoscopic Techniques

Single-incision laparoscopic (SIL) colectomy is an advance in minimally invasive colorectal surgical techniques. Feasibility and safety of SIL colectomy has been reported; however, benefits and outcomes are not well-defined. The purpose of this study was to compare outcomes of SIL right colectomy with multiport laparoscopic (LAP) and hand-assisted laparoscopic (HAL) techniques. SIL right colectomy cases performed between August 2009 and April 2010 were case-matched for age, sex, body mass index, American Society of Anesthesiologists score, previous abdominal surgery, and pathology to an equivalent number of LAP and HAL right colectomy cases. Data analyzed included operative time, procedure conversion, incision length, length of hospital stay, 30-day hospital readmission, surgical site infection and maximum postoperative pain score. Twenty-nine patients were analyzed in each of 3 groups (SIL, LAP, and HAL). The mean age (p = 0.96), body mass index (p = 0.48), American Society of Anesthesiologists score (p = 0.74), and rate of previous abdominal operation (p = 0.95) were similar, and sex and pathology were identical among groups. Operative time and conversion rates were similar. The incision length for SIL (4.5 cm) and LAP (5.1 cm) groups was similar, and both were significantly shorter than HAL group (7.2 cm; p < 0.001). Length of hospital stay was 3.4 days for the SIL group and was more than 1-day shorter than LAP and HAL groups (p < 0.05). Postoperative surgical site infection and hospital readmission were similar among groups. Maximum pain score on postoperative days 1 and 2 was significantly lower in SIL group (p < 0.05). SIL right colectomy can improve patient recovery through a decrease in early postoperative pain and shorter length of hospital stay when compared with established laparoscopic techniques.

Hand-Assisted Laparoscopic vs. Laparoscopic Colorectal Surgery: A Multicenter, Prospective, Randomized Trial

This study was designed to compare short-term outcomes after hand-assisted laparoscopic vs. straight laparoscopic colorectal surgery. Eleven surgeons at five centers participated in a prospective, randomized trial of patients undergoing elective laparoscopic sigmoid/left colectomy and total colectomy. The study was powered to detect a 30-minute reduction in operative time between hand-assisted laparoscopic and straight laparoscopic groups. There were 47 hand-assisted patients (33 sigmoid/left colectomy, 14 total colectomy) and 48 straight laparoscopic patients (33 sigmoid/left colectomy, 15 total colectomy). There were no differences in the patient age, sex, body mass index, previous surgery, diagnosis, and procedures performed between the hand-assisted and straight laparoscopic groups. Resident participation in the procedures was similar for all groups. The mean operative time (in minutes) was significantly less in the hand-assisted laparoscopic group for both the sigmoid colectomy (175 +/- 58 vs. 208 +/- 55; P = 0.021) and total colectomy groups (time to colectomy completion, 127 +/- 31 vs. 184 +/- 72; P = 0.015). There were no apparent differences in the time to return of bowel function, tolerance of diet, length of stay, postoperative pain scores, or narcotic usage between the hand-assisted laparoscopic and straight laparoscopic groups. There was one (2 percent) conversion in the hand-assisted laparoscopic group and six (12.5 percent) in the straight laparoscopic group (P = 0.11). Complications were similar in both groups (hand-assisted, 21 percent vs. straight laparoscopic, 19 percent; P = 0.68). In this prospective, randomized study, hand-assisted laparoscopic colorectal surgery resulted in significantly shorter operative times while maintaining similar clinical outcomes as straight laparoscopic techniques for patients undergoing left-sided colectomy and total abdominal colectomy.

Total Laparoscopic Restorative Proctocolectomy: Are There Advantages Compared with the Open and Hand-Assisted Approaches?

PurposeA randomized, controlled trial comparing hand-assisted laparoscopic restorative proctocolectomy with open surgery did not show an advantage for the laparoscopic approach. The trial was criticized because hand-assisted laparoscopic restorative proctocolectomy was not considered a true laparoscopic proctocolectomy. The objective of the present study was to assess whether total laparoscopic restorative proctocolectomy has advantages over hand-assisted laparoscopic restorative proctocolectomy with respect to early recovery.MethodsThirty-five patients underwent total laparoscopic restorative proctocolectomy and were compared to 60 patients from a previously conducted randomized, controlled trial comparing hand-assisted laparoscopic restorative proctocolectomy and open restorative proctocolectomy. End points included operating time, conversion rate, reoperation rate, hospital stay, morbidity, quality of life, and costs. The Medical Outcomes Study Short Form 36 and the Gastrointestinal Quality of Life Index were used to evaluate general and bowel-related quality of life.ResultsGroups were comparable for patient characteristics, such as sex, body mass index, preoperative disease duration, and age. There were neither conversions nor intraoperative complications. Median operating time was longer in the total laparoscopic compared with the hand-assisted laparoscopic group (298 vs. 214 minutes; P < 0.001). Morbidity and reoperation rates in the total laparoscopic, hand-assisted laparoscopic, and open groups were comparable (29 vs. 20 vs. 23 percent and 17 vs.10 vs. 13 percent, respectively). Median hospital-stay was 9 days in the total laparoscopic group compared with 10 days in the hand-assisted laparoscopic group and 11 days in the open group (P = not significant). There were no differences in quality of life and total costs.ConclusionsThere were no significant short-term benefits for total laparoscopic compared with hand-assisted laparoscopic restorative proctocolectomy with respect to early morbidity, operating time, quality of life, costs, and hospital stay.

Laparoscopic- vs. Hand-Assisted Ultralow Anterior Resection: A Prospective Study

A standard laparoscopic-assisted operation can be conducted with colorectal anastomosis performed after extraction of specimen and insertion of a pursestring via a small left iliac fossa or suprapubic incision, or completed via hand-assisted laparoscopic technique with a 7-cm to 8-cm suprapubic incision. This study compares the short-term outcomes of either technique. Sixty-three consecutive patients undergoing laparoscopic-assisted ultralow anterior resection or total mesorectal excision for rectal cancer were examined. The laparoscopic-assisted group (n = 31) had standard laparoscopic-assisted resection, whereas the hand-assisted laparoscopic group (n = 32) had a 7-cm to 8-cm suprapubic incision to allow an open colorectal anastomosis. In patients who were obese or have had multiple abdominal surgeries, the hand-assisted approach was generally favored. All patients had a diverting ileostomy. There was no conversion in either group. Mean operating time was significantly longer in the laparoscopic-assisted group (188.2 vs. 169.8 minutes; P < 0.0001). Mean duration for narcotic analgesia (1.65 vs. 3.38 days, P < 0.0001), mean time to flatus (1.97 vs. 3.19 days, P < 0.0001), and mean duration of intravenous hydration (2.45 vs. 3.88 days, P < 0.0001) were longer in the hand-assisted laparoscopic group. However, the mean length of hospital stay (5.8 vs. 5.9 days, P = 0.379) was similar. There was no major surgical complication in either group; chest infection, wound infection, and thrombophlebitis were similar between the laparoscopic-assisted group and the hand-assisted laparoscopic group. Adequacy of specimen harvest (distal tumor margins, P = 0.995; circumferential resection margin, P = 0.946; number of lymph nodes, P = 0.845) was similar. Although both laparoscopic-assisted and hand-assisted laparoscopic surgeries are safe and feasible for ultralow anterior resection, the hand-assisted technique significantly shortens operating time.

Third Prize: Randomized Trial of Laparoscopic Donor Nephrectomy with and without Hand Assistance

To compare the early results of standard laparoscopic (SL) and hand-assisted laparoscopic (HAL) donor nephrectomy in a randomized study. Forty donors were randomly assigned in equal numbers to either SL or HAL. Two donors in the SL group and three patients in the HAL group underwent right nephrectomy; the others underwent left nephrectomy. In the SL group, specimen extraction was performed via a Pfannenstiel incision and in HAL group through a periumbilical midline incision. Objective intraoperative, hospital stay, and postoperative data as well as pain analog scores were collected prospectively. Patients completed the quality-of-life (QoL) SF-36 questionnaire preoperatively and at 1 month and 3 months of follow-up. There was a statistically significant difference in the mean operative time in the two groups (200 +/- 20.8 minutes for SL v 219 +/- 28.3 minutes for HAL; P = 0.02). There was no difference in the mean estimated blood loss (141.5 +/- 221.8 mL v 97.4 +/- 73 mL, respectively; P = 0.41), warm ischemia time (157.5 +/- 76.3 seconds v 135.5 +/- 53.7 seconds; P = 0.32), length of postoperative hospital stay (1.9 +/- 0.5 days v 2.1 +/- 0.5 days; P = 0.61), intravenous analgesia (22.1 +/- 14.0 mg v 28.3 +/- 14.8 mg of morphine sulfate equivalent; P = 0.18), or pain score on postoperative day 1 (6.1 +/- 1.0 v 6.2 +/- 1.1) and 2 (3.3 +/- 1.2 and 3.4 +/- 1.3). There were five minor complications in the SL group and three in the HAL group. The mean preoperative (89.7 +/- 4.8 v 89.2 +/- 7.4; P = 0.84), 1-month (63.4 +/- 13.9 v 64.5 +/- 12.6; P = 0.82), and 3-month (82.7 +/- 7.4 v 80.2 +/- 8.4; P = 0.41) postoperative QoL scores did not differ significantly between the groups. None of the recipients required postoperative dialysis, and there was no statistical difference between the two groups in the serum creatinine concentration. Laparoscopic and hand-assisted donor nephrectomies have similar outcomes and postoperative pain. Both approaches are well tolerated with minimal complication rates and have similar impact on patients' quality of life.

Hand-assisted Laparoscopy Versus Conventional Median Laparotomy for Aortobifemoral Bypass for Severe Aorto-iliac Occlusive Disease: A Prospective Randomised Study

To demonstrate that hand-assisted laparoscopy for aortofemoral bypass for severe aorto-iliac occlusive disease reduces morbidity with earlier recovery of bowel function and shorter in-hospital stay. Randomised controlled trial. Thirty-six consecutive patients with severe aorto-iliac occlusive disease (TASK C/D) without history of major abdominal surgery necessitating an aortobifemoral bypass were randomised between a hand-assisted laparoscopic (HALS) approach and a conventional medial laparotomy. Operative data, early recovery data, quality of life and vascular outcome were analysed. No significant differences in operative data were found. Fluid and solid diet were resumed earlier (28.8 hrs vs. 76.9 hrs; p = 0.016) (45.6 hrs vs. 105.6 hrs; p = 0.02) and in-hospital stay was shorter (7.5 vs. 8.9 days; p = 0.005) in the HALS group. Six weeks post-operatively social functioning measured by the SF-36 survey score was better in patients randomised to HALS (p=0.023). HALS is a less invasive approach for aortofemoral bypass.