Hand-assisted Laparoscopic Surgery Research Articles

Different doses of nalmefene combined with hydromorphone hydrochloride for postoperative analgesia after colorectal surgery: a randomized controlled study

BackgroundHydromorphone hydrochloride has a satisfactory postoperative analgesic effect for patients with colorectal cancer but is accompanied by a relatively high incidence of adverse events. Low-doses of naloxone combined with opioids for patient-controlled analgesia can reduce the incidence of drug-related adverse events. Nalmefene is a more selective opioid receptor antagonist than naloxone. The aim of this study was to determine the impact of low-doses of nalmefene on the analgesic effect and incidence of adverse events of patients with hydromorphone patient-controlled analgesia (PCA) undergoing colorectal radical surgery.MethodsNinety-nine patients undergoing elective laparoscopic or hand-assisted laparoscopic radical surgery under general anaesthesia were randomly divided into three groups. Group N1 received hydromorphone hydrochloride 0.15 mg/kg + nalmefene 2 µg/kg; Group N2 received hydromorphone hydrochloride 0.15 mg/kg + nalmefene 0.5 µg/kg; and the control group (Group C) received hydromorphone hydrochloride 0.15 mg/kg. All medications were diluted to 100 ml with normal saline. The primary outcome was pain intensity at 12 h after surgery; the secondary outcomes were the occurrence of nausea, vomiting and pruritus and the total analgesic consumption of the PCA pump at 1 h, 6 h, 12 h, 24 and 48 h after surgery.ResultsThe NRS scores of Group N1 (2 µg/kg) were significantly lower than those of Group C (P = 0.025), and no difference was found between group N2 and group C (P > 0.05). Among the three groups, the NRS scores of Group N1 (2 µg/kg) were significantly lower than those of Group C at 12 h (P = 0.01) and 48 h (P = 0.01) postoperatively. Compared with 12 h postoperatively, the NRS scores were lower at 24 h postoperatively in Group N1 and Group C (P < 0.05) and significantly lower at 48 h postoperatively in all three groups (P < 0.001). There was a significant difference in the incidence of pruritus among the three groups (P = 0.036).ConclusionsNalmefene at a dosage of 2 µg/kg enhances the postoperative analgesic effect of hydromorphone hydrochloride and reduces the occurrence of postoperative pruritus.Trial RegistrationThe trial was registered with the Chinese Clinical Trial Registry (Registration number: ChiCTR2000033520, date: 03/06/2020).

Hand-assisted laparoscopic splenectomy and gastropancreatic fold division: a less-invasive simplified technique of Hassab's procedure for refractory esophagogastric varices.

Some patients with refractory esophagogastric varices require surgery, such as gastric devascularization and splenectomy (Hassab's procedure). However, these patients are at risk of perioperative morbidities when undergoing devascularization to develop collateral vessels. We performed a more simplified procedure, splenectomy, and en bloc gastropancreatic fold division (GPFD) with hand-assisted laparoscopic surgery. Four patients with refractory esophagogastric varices and portal hypertension underwent splenectomy and GPFD. We reviewed patients' perioperative laboratory and morphological data, operative variables, and postoperative outcomes. Esophagogastric varices improved in 3 (75%) of the 4 patients. In one patient, esophageal varices (F1RC0) were observed 3years after surgery, but they required no treatment and only received follow-up. Treatment with splenectomy and GPFD is not only less invasive than Hassab's procedure but also provides effective outcomes for refractory esophagogastric varices.

No difference in the incidence of postoperative pulmonary complications between abdominal laparoscopy and laparotomy for minimally invasive thoracoscopic esophagectomy: a retrospective cohort study using a nationwide Japanese database.

There remains a lack of evidence regarding the optimal abdominal approach, including laparoscopy, hand-assisted, and open laparotomy for minimally invasive thoracoscopic esophagectomy. We aimed to compare the incidence of postoperative complications, particularly pulmonary complications, between laparoscopy and open laparotomy for minimally invasive thoracoscopic esophagectomy using nationwide Japanese databases. Data from patients in the National Clinical Database (NCD) who underwent thoracoscopic esophagectomy for esophageal cancer were analyzed. The incidence of pulmonary complications was compared between abdominal laparoscopy and laparotomy after matching the propensity scores (PS) from preoperative factors to account for confounding bias. Laparoscopic-assisted surgery (LAS) was also compared to hand-assisted laparoscopic surgery (HALS). Of the 24,790 patients who underwent esophagectomy between 2018 and 2021, data from 12,633 underwent thoracoscopic procedure. The proportion of patients who experienced pulmonary complications did not significantly differ between the laparoscopy group and the laparotomy group after matching (664/3195 patients, 20.8% versus 702/3195 patients, 22.0%; P = 0.25). No difference in the incidence of pulmonary complications was observed among patients treated using the laparoscopic approach (508/2439 patients, 20.8% in the LAS group versus 498/2439 patients, 20.4% in the HALS group; P = 0.72). We observed no significant difference in the incidence of postoperative pulmonary complications between laparoscopy and laparotomy for thoracoscopic esophagectomy. Short-term outcomes were similar between the laparoscopic-assisted approach and the hand-assisted approach. This study provides valuable insights into the optimal abdominal approach for thoracoscopic esophagectomy using data from a nationwide database that reflect real-world clinical practice.

Appropriate indications for laparoscopic repeat hepatectomy

BackgroundLaparoscopic repeat hepatectomy (LRH) has increased, but appropriate indications for LRH are unclear. This study aimed to clarify appropriate indications for LRH.MethodsWe retrospectively compared surgical outcomes between open RH (ORH) (n = 57) and LRH (n = 40) groups. To detect difficult cases of complete pure LRH, we examined patients with unplanned intraoperative hand-assisted laparoscopic surgery (HALS)/open conversion (n = 6).ResultsIn the LRH versus ORH group, as previous hepatectomy, laparoscopic (75% vs. 12%, p < 0.001) and partial hepatectomy (Hr0) (73% vs. 37%, p = 0.002) were more frequently performed, and as RH procedure, partial hepatectomy (Hr0) (88% vs. 47%, p = 0.0002) was more frequently performed. S1 tumor cases were higher in ORH group (11% vs. 0%), but S2-6 cases were higher in LRH group (73% vs. 49%) (p = 0.02). In LRH group, compared to the pure LRH patients, HALS/open conversion patients underwent significantly more previous hepatectomy with more than lobectomy (Hr2-3) (33% vs. 2.9%, p = 0.033) and more RH procedures with segmentectomy (HrS) (33% vs. 2.9%, p = 0.03). All LRH requiring a repeat hepatic hilar approach were HALS conversions.ConclusionAppropriate indications for LRH were previous hepatectomy was laparoscopic partial hepatectomy (Hr0), and RH procedure was partial hepatectomy (Hr0) for S2-6 tumor location. When RH is more than segmentectomy (HrS) requiring a repeat hepatic hilar approach, planned HALS or ORH may be a better approach than pure LRH.

Lending a hand: The utility of hand-assisted laparoscopic surgery in diverticulitis with fistula

BackgroundCurrent guidelines recommend elective colectomy for the management of diverticulitis-associated fistulas. These cases present considerable operative challenges, and surgical approaches and fistula tract management vary widely. Hand-assisted laparoscopic surgery offers the benefits of minimally invasive surgery while maintaining the tactile advantages of open surgery. This study aims to evaluate outcomes of hand-assisted laparoscopic surgery colectomy for diverticulitis-associated fistulas, fistula tract, and urinary catheter management. MethodsA retrospective review of patients with diverticulitis-associated fistula who underwent elective hand-assisted laparoscopic surgery colectomy between January 2, 2008, and September 8, 2022, was performed. Patients with Crohn disease or who underwent emergency surgery were excluded. ResultsSeventy patients were included; the mean patient age was 64.1 ± 14.8 years, and the mean body mass index was 30.9 ± 9.1 kg/m2. Colovesical fistulas were most common (n = 48; 68.6%), followed by colovaginal fistulas (n = 22; 31.4%). The median operative time was 186 minutes. Conversion to an open approach occurred in 4 cases (5.7%). The fistula tract remnant was left without intervention in 35 patients (50%), and omental coverage occurred in 23 cases (32.9%). The median duration of the urinary catheter was 3 days (range = 1–63). There were no postoperative urine leaks. Three patients (4.3%) were readmitted in ≤30 days. There were no 30-day mortalities. ConclusionThe challenges of colectomy for diverticulitis-associated fistulas can be mitigated using the hand-assisted laparoscopic surgery technique. We found a low conversion-to-open rate, falling below rates reported for laparoscopic colectomy. There were no cases of postoperative urine leak, suggesting that no intervention or omental coverage is a safe approach to fistula tract management.

A Novel Isobaric (Gas-Less) Laparoscopic Surgery Device.

Laparoscopic Surgery is performed using carbon dioxide gas insufflated into the abdominal cavity to create a space for endoscopic visualization. During a laparoscopic surgical dissection plume is formed from electrocautery dissection. This plume contains viruses and sometimes COVID-19 viruses. The plume obscures the visual field. The unfiltered plume release is dangerous to surgeons, nurses, and patients. The loss of visualization during carbon dioxide release delays surgery. The use of carbon dioxide insufflated gas can have side effects such as C02 embolus, pain from diaphragmatic stretching, physiological complications such as respiratory infections and renal problems. The release of carbon dioxide gas into the atmosphere, unfiltered is significant. This accounts for 7% of greenhouse gases globally. This percentage is rising due to expansion of minimally invasive surgery. The proposed system for gasless surgery was designed by algorithms of tensegrity and geodesic dome pressures. 100 simulator studies were performed to develop the device to elevate the abdominal wall to create a gas free (isobaric) space for Laparoscopic Surgery. After design freeze, 4 animal studies were performed using ethical research guidelines at Amsterdam Medical Centre Research Department, Netherlands. 3 cadaveric studies were performed using Ethical guidelines at Hackensack University Medical Centre, New Jersey, USA, to evaluate the device in a human setting. These devices for Laparoscopic Surgery, Robotic Surgery, and Hand Assisted Laparoscopic Surgery (HALS) successfully proved that a superior intra-abdominal space can be created without carbon dioxide insufflation. The devices are patented in USA and Europe.

Short- and Long-Term Outcomes in Elderly Patients Following Hand-Assisted Laparoscopic Surgery for Colorectal Liver Metastasis.

(1) Background: Hand-assisted laparoscopic surgery (HALS) has engendered growing attention as a safe procedure for the resection of metastatic liver disease. However, there is little data available regarding the outcomes of HALS for colorectal liver metastasis (CRLM) in patients over the age of 75. (2) Methods: We compare the short- and long-term outcomes of patients >75-years-old (defined in our study as "elderly patients" and referred to as group 1, G1), with patients <75-years-old (defined in our study as "younger patients" and referred to as group 2, G2). (3) Results: Of 145 patients, 28 were in G1 and 117 were in G2. The most common site of the primary tumor was the right colon in G1, and the left colon in G2 (p = 0.05). More patients in G1 underwent laparoscopic anterior segment resection compared with G2 (43% vs. 39% respectively) (p = 0.003). 53% of patients in G1 and 74% of patients in G2 completed neoadjuvant therapy (p = 0.04). The median size of the largest metastasis was 32 (IQR 19-52) mm in G1 and 20 (IQR 13-35) mm in G2 (p = 0.001). The rate of complications (Dindo-Clavien grade ≥ III) was slightly higher in G1 (p = 0.06). The overall 5-year survival was 30% in G1 and 52% in G2 (p = 0.12). (4) Conclusions: Hand-assisted laparoscopic surgery for colorectal liver metastasis is safe and effective in an elderly patient population.

Safety and Feasibility of Laparoscopic Parenchymal-Sparing Hepatectomy for Lesions with Proximity to Major Vessels in Posterosuperior Liver Segments 7 and 8

Laparoscopic parenchymal-sparing hepatectomy (PSH) for lesions with proximity to major vessels (PMV) in posterosuperior segments (PSS) has not yet been sufficiently examined. The aim of this study is to examine the safety and feasibility of laparoscopic PSH for lesions with PMV in PSS 7 and 8. We retrospectively reviewed the outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) for PSS lesions and focused on patients who underwent laparoscopic PSH for lesions with PMV in PSS. Blood loss was lower in the LLR group (n = 110) than the OLR group (n = 16) (p = 0.009), and no other short-term outcomes were significantly different. Compared to the pure LLR group (n = 93), there were no positive surgical margins or complications in hand-assisted laparoscopic surgery (HALS) (n = 17), despite more tumors with PMV (p = 0.009). Regarding pure LLR for one tumor lesion, any short-term outcomes in addition to the operative time were not significantly different between the PMV (n = 23) and no-PMV (n = 48) groups. The present findings indicate that laparoscopic PSH for lesions with PMV in PSS is safe and feasible in a matured team, and the HALS technique still plays an important role.

Hand-assisted laparoscopic surgery for an esophageal hiatal hernia with incarcerated transverse colon presenting after laparoscopic gastrectomy: a case report

BackgroundEsophageal hiatal hernia (EHH) presenting after gastrectomy for carcinoma is a type of internal hernia and very rare. There have been no published reports on the use of hand-assisted laparoscopic surgery (HALS) for the treatment of an incarcerated EHH that presented after a gastrectomy. Herein, we report a rare case of HALS performed for an incarcerated EHH presenting after a laparoscopic gastrectomy.Case presentationThis case report presents the case of a 66-year-old man who underwent hernia repair for an incarcerated hernia that presented after he underwent a laparoscopic proximal gastrectomy with double-tract reconstruction for cancer in the esophagogastric junction. Emergency laparoscopic hernia repair was performed and herniation of the transverse colon into the left thoracic cavity through a hiatal defect was confirmed. Since it was difficult to return the transverse colon into the abdominal cavity using forceps, the procedure was converted to HALS and the transverse colon was pulled back into the abdominal cavity. The hernia defect was closed using a non-absorbable suture. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day.ConclusionsThe HALS approach provides the tactile experience of an open surgery combined with the benefits of a laparoscopic procedure such as good visualization and low invasiveness. In this case, when the transverse colon that had herniated into the left hemithorax was returned to the abdominal cavity, damage to the transverse colon was avoided by using the hand. Hence, HALS was safely performed to repair an incarcerated EHH after gastrectomy.

Short- and Long-term Oncological Outcomes in Elderly Patients Following Hand-assisted Laparoscopic Surgery for Colorectal Liver Metastasis

Short- and Long-term Oncological Outcomes in Elderly Patients Following Hand-assisted Laparoscopic Surgery for Colorectal Liver Metastasis

[Current status of influencing factors for postoperative anastomotic leakage in low rectal cancer].

The incidence of anastomotic leakage, a common and serious postoperative complication of low rectal cancer, remains high. Clarifying the risk factors for anastomotic leakage in patients with low rectal cancer after surgery can help guide clinical treatment and help patients improve their prognosis. The current literature suggests that the risk factors affecting the occurrence of anastomotic leakage after low rectal cancer include three aspects: (1) individual factors: male gender, high body mass index, malnutrition, smoking, alcoholism, and metabolic diseases; (2) tumor factors: the lower margin of tumor <5 cm from the anal verge, tumor diameter >2.5 cm, late tumor stage, high level of tumor markers and preoperative intestinal obstruction; (3) surgical factors: long operative time (>180 min), intraoperative bleeding (≥70 ml), more than 2 cartridges of stapling for anastomosis, contamination of the operative field, epidural analgesia and intraoperative hypothermia. Notably, the surgical approach (laparoscopic, open and hand-assisted laparoscopic surgery) was not a factor influencing the occurrence of postoperative anastomotic leakage in low rectal cancer. The findings on the effects of receiving neoadjuvant therapy, gut microbiota,intestinal bowel preparation, insufficient time for preoperative antibiotic prophylaxis, left colonic artery dissection, intraoperative blood transfusion, pelvic drainage, transanal drainage and combined organ resection, and postoperative diarrhea on postoperative anastomotic leakage in low rectal cancer are controversial. However, clinical workers can still take measures to reduce the risk of anastomotic leakage according to the above risk factors by making a good assessment before surgery, actively avoiding them during and after surgery, and taking measures for each step, so as to bring maximum benefits to patients.

Hand-assisted versus straight laparoscopy for colorectal surgery — a systematic review and meta-analysis

PurposeHand-assisted laparoscopic surgery (HALS) is an alternative to straight laparoscopy (LAP) in colorectal surgery. Many studies have compared the two in terms of efficacy, complications, and outcomes. This meta-analysis aims to uncover if there are any significant differences in conversion rates, operative times, body mass index (BMI), incision lengths, intraoperative and postoperative complications, and length of stay.MethodsComprehensive searches were performed on databases from their respective inceptions to 16 December 2021, with a manual search performed through Scopus. Randomized controlled trials (RCTs), cohort studies, and case series involving more than 10 patients were included.ResultsA total of 47 studies were found fitting the inclusion criteria, with 5 RCTs, 41 cohort studies, and 1 case series. Hand-assisted laparoscopic surgery was associated with lower conversion rates (odds ratio [OR] 0.41, 95%CI 0.28–0.60, p < 0.00001), shorter operative times (Mean Difference [MD] − 8.32 min, 95%CI − 14.05– − 2.59, p = 0.004), and higher BMI (MD 0.79, 95%CI 0.46–1.13, p < 0.00001), but it was also associated with longer incision lengths (MD 2.19 cm, 95%CI 1.66–2.73 cm, p < 0.00001), and higher postoperative complication rates (OR 1.15, 95%CI 1.06–1.24, p = 0.0004). Length of stay was not different in HALS as compared to Lap (MD 0.16 days, 95%CI − 0.06–0.38 days, p = 0.16, and intraoperative complications were the same between both techniques.ConclusionsHand-assisted laparoscopy is a suitable alternative to straight laparoscopy with benefits and risks. While there are many cohort studies comparing HALS and LAP, more RCTs would be needed for a better quality of evidence.

251. COMPARISON OF LAPAROSCOPIC SURGERIES WITH OR WITHOUT HAND-ASSISTED PROCEDURE IN THE ABDOMINAL PHASE OF THORACOSCOPIC ESOPHAGECTOMY IN THE PRONE POSITION

Abstract Laparoscopic surgery is less invasive than open surgery in the abdominal phase of thoracoscopic esophagectomy in the prone position (TEP). Laparoscopic surgery (LAP) and hand-assisted laparoscopic surgery (HALS) for mobilization of the stomach and abdominal lymph node dissection have been standard procedures. We aimed to compare the safety and feasibility of those procedures in patients undergone TEP. We evaluated 69 patients who underwent TEP and received gastric conduit reconstruction for esophageal cancer. The LAP group consisted of 42 patients, whereas the HALS group consisted of 27 patients. Surgical outcomes and postoperative complications (Clavien-Dindo classification, grade II or higher) were evaluated between the two groups. No significant differences were found in age, sex, clinical T stage, clinical N status, and neoadjuvant chemotherapy status between the two groups. According to surgical outcomes, there were no significant differences in overall operation time and reconstruction route. Abdominal operation time was significantly shorter in HALS group than in LAP group (LAP: 157 min (73–238), HALS: 96 min (35–157), P &amp;lt; 0.0001). No significant differences were observed in anastomotic leakage, recurrent laryngeal nerve palsy, pneumonia, and postoperative stay (LAP vs HALS: 19.0% vs 25.9%, P = 0.558; 2.4% vs 3.7%, P = 1.000; 16.7% vs 29.6%, P = 0.240; 31 days (16–83) vs 36 days (16–97), P = 0.301). There were no significant differences in postoperative complications between the two groups. HALS is a feasible procedure with short abdominal operative time for patients with esophageal cancer.

539. SURGICAL TECHNIQUES AND OUTCOMES OF GASTRIC CONDUIT RECONSTRUCTION FOLLOWING ESOPHAGECTOMY BY HAND-ASSISTED LAPAROSCOPIC SURGERY (HALS) FOR ESOPHAGEAL CANCER

Abstract After esophagectomy with reconstruction using a gastric conduit for esophageal cancer, anastomotic leak can cause serious complications and has a significant impact on the postoperative course. At our institution, gastric conduit reconstruction by hand-assisted laparoscopic surgery (HALS) is the first-line technique for reconstruction following esophagectomy due to its reliability and shortened operative time. In this study, we performed a retrospective review of the surgical outcomes. We reviewed characteristics and perioperative outcomes of 124 patients who underwent esophagectomy with gastric conduit reconstruction for esophageal cancer by HALS from February 2011 to December 2021. Surgical procedure: We created a gastric tube via the HALS incision. A 3-cm wide gastric tube was fashioned using the linear staplers. We mobilized and manually stretched the stomach to ensure the length of the gastric tube. Then the blood flow in the gastric tube was evaluated by ICG fluorescence method followed by esophagogastric anastomosis using a 25-mm circular stapler on the greater curvature side. Among the 124 patients, there were 99 males and 25 females with a median age of 70 years (range, 46 – 85 years). Neoadjuvant therapy was performed in 50 patients. The median operative time was 259 minutes (135-454 minutes). Complications related to the gastric conduit reconstruction included anastomotic leak in two patients (1.6%) and anastomotic stricture requiring dilatation in 39 patients (31.5%), of whom 15 (12.1%) underwent repeat dilatation. Gastric tube stenosis, gastric tube hemorrhage, and gastric tube-to-pulmonary fistula were also observed in one case each. In the present study, while the incidence of anastomotic leak was low (1.6%) in patients received HALS esophagectomy with gastric conduit reconstruction, almost one-third (31.5%) of the patients had anastomotic stricture and required dilatation.

Development of Surgical System Using Bellows-Type Foldable Five-Fingered Robot Hand Inserted through a 20-mm Port.

The purpose of this study was to develop a robotic hand to assist with large organs, instead of using a surgeon, in laparoscopic surgery. Grasping, pinching, and exclusion were performed by three subjects with no medical knowledge. The results indicate that the proposed system can perform surgical operations in hand-assisted laparoscopic surgery when the subjects are proficient. However, the thumb mechanism and the wrist control method were required improvement because it was difficult to approach organs. Surgeons were asked to operate the robotic hand while watching the laparoscope image, and they were able to grasp and pinch with little practice.

Hand-assisted laparoscopic versus laparoscopic-assisted radical gastrectomy in the treatment of advanced distal gastric cancer: final results of a single-center randomized study.

ObjectiveTo compare the results and 5- and 8-year overall survival (OS) and disease-free survival (DFS) of hand-assisted laparoscopic surgery (HALS) and laparoscopic-assisted surgery (LAS) in radical gastrectomy for advanced distal gastric cancer.MethodsA total of 124 patients admitted to our institution from May 2009 to April 2013 were randomly divided into a HALS group (n = 62) and a LAS group (n = 62). Postoperatively, 110 patients were followed for 5 and 8 years, and 14 patients were lost to follow-up. The 5- and 8-year OS and DFS rates of the groups were compared and analyzed.ResultsThe 5- and 8-year OS rates, respectively, were 38.8% and 19.4% in the HALS group and 38.3% and 15.3% in the LAS group (log-rank test, χ2 = 0.250). The 5- and 8-year DFS rates, respectively, were 23.1% and 10.6% in the HALS group and 19.3% and 11.6% in the LAS group (log-rank test, χ2 = 0.109). No significant differences were found.ConclusionCompared with LAS, HALS radical gastrectomy for advanced distal gastric cancer had a lower conversion rate to open surgery, shorter surgical duration, and more thorough dissection of lymph nodes; 5- and 8-year OS and DFS rates were similar to those with LAS.

Hand Assisted Laparoscopic Surgery for Colorectal Cancer: Surgical and Oncological Outcomes from a Single Tertiary Referral Centre.

The aim of this study was to report overall experience, perioperative and long-term survival results in a single tertiary referral center in Lithuania with hand assisted laparoscopic surgery (HALS) for colorectal cancer. A prospectively maintained database included 467 patients who underwent HALS for left-sided colon and rectal cancer, from April 2006 to October 2016. All those operations were performed by three consultant surgeons and nine surgical residents, in all cases assisted by one of the same consultant surgeons. There were 230 (49.25%) females, with an average age of 64 ± 9.7 years (range, 26–91 years). The procedures performed included 170 (36.4%) anterior rectal resections with partial mesorectal excision, 160 (34.26%) sigmoid colectomies, 81 (17.35%) left hemicolectomies, 45 (9.64%) low anterior rectal resections with total mesorectal excision, and 11 (2.25%) other procedures. Stage I colorectal cancer was found in 140 (29.98%) patients, 139 (29.76%) stage II, 152 (32.55%) stage III and 36 (7.71%) stage IV. There were five conversions to open surgery (1.1%). The mean postoperative hospital stay was 6.9 ± 3.4 days (range, 1–30 days). In total, 33 (7.06%) patients developed postoperative complications. The most common complications were small bowel obstruction (n = 6), anastomotic leakage (n = 5), intraabdominal abscess (n = 4) and dysuria (n = 4). There were two postoperative deaths (0.43%). Overall, 5-year survival for all TNM stages was 85.7%, 93.2% for stage I, 88.5% for stage II and 76.3% for stage III. Hand assisted colorectal surgery for left-sided colon and rectal cancer in a single tertiary referral center was feasible and safe, having all the advantages of minimally invasive surgery, with good perioperative parameters, adequate oncological quality and excellent survival.

Predictors of a difficult Pringle maneuver in laparoscopic liver resection and evaluation of alternative procedures to assist bleeding control.

To evaluate the predictors of a difficult Pringle maneuver (PM) in laparoscopic liver resection (LLR) and to assess alternative procedures to PM. Data from patients undergoing LLR between 2013 and 2020 were reviewed retrospectively. Univariate and multivariate analyses were performed and the outcomes of patients who underwent PM or alternative procedures were compared. Among 106 patients who underwent LLR, PM could not be performed in 18 (17.0%) because of abdominal adhesions in 14 (77.8%) and/or collateral flow around the hepatoduodenal ligament in 5 (27.8%). Multivariate analysis revealed that Child-Pugh classification B (p = 0.034) and previous liver resection (p < 0.001) were independently associated with difficulty in performing PM in LLR. We evaluated pre-coagulation of liver tissue using microwave tissue coagulators, saline irrigation monopolar, clamping of the hepatoduodenal ligament using an intestinal clip, and hand-assisted laparoscopic surgery as alternatives procedures to PM. There were no significant differences in blood loss (p = 0.391) or transfusion (p = 0.518) between the PM and alternative procedures. Child-Pugh classification B and previous liver resection were identified as predictors of a difficult PM in LLR. The alternative procedures were found to be effective.

Hand-assisted laparoscopic resection versus total laparoscopic gastric surgery for primary gastric gastrointestinal stromal tumors (GISTs): an analysis from a high-volume institution

BackgroundLaparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) is technically feasible and associated with favorable outcomes. We compared the clinical efficacy of hand-assisted laparoscopic surgery (HLS) and total laparoscopic surgery (TLS) for gastric GISTs.MethodsWe retrospectively analyzed the clinical data of 69 consecutive patients diagnosed with a gastric GIST in a tertiary referral teaching hospital from December 2016 to December 2020. Surgical outcomes were compared between two groups.ResultsFifty-three patients (TLS group: n = 36; HLS group: n = 17) were included. The mean age was 56.9 and 58.1 years in the TLS and HLS groups, respectively. The maximum tumor margin was significantly shorter in the HLS group than in the TLS group (2.3 ± 0.9. vs. 3.0 ± 0.8 cm; P = 0.004). The operative time of the HLS group was significantly shorter than that of the TLS group (70.6 ± 19.1 min vs. 134.4 ± 53.7 min; P < 0.001). The HLS group had less intraoperative blood loss, a shorter time to first flatus, and a shorter time to fluid diet than the TLS group (P < 0.05). No significant difference was found between the groups in the incidence or severity of complications within 30 days after surgery. Recurrence or metastasis occurred in four cases (HLS group; n = 1; TLS group; n = 3).ConclusionsThis study demonstrated that compared with TLS, HLS for gastric GISTs has the advantages of simpler operation, shorter operative time, and faster postoperative recovery.

[Hand-assisted Laparoscopic Surgery: experience with an original technique].

Hand-assisted laparoscopic colorectal surgery (HALS) is an alternative to straight laparoscopic approach (SL) that requires the use of a specific device to maintain the pneumoperitoneum. Our group has described an original double glove technique to replace it. Our purpose was to compare perioperative outcomes of patients undergoing HALS using this original technique vs SL. Retrospective review of a prospective database including patients who underwent elective laparoscopic colorectal resections between 2004 to 2020 at the Hospital Italiano, Argentina. Logistic regression analysis, propensity score matching, and inverse probability weighting were used to estimate adjusted treatment effects for perioperative outcomes. HALS (n=458) and SL (n=1692) cases were demographically similar. HALS was associated with a shorter operative time (170.3 vs 206.9 minutes, p<0.001). Such difference was even more pronounced in obese (44.1 min), large patients (37.5 min), complex procedures (33.8 min) and surgeries carried out by non-trained surgeons (57,6 vs 31,6 minutes, p<0.001). Hand-assisted was associated with a lower conversion rate (5% vs 9.9%, p<0.001) with an adjusted odds ratio of 0.45 (95%CI 0.28-0.73). No difference in hospital stay, morbidity, and readmission rates was found. HALS with double-glove technique is comparable to SL in terms of postoperative outcomes keeping reduced operative time and conversion rates, especially in obese patients undergoing complex procedures.