Hand-assisted Laparoscopic Technique Research Articles

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.

Robot-assisted donor nephrectomy: Initial results and comparison with the hand-assisted laparoscopic technique. A retrospective study

BackgroundThe aim of this study is to evaluate feasibility and safety of robotic-assisted donor nephrectomy (RADN) as compared with the hand-assisted laparoscopic technique (HALDN). Patient and methodsThis is a retrospective study of the first 83 consecutive RADN procedures which were compared with a group of 103 consecutive HALDN procedures. ResultsThe median operating time in the RADN group and the HALDN group were respectively 173 (SD = 37) and 137 (SD = 29) min (p = 0.000). The mean first warm ischemia time (min, SD) in the RADN and HALDN group were respectively 2.60 (0.78) and 2.15 (0.38) (p = 0.000). The median blood loss (ml, SD) in the RADN and HALDN group were respectively 33 (87) and 64 (146) ml (p = 0.000). There were no statistically significant differences in post-operative pain-score, post-operative length of stay and complications between the two groups. There were also no statistically significant differences in recipient serum creatinine at 1 week and 1 month after transplantation. The median recipients eGFR (CKD-EPI) at 1 week in the RADN and HALDN group were respectively 50 (SD = 20) and 38 (SD = 19) (p = 0.018) and at 1 month respectively 52 (SD = 16) and 47 (SD = 15) ml/min/1.73m2 (p = 0.090). ConclusionRobotic-assisted donor nephrectomy is an evolving technique which is safe for the donor and for the graft.

Laparoscopic Nephrectomy for Massive Kidneys in Polycystic Kidney Disease.

Background and Objectives:Laparoscopic nephrectomy is now considered a feasible surgical approach, even for large kidneys. In the case of massive kidneys, laparoscopy can be problematic, so that some authors suggest an open approach. However, previous studies have shown that hand-assisted laparoscopic nephrectomy (HALN) may represent a useful compromise.We describe our hand-assisted laparoscopic technique for nephrectomy of large kidneys (> 2500 g) to encourage the use of laparoscopy for nephrectomy in autosomal dominant polycystic kidney disease.Methods:We retrospectively analyzed data from 26 nephrectomies in 17 patients who underwent HALN for ADPKD and compared them to a group of 22 nephrectomies in 18 patients with open surgical technique.Results:The duration of the procedure was significantly longer in the laparoscopic group, with a median of 180 minutes versus 90 minutes for the unilateral nephrectomies, and 240 minutes versus 122 minutes for the bilateral procedures. The median kidney weight in the open group was 2500 g (range 1300 – 4500 g), while the median weight in the HALN group was 2375 g (range 1000 – 4700 g). The median hospital stay was comparable. No significant differences were recorded in the intra- and postoperative complication rate.Conclusion:Hand-assisted laparoscopic nephrectomy can be considered a technique of choice for patients suffering from ADPKD requiring nephrectomy, also with massive kidneys weighing more than 3500 g. Compared to open nephrectomy, HALN can be performed safely, with reasonably longer operating times and without major complications, and offers a significant reduction in hospitalization time, pain and postoperative discomfort.

Retroileal anastomosis in hand-assisted laparoscopic left colectomy: experience at a single institution

Left hemicolectomy and complicated sigmoid colectomy require an anastomosis between the transverse colon and rectum. Generous mobilization will typically allow the colon to reach to the rectum. However, despite full mobilization of the splenic flexure and extensive work on the mesentery, there are cases in which reach to the pelvis is still an issue. Retroileal routing of the colon is one technique for overcoming such a reach problem and achieving a tension-free anastomosis. Performing retroileal routing using laparoscopic techniques has been reported rarely, and to date, there are no data on this technique when performed in a hand-assisted laparoscopic fashion. This study aimed to describe the feasibility of doing a retroileal routing using a hand-assisted laparoscopic technique. This was a retrospective chart review of patients who underwent a colon or rectal resection, either open or laparoscopic, with a pelvic anastomosis, by a single colorectal surgeon at an academic institution between 2008 and 2015 with a focus on the immediate and long-term postoperative complications, estimated blood loss, and operating room time for patients having an operation that included retroileal routing for construction of a colorectal anastomosis. A total of 340 patients fit inclusion criteria and of these, 13 underwent hand-assisted laparoscopic procedures with retroileal routing of the proximal colon to the colorectal anastomosis. Postoperative morbidity included intubation for CO2 retention in one patient and a RLL effusion in another patient; there were no anastomotic leaks. Long-term morbidities included two ventral hernias at 2years postoperatively. Mean operating room time was 208min. There were no 30- or 90-day mortalities. Hand-assisted laparoscopic retroileal routing is a feasible and safe technique in accomplishing a tension-free colorectal anastomosis when proximal colon length makes standard routing of the colon to the rectum an issue.

Laparoscopic hand-assisted adrenalectomy for tumours larger than 5cm.

ObjectiveAdrenal surgery remains a distinct surgical challenge. Technical challenges associated with laparoscopic adrenalectomy are tumour size, haemorrhage control and oncological compromise. Hand‐assisted laparoscopic (HAL) adrenalectomy, utilizing a hand‐port device, offers minimally invasive surgery with the advantages and safety of tactile feedback. We aimed to assess the efficacy of HAL for patients requiring adrenalectomy for tumours over 5 cm in size.ContextHand‐assisted laparoscopic surgery is used in several surgical specialities over totally laparoscopic surgery to manage sizeable pathology, reduce operating time and conversion rates. HAL adrenalectomy is demonstrated in this series as a safe alternative to laparoscopic adrenalectomy for large adrenal tumours.DesignA retrospective analysis of all HAL adrenalectomies performed over 8 years (October 2006‐May 2015) by a single surgeon was performed. This case series is the largest study of this technique.PatientsAll patients who were fit for surgery with adrenal tumours (over 5 cm) were included.AnalysisPrimary endpoints were overall mortality, operating time, hospital stay, complications and conversion to open surgery.ResultsA total of 56 patients underwent the procedure. A total of 43 had unilateral and 13 bilateral lesions. Most lesions (45) were histologically benign. These included functioning and non‐functioning tumours. Median tumour size was 8 cm (range 5‐19 cm). There was one (1.8%) intra‐operative conversion and no peri‐operative mortality. Postoperative complications occurred in 8 (14%) patients, all self‐limiting. The median length of stay was 6 days (range 2‐21). There was one recurrence of pathology with repeat surgery.ConclusionHand‐assisted laparoscopic surgery offers a safe reproducible approach to adrenal surgery combining minimally invasive surgery with tactile integration. Although previously described in small numbers, this represents the largest case series to date. HAL is a safe minimally invasive surgical option for larger tumours, including malignancies. The HAL technique may additionally offer a shorter learning curve for trainee adrenal surgeons.

Right posterior sectionectomy with glissonian approach: advantages of hand- assisted laparoscopic technique

Background: The aim of this video is to present a hand-assisted technique and point to some advantages over the totally laparoscopic approach for right posterior sectionectomy of the liver. Methods: Patient with B virus hepatitis, in the late postoperative of laparoscopic right total nephrectomy (3 years ago) for clear cell renal carcinoma. Follow-up with magnetic resonance imaging disclosed 3 liver tumors in the right posterior sector. Diagnostic hypotheses were hepatocellular carcinoma or renal tumor metachronous metastases. Patient was refered for surgery. The proposed surgery was laparoscopic right posterior sectionectomy. There was concern related to adhesions related to previous surgery (right nefrectomy), therefore we opted for a hand-assisted approach. Results: The operative time was 180 min. Estimated blood loss was 50 ml. Recovery was uneventful and the patient was discharged on fourth PO. Final pathology showed hepatocelular carcinoma with free surgical margins. Hand-assisted advantages over totally laparoscopic technique were: tactile feedback, facilitation of liver mobilization, ability to manually compress the liver, standard ultrasound probe introduction, avoidance of a separate extraction site incision. Conclusion: The hand-assisted laparoscopic technique is a good option to totally laparoscopic approach for right posterior sectionectomy of the liver, and may reveal some advantages

The Hand-Assisted Laparoscopic Approach to Resection of Pancreatic Mucinous Cystic Neoplasms: An Underused Technique?

Pancreatic mucinous cystic neoplasms (MCNs) are rare tumors typically of the distal pancreas that harbor malignant potential. Although resection is recommended, data are limited on optimal operative approaches to distal pancreatectomy for MCN. MCN resections (2000-2014; eight institutions) were included. Outcomes of minimally invasive and open MCN resections were compared. A total of 289 patients underwent distal pancreatectomy for MCN: 136(47%) minimally invasive and 153(53%) open. Minimally invasive procedures were associated with smaller MCN size (3.9 vs 6.8 cm; P = 0.001), lower operative blood loss (192 vs 392 mL; P = 0.001), and shorter hospital stay(5 vs 7 days; P = 0.001) compared with open. Despite higher American Society of Anesthesiologists class, hand-assisted (n = 46) had similar advantages as laparoscopic/robotic (n = 76). When comparing hand-assisted to open, although MCN size was slightly smaller (4.1 vs 6.8 cm; P = 0.001), specimen length, operative time, and nodal yield were identical. Similar to laparoscopic/robotic, hand-assisted had lower operative blood loss (161 vs 392 mL; P = 0.001) and shorter hospital stay (5 vs 7 days; P = 0.03) compared with open, without increased complications. Hand-assisted laparoscopic technique is a useful approach for MCN resection because specimen length, lymph node yield, operative time, and complication profiles are similar to open procedures, but it still offers the advantages of a minimally invasive approach. Hand-assisted laparoscopy should be considered as an alternative to open technique or as a successive step before converting from total laparoscopic to open distal pancreatectomy for MCN.

Multi-institutional comparison of open, laparoscopic, hand-assisted laparoscopic, and robotic techniques for distal pancreatectomy

Objective: The literature comparing minimally invasive distal pancreatectomy (DP) to open DP is mostly limited to one or two minimally invasive surgical (MIS) techniques. Previous studies have addressed outcomes between robotic, laparoscopic, and open DP but have not included hand-assisted laparoscopic surgery. We evaluated outcomes of these four DP techniques in a multi-center study. Methods: Data was collected from a prospectively maintained pancreas surgery consortium database at three high-volume pancreatic centers. We analyzed pre-operative, oncologic, and post-operative outcomes including complications, pancreatic fistula of any grade, and clinically relevant fistula in each DP procedure type. Results: 261 patients underwent DP. 36% underwent open, 25% laparoscopic, 14% hand-assisted, and 25% robotic DP. The most common diagnosis was cystic lesion (39%) followed by pancreatic adenocarcinoma (PDAC) (27%). Open DP was more common in patients with PDAC (p=0.001) and with greater co-morbidities, particularly HTN (p=0.02) and smoking history (p=0.02). EBL and transfusions were greater with open DP. Length of procedure was greater with MIS. Soft gland texture was more common in the MIS groups (Table 1). There was no difference in post-operative complications except for increased fistula of any grade with MIS (p=0.02). However, there was no difference in clinically relevant fistula (p=0.4). There was no difference in LOS, R0 resection, or lymph node yield. Conclusion: There is no difference in post-operative complications and oncologic outcomes between open and various MIS modalities for DP. The increased use of open DP for PDAC patients is likely a result of selection bias.Table 1ResultsOpenLapHALRoboticp-valueBaseline characteristicsHTN56 (61%)25 (44%)21 (60%)23 (38%)0.02Smoking history53 (58%)30 (47%)13 (35%)19 (28%)0.02Initial diagnosis PDAC43 (45%)7 (11%)10 (27%)9 (14%)0.001Perioperative characteristicsEBL (mL)43823960225<0.0005Transfusion10 (11%)2 (3%)02 (3%)0.009Soft gland texture69 (75%)49 (83%)32 (91%)58 (98%)0.001Post-operative complicationsFistula any grade21 (23%)25 (48%)12 (39%)17 (33%)0.02CR-POPF (ISGPS Grade B/C)9 (10%)10 (19%)3 (10%)7 (14%)0.4Patients with any complications44 (42%)33 (28%)15 (41%)23 (36%)0.3Patients with Accordion ≥ grade 3 complications20 (21%)13 (20%)5 (14%)11 (20%)0.8 Open table in a new tab

Salvage Technique for Intraoperative Hemorrhage during Laparoscopic Resection of Large Pheochromocytoma: A Case Report and Literature Review

ABSTRACTAimWe described the use of a hand-port assisted laparoscopic adrenalectomy for excising a large 10 cm vascular left adrenal pheochromocytoma. The useful technical tips and important pitfalls to avoid for a successful outcome are discussed in this article.IntroductionA 64-year-old man who was investigated for microalbuminuria was found to have a 10-cm left adrenal mass. Blood investigation and imaging confirmed it to be a pheochromocytoma.Case reportInitial mobilization of the adrenal mass was performed laparoscopically using two 5-mm ports in the epigastric. While dissecting the inferomedial pedicle, the aberrant adrenal vessel was injured and resulted in torrential bleeding. A gelport for hand assistance was inserted as a salvage approach for hemostasis.ConclusionHand-port assisted laparoscopic adrenalectomy is a very practical and easy-to-adopt technique that preserves the minimally invasive surgical advantages in patients with large adrenal masses.Clinical significance: We advocate the use of hand-assisted laparoscopic adrenalectomy technique for complex pheochromocytoma as an alternative for surgeons with vast experience in laparoscopic adrenalectomy.How to cite this articleLee DJK, Tan YP, Singaporewalla RM. Salvage Technique for Intraoperative Hemorrhage during Laparoscopic Resection of Large Pheochromocytoma: A Case Report and Literature Review. World J Endoc Surg 2017;9(1):27-31.

Hand-Assisted Laparoscopic (HAL) Multiple Segmental Colorectal Resections: Are They Feasible and Safe?

The objective of this study was to evaluate the short-term outcomes of synchronous hand-assisted laparoscopic (HAL) segmental colorectal resections. The surgical options for synchronous colonic pathology include extensive colonic resection with single anastomosis, multiple synchronous segmental resections with multiple anastomoses, or staged resections. Traditionally, multiple open, synchronous, segmental resections have been performed. There is a lack of data on HAL multiple segmental colorectal resections. A retrospective chart review was compiled on all patients who underwent HAL synchronous segmental colorectal resections by all the colorectal surgeons from our Group during the period of 1999 to 2014. Demographics, operative details, and short-term outcomes are reported. During the period, 9 patients underwent HAL synchronous multiple segmental colorectal resections. There were 5 women and 4 men, with median age of 54 (24-83) years and median BMI of 24 (19.8-38.7) kg/m(2). Two patients were on long-term corticosteroid therapy. The median operative time was 210 (120-330) minutes and median operative blood loss was 200 (75-300) mLs. The median duration for return of bowel function was 2 days and the median length of stay was 3.5 days. We had 2 minor wound infections. There were no deaths. Synchronous segmental colorectal resections with anastomoses using the hand-assisted laparoscopic technique are safe. Early conversion to open and use of stomas are advisable in challenging cases.

Hand-Assisted Laparoscopic Right Colectomy: Is It Useful?

See Article on Page 11-17 These days, minimally invasive surgery (MIS) has become the standard surgical procedure in Korea for patients with colon cancer. Among various techniques for MIS, conventional laparoscopic surgery (CLS) has gained in popularity. Furthermore, high-quality articles regarding outcomes of MIS for colorectal cancer treatment that were written by Korean surgeons have been published in leading medical journals [1, 2]. On the other hand, hand-assisted laparoscopic surgery (HALS) is still infrequently implemented in Korea because its position as a surgical option is still unsettled. In the literature, whether or not the HALS procedure is useful for a right colectomy is a subject of controversy. Ng et al. [3] reported that a HALS right colectomy did not confer additional advantages over a laparoscopic right colectomy in terms of clinical, operative or oncological outcomes. For this reason, the routine use of the hand-assisted laparoscopic technique for treating right colonic cancers cannot be recommended. Vogel et al. [4] conduct a similar study, and the short-term outcomes of a HALS and a CLS right colectomy were similar. However, they arrived at a different conclusion in that they recommended that the decision to perform a HALS or a CLS right colectomy should be based on the surgeons' preference and not on the perception that one technique was preferable to the other. In this present study, the HALS group included more advanced cancers than the CLS group did. Thus, the authors' conclusions were similar to those of Ng et al. [3] in that the HALS technique had an advantage for treating complex and extensive cancers only [5]. From a CLS surgeon's point of view, it was only natural for CLS surgeons to come to this conclusion. CLS surgeons are used to performing CLS, so they feel no need to conduct HALS. However, the similar clinical outcomes for CLS and HALS do not mean that HALS is an unnecessary procedure; rather, it means that surgeons can choose the procedure they like. Thus, although I agree with the authors' conclusion in this present study, if the true value of a HALS right colectomy is to be determined, a comparative, prospective study should be conducted on the two groups under equal conditions.

Use of a hand-assisted laparoscopic surgical technique for closure of an extensive mesojejunal rent in a horse

A 7-year-old 573-kg (1,261 -lb) Swiss Warmblood gelding was evaluated because of signs of acute abdominal pain. Physical examination revealed a markedly distended abdomen with subjectively reduced borborygmi in all abdominal quadrants. A large, gas-distended viscus was present at the pelvic brim preventing complete palpation of the abdomen per rectum. Ultrasonographic evaluation could not be safely performed in the initial evaluation because of severe signs of abdominal pain. Ventral midline celiotomy was performed, and right dorsal displacement of the ascending colon was corrected. Progressive signs of abdominal pain after surgery prompted repeat ventral midline celiotomy, and small intestinal incarceration in a large, radial mesojejunal rent was detected. The incarceration was reduced, but the defect was not fully accessible for repair via the celiotomy. Repair of the mesenteric defect was not attempted, and conservative management was planned after surgery; however, signs of colic returned. A standard laparoscopic approach was attempted from both flanks in the standing patient, but the small intestine could not be adequately mobilized for full evaluation of the rent. Hand-assisted laparoscopic surgery (HALS) allowed identification and reduction of jejunal incarceration and repair of the mesenteric rent. Although minor ventral midline incisional complications were encountered, the horse recovered fully. HALS techniques should be considered for repair of mesenteric rents in horses. In the horse of this report, HALS facilitated identification, evaluation, and repair of a large radial mesenteric rent that was not accessible from a ventral median celiotomy.

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.

Standing Hand‐Assisted Laparoscopic Treatment of Left Dorsal Displacement of the Large Colon and Closure of the Nephrosplenic Space

To report a standing hand-assisted laparoscopic technique for closure of the nephrosplenic space (NS), and short-term outcome in horses. Case series. Horses (n = 12) aged 5-14 years. Medical records (2007-2010) of horses treated for left dorsal displacement of the large colon (LDDLC) using a hand-assisted laparoscopic correction technique with closure of the NS in the same surgical procedure were reviewed. A modified grid laparotomy in the left paralumbar fossa was used with manual correction of LDDLC, after which the NS was closed with a laparoscopic technique. Follow up was obtained by telephone interview of owners or referring veterinarians. Resolution of LDDLC and closure of the NS was successful, with only minor postoperative complications, in all horses. On short-term follow-up (>10 months; mean, 23.8 months), 2 horses had displacement of the large colon between the spleen and the body wall. Standing hand-assisted laparoscopic correction of LDDLC and closure of the NS in a single surgical procedure is feasible. Appropriate case selection is mandatory when performing this combined technique.

Single-Incision Laparoscopic Colectomy for Cancer: Short-Term Outcomes and Comparative Analysis

Introduction. Single-incision laparoscopic colectomy (SILC) is a viable and safe technique; however, there are no single-institution studies comparing outcomes of SILC for colon cancer with well-established minimally invasive techniques. We evaluated the short-term outcomes following SILC for cancer compared to a group of well-established minimally invasive techniques. Methods. Fifty consecutive patients who underwent SILC for colon cancer were compared to a control group composed of 50 cases of minimally invasive colectomies performed with either conventional multiport or hand-assisted laparoscopic technique. The groups were paired based on the type of procedure. Demographics, intraoperative, and postoperative outcomes were assessed. Results. With the exception of BMI, demographics were similar between both groups. Most of the procedures were right colectomies (n = 33) and anterior resections (n = 12). There were no significant differences in operative time (127.9 versus 126.7 min), conversions (0 versus 1), complications (14% versus 8%), length of stay (4.5 versus 4.0 days), readmissions (2% versus 2%), and reoperations (2% versus 2%). Oncological outcomes were also similar between groups. Conclusions. SILC is an oncologically sound alternative for the management of colon cancer and results in similar short-term outcomes as compared with well-established minimally invasive techniques.

Laparoscopic Versus an Open Colectomy in an Emergency Setting: A Case-Controlled Study

PurposeLaparoscopy continues to be increasingly adopted for elective colorectal resections. However, its role in an emergency setting remains controversial. The aim of this study was to compare the outcomes between laparoscopic and open colectomies performed for emergency colorectal conditions.MethodsA retrospective review of all patients who underwent emergency laparoscopic colectomies for various surgical conditions was performed. These patients were matched for age, gender, surgical diagnosis and type of surgery with patients who underwent emergency open colectomies.ResultsTwenty-three emergency laparoscopic colectomies were performed from April 2006 to October 2011 for patients with lower gastrointestinal tract bleeding (6), colonic obstruction (4) and colonic perforation (13). The hand-assisted laparoscopic technique was utilized in 15 cases (65.2%). There were 4 (17.4%) conversions to the open technique. The operative time was longer in the laparoscopic group (175 minutes vs. 145 minutes, P = 0.04), and the duration of hospitalization was shorter in the laparoscopic group (6 days vs. 7 days, P = 0.15). The overall postoperative morbidity rates were similar between the two groups (P = 0.93), with only 3 patients in each group requiring postoperative surgical intensive-care-unit stays or reoperations. There were no mortalities. The cost analysis did not demonstrate any significant differences in the procedural (P = 0.57) and the nonprocedural costs (P = 0.48) between the two groups.ConclusionEmergency laparoscopic colectomy in a carefully-selected patient group is safe. Although the operative times were longer, the postoperative outcomes were comparable to those of the open technique. The laparoscopic group did not incur a higher cost.

Single-incision laparoscopic surgery: Impact on direct cost and resource utilization for right colectomy

Aim-Background Single-incision laparoscopic (SIL) colectomy is feasible and safe. The impact of SIL technique on cost is unknown. This study compares direct cost and resource utilization of SIL right-colectomy to multiport laparoscopic (LAP) and hand-assisted laparoscopic (HAL) techniques. The purpose of this study is to determine whether the SIL technique affects cost and resource utilization in the operating room.

Living Kidney Donors Follow Up after 3-Months and 1 Year

Background: In our centre, 45% of the kidney transplants come from living donors. We accept related and unrelated family donors, emotionally related donors and in a few cases also anonymous donors. The Swedish system should reimburse all costs related to the donation and provide full pay during sick leave. Aim: To follow-up living kidney donors 3 months and 1 year after donation. Materials and methods: All donors are reported to the Scandiatransplant living donor database. Since 2006, 3-months follow-up forms are given out to the donors, and a one year follow-up are sent out to responsible doctor. At 3-months follow-up questions about sick leave, financial loss as well as physical and mental experiences are followed up. At one year the form focuses on physical data and reimbursement. During this period, a total of 124 living donor nephrectomies were performed, >90% using the hand-assisted retroperitoneal laparoscopic technique. Results: Response rates at 3-months and one year were 72% and 78%, respectively. 33% of the donors reported at 3-months follow-up that their health status at the time was negatively affected by the donation. The most frequent complaint was a physically impaired capacity in form of fatigue, followed by pain. At one year, mean creatinine was 100 (64-150). 2% had developed proteinuria, non had developed diabetes, 5% were on antihypertensive drugs. 78% stated at 3 months follow-up that the donation over all was a positive experience. The average duration of sick leave was 7.3 weeks (median 8, range between 0-24 weeks). The number of donors who reported financial loss in relation to the donation was 14% at 3 months follow-up, 28% at one year follow-up. Conclusion: Many donors have difficulties to get reimbursement for their costs related to the donation. This process must be facilitated and compensation should be provided without need for extra efforts from the donor.

Hand‐assisted laparoscopic versus total laparoscopic right colectomy: a randomized controlled trial

Laparoscopic colectomy for colorectal cancer is associated with definite short-term benefits, and is increasingly practised worldwide. The limitations of a pure laparoscopic approach include a relative lack of tactile feedback and long procedural time. Hand-assisted laparoscopic surgery was introduced in an attempt to facilitate operation by improving the tactile sensation. To date, there is no consensus as to which approach is better. Herein we conducted a randomized controlled trial comparing hand-assisted laparoscopic colectomy (HALC) with total laparoscopic colectomy (TLC) in the management of right-sided colonic cancer. Adult patients with carcinoma of the caecum and ascending colon were recruited and randomized to undergo either HALC or TLC. Measured outcomes included operative time, blood loss, conversion rate, postoperative morbidities, postoperative pain, length of hospital stay, disease recurrence and patient survival. Sixty patients (HALC=30, TLC=30) were recruited. The two groups were comparable with regard to age, gender distribution, body mass index and final histopathological staging. No difference was observed between the groups in terms of operating time, conversion rate, operative blood loss, pain score and length of hospital stay. With a median follow-up of 27 to 33 months, no difference was observed in terms of disease recurrence, and the 5-year survival rates remained similar (83%vs 80%, P=0.923). HALC is safe and feasible, but it does not show any significant benefits over TLC in terms of operating time and conversion rate. Routine use of the hand-assisted laparoscopic technique in right hemicolectomy is therefore not recommended.

A randomized clinical trial of living donor nephrectomy: a plea for a differentiated appraisal of mini-open muscle splitting incision and hand-assisted laparoscopic donor nephrectomy

A randomized controlled trial was designed to compare various outcome variables of the retroperitoneal mini-open muscle splitting incision (MSI) technique and the transperitoneal hand-assisted laparoscopic technique (HAL) in performing living donor nephrectomies. Fifty living kidney donors were randomized to MSI or HAL. Primary endpoint was pain experience scored on a visual analogue scale (VAS). After MSI living donors indicated lower median (range) VAS scores at rest than HAL living donors on postoperative day 2.5 [10 (0-44) vs. 15 (0-70), P = 0.043] and day 3 [7 (0-28) vs. 10 (0-91), P = 0.023] and lower VAS scores while coughing on postoperative day 3 [20 (0-73) vs. 42 (6-86), P = 0.001], day 7 [8 (0-66) vs. 33 (3-76), P < 0.001] and day 14 [2 (0-17) vs. 12 (0-51), P = 0.009]. The MSI technique also resulted in reduced morphine requirement, better scores on three domains of the RAND-36, reduced costs and reduced CRP and IL-6 levels. The HAL technique was superior in operating time and postoperative decrease of hemoglobin level. The MSI technique is superior to the HAL technique in performing living donor nephrectomies with regard to postoperative pain experience. This study reopens the discussion of the way to go in performing the living donor nephrectomy.