Hand-assisted Laparoscopy Research Articles

A Novel Technique for Hand-Assisted Laparoscopy in Difficult Nephrectomies-Is One Hand Better Than Two? A Single-Centre, Single-Surgeon Series.

Laparoscopic radical nephrectomy is the standard of care for T1 renal tumors and nowadays being used for T2 or higher tumors, resulting in higher the conversion rates. To bridge this gap, the hand-assisted laparoscopy (HAL) method was introduced. Even now, in the robotic era, this HAL approach continues to find importance in urology, especially in the most challenging cases, albeit, with a relatively low usage rate due to the cost involved and availability of hand port devices. Here, we report a case series using a novel modification of the HAL nephrectomy (HALN) technique when open conversion is needed. From a prospective database, we retrospectively analyzed the data of Six patients who underwent HALN at the All India Institute of Medical Sciences between January 2019 and December 2022. Indications for surgery included both malignant and benign renal disease. Four surgeries were performed on the right side while two were performed on the left. Five patients underwent a HALN for renal cell carcinoma (RCC) and 1 for a benign non-functioning kidney. In our series, all the cases with RCC had were T2a or higher. Our case series shows that HALN is technically safe, effective, and a great adjunct to conventional laparoscopy. The ingenious use of a surgical glove as a hand port is an easy-to-make-and- use device in such challenging surgeries.

P1104 Shifting Surgical Landscape in Crohn's Colitis: Laparoscopic Supremacy and Robotic Upsurge

Abstract Background Crohn's disease (CD) is a chronic inflammatory bowel disorder that can cause transmural inflammation throughout the digestive tract. When CD affects the colon, it is known as Crohn's colitis (CC), a serious condition often requiring surgical resection. Surgical trends in CC have changed significantly over the past decade, shifting towards minimally invasive surgery, with laparoscopic and robotic procedures becoming increasingly common. This study examines how surgical trends in CC have changed in recent years and predicts how they may change. Methods We conducted a retrospective analysis using the ACS-NSQIP database, focusing on patients who underwent colonic resections for CC between 2012 and 2021, including 20,109 patients. Our main goal was to examine trends in open, laparoscopic, hand-assisted, and robotic surgery. We utilized time series analysis, specifically quarter and year of admission data, and employed Vector Autoregressive (VAR) models to explore the dynamic relationships among these surgical techniques. To analyze the time trends, we reported the quarter (Q) and year of admission. These models enabled us to forecast future trends, accompanied by 95% confidence intervals, extending our predictions up until Q2 of 2025. Results As shown in Figure 1, open surgery has been the most common approach to CC since Q1 2012, accounting for 52.3% of all procedures. Laparoscopic surgery was the next most common approach, at 33.3%, followed by hand-assisted laparoscopy at 14.4%. Laparoscopy rapidly expressed market supremacy, by steadily becoming the most widespread approach by Q2 of 2017, representing 42.2% of CC surgery and peaking in Q2 2020 at 43.5%. This growth in laparoscopy came at the expense of open surgery, which experienced a significant decline, reaching its lowest point of 28.5% in Q2 2021. Hand-assisted procedures gradually increased in popularity over the years but remained less popular than open and laparoscopic methods, peaking at 24.0% in Q4 2019. Robotic procedures experienced slow but steady growth, from 1.9% in Q1 2013 to 10% in Q2 2021. Future trends suggest that laparoscopy will continue to grow steadily, reaching 45% (95% CI 28.2-61.7%) by the end of our prediction period. Robotic surgery is poised to significantly shift CC surgery trends, with resections expected to reach 12.6% (95% CI 9.3-15.8%) by Q2 2025, while a subsequent decline in open procedures to 20.8% (95% CI 0-43%). Conclusion Laparoscopic surgery has emerged as the favored surgical approach in CC and is expected to maintain its supremacy into the near future. Open colonic resections are anticipated to decline, making way for the increasing prevalence of robotic surgery.

Long-term oncological outcomes for HALS/Hybrid vs pure laparoscopic approach in colorectal liver metastases: a propensity score matched analysis.

Studies comparing hand-assisted laparoscopic (HALS)/Hybrid and pure laparoscopic (PLS) resection for colorectal cancer liver metastasis have focused on short-term results, while long-term oncological outcomes remain understudied. We established a multi-institutional retrospective cohort study from four centers with experience in minimally invasive surgery between 2004 and 2020. Primary endpoints were overall survival (OS) and disease-free survival (DFS). Other endpoints analyzed were intraoperative and postoperative outcomes. Propensity score matching (PSM) was used to minimize baseline differences. A total of 219 HALS/Hybrid (57.8%) and 160 PLS (42.2%) patients were included. After PSM, 155 patients remained in each group. Operative time (182 vs. 248min, p = 0.012), use of intraoperative ablation (12.3 vs. 4.5%, p = 0.024), positive resection margin (4.5 vs 13.2%, p = 0.012), and pringle time (21 vs. 37min, p = 0.001) were higher in PLS group. DFS at 1, 3, 5, and 7years in HALS/Hybrid and PLS groups were 65.4%, 39.3%, 37.5%, and 36.3% vs. 64.9%, 38.0%, 33.1%, and 33.1%, respectively (p = 0.84). OS at 1, 3, 5, and 7years in HALS/Hybrid and PLS groups were 94.5%, 71.4%, 54.3%, and 46.0% vs. 96.0%, 68.5%, 51.2%, and 41.2%, respectively (p = 0.73). Our study suggests no differences in long-term oncologic outcomes between the two techniques. We discovered that longer total operative, pringle time, higher rates of intraoperative ablation, and positive resection margins were associated with PLS. These differences in favor of HALS/Hybrid could be due to a shorter learning curve and a greater ability to control hemorrhage.

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.

Efficacy of hand-assisted laparoscopic surgery (HALS) in older adult patients (≥80 years) with primary colorectal cancer.

From 2004 to 2014, 821 colorectal cancer primary resections were conducted at our institution. Of these, 102 patients (12.4%) were older adults over 80 years old. underwent either the conventional laparotomy group (72 patients) or the hand-assisted laparoscopic surgery (HALS) group (30 patients). Data were extracted for 102 patients over 80 years old who underwent primary resection for colorectal cancer and were divided into two groups: conventional laparotomy (CL) (n=72) and hand-assisted laparoscopy (n=30). Pre-operative characteristics and outcomes were compared. Baseline characteristics were similar between groups, except for age: CL group median 83.5 years old (range, 80-92 years old) and hand-assisted laparoscopy (HALS) group median 81.5 years old (range, 80-88 years old) (P=0.027). Pre-operative cardiac and lung function risk, performance status, and pathological classification stage (pStage) were almost similar between groups (P=0.668, P=0.176, P>0.999, P=0.217). No significant differences were found for operation time. The HALS group resulted in less blood loss (median 204 mL in the CL group and median 68 mL in the HALS group, P=0.003), shorter postoperative hospital stay (median was 18 days in the CL group and median was 12 days in the HALS group, P<0.001), and fewer postoperative wound infections (18 cases in the CL group and 2 cases in the HALS group, P=0.034). Five-year relapse-free survival (5Y-RFS) was 48.1% in the CL group and 73.3% in the HALS group (P=0.028). Five-year overall survival (5Y-OS) was 48.2% in the CL group and 73.3% in the HALS group (P=0.027). Approximately 70% of surgical treatment for patients over 80 years old with colorectal carcinoma were performed by CL. However, HALS had significant advantages including less blood loss, fewer wound infections, and shorter hospital stays. Therefore, HALS could proactively be considered to older adult patients with colorectal cancer.

Minimally Invasive and Open Donor Nephrectomy: Lessons Learned From a French Multicenter Experience

We evaluated different techniques of donor nephrectomy. Outcomes of 4 surgical approaches (open surgery [OS], standard laparoscopy [SL], hand-assisted laparoscopy [HAL], and robot-assisted la`paroscopy [RAL]) were compared. A total of 264 nephrectomies were performed: 65 in the OS group, 65 in the SL group, 65 in the HAL group, and 69 in RAL group. Operative time was longer for the RAL group (P < .001) with a mean time of 202 minutes (RAL), 182 minutes (OS), 173 minutes (SL), and 157 minutes (HAL). Complications (P=.002) and consumption of morphine derivates (P=.31) were lower for the RAL group (P=.0002). The visual analog scale pain scores (P=.002), hospital stay (P=.023), and time to return to full activities (P=.79) were higher for OS. The 4 different nephrectomy surgical approaches had similar favorable results. The robot-assisted technique presented as an alternative option, with low incidence of complications, less pain, and results comparable to the other techniques.

Safety and Intraoperative Results in Live Kidney Donors with Vascular Multiplicity After Hand-Assisted Laparoscopy Living Donor Nephrectomy.

Background and PurposeVascular multiplicity is the most frequent anatomic variation in kidney donors. Despite concerns about risks, these allografts are increasingly used to overcome the shortage of kidney donors. The safety and clinical outcomes in living kidney donors were evaluated with vascular multiplicity after hand-assisted laparoscopic living donor nephrectomy (HALDN).Patients and MethodsData from all living kidney donors who underwent HALDN from 2008 to 2021 was retrospectively reviewed. Patients were divided into two groups as single (SRV) and multiple renal vessels (MRV), and a comparative analysis was done. The primary outcomes include operating room time (ORT), days of hospital stay, estimated blood loss, complications, conversion, and re-operations.ResultsMRV were present in 166 out of 612 donors (27.1%). Among those, 10 (1.6%) donors had simultaneous multiple arteries and veins. Additionally, the prevalence of artery and vein multiplicity was 21.8% (n = 134) and 3.5% (n = 22), respectively. Warm ischemia time was significantly different among the two groups but not clinically important. The number of conversions to open technique, the mean ORT, the median blood loss, and days of hospital stay were similar between the SRV and MRV groups, without significant differences. According to the modified Clavien-classification system, no differences were found in the complication rates between the two groups (p = 0.29). Complication rates were 3.3% and 3.6% for the SRV and MRV groups, respectively.ConclusionHALDN is a procedure with safe intraoperative results, even with vascular multiplicity. The presence of multiple renal arteries or veins has no negative impact on the outcome of the donor after living donor nephrectomy.

P-165 Comparative study on the clinical effect of hand-assisted laparoscopic and laparoscopic gastrectomy for gastric stromal tumor

This study aimed to compare the clinical efficacy of hand-assisted laparoscopy and laparoscopy in the treatment of gastric stromal tumors, to explore the clinical application value of hand-assisted laparoscopy in the treatment of gastric stromal tumors.

Evolution of laparoscopic liver surgery: 20-year experience of a Norwegian high-volume referral center

BackgroundLaparoscopic liver surgery has evolved to become a standard surgical approach in many specialized centers worldwide. In this study we present the evolution of laparoscopic liver surgery at a single high-volume referral center since its introduction in 1998.MethodsPatients who underwent laparoscopic liver resection (LLR) between August 1998 and December 2018 at the Oslo University Hospital were analyzed. Perioperative outcomes were compared between three time periods: early (1998 to 2004), middle (2005 to 2012) and recent (2013–2018).ResultsUp to December 2020, 1533 LLRs have been performed. A total of 1232 procedures were examined (early period, n = 62; middle period, n = 367 and recent period, n = 803). Colorectal liver metastasis was the main indication for surgery (68%). The rates of conversion to laparotomy and hand-assisted laparoscopy were 3.2% and 1.4%. The median operative time and blood loss were 130 min [interquartile range (IQR), 85–190] and 220 ml (IQR, 50–600), respectively. The total postoperative complications rate was 20.3% and the 30-day mortality was 0.3%. The median postoperative stay was two (IQR, 2–4) days.When comparing perioperative outcomes between the three time periods, shorter operation time (median, from 182 to 120 min, p < 0.001), less blood loss (median, from 550 to 200 ml, p = 0.023), decreased rate of conversions to laparotomy (from 8 to 3%) and shorter postoperative hospital stay (median, from 3 to 2 days, p < 0.001) was observed in the later periods, while the number of more complex liver resections had increased.ConclusionDuring the last two decades, the indications, the number of patients and the complexity of laparoscopic liver procedures have expanded significantly. Initially being an experimental approach, laparoscopic liver surgery is now safely implemented across our unit and has become the method of choice for surgical treatment of most liver tumors.

Short-Term Outcomes Following Hand-Assisted Laparoscopy for Left-Sided Colon and Rectal Malignancies: Single-Center Experience of 580 Cases

Short-Term Outcomes Following Hand-Assisted Laparoscopy for Left-Sided Colon and Rectal Malignancies: Single-Center Experience of 580 Cases

Nonvisualized palpable bowel endometriotic satellites.

STUDY QUESTIONWhat is the prevalence of laparoscopically nonvisualized palpable satellite bowel nodules at or near the planned stapler site in women undergoing segmental bowel resection for endometriosis?SUMMARY ANSWEROverall, 13 (25.5%) of 51 patients who underwent resection had nonvisualized palpable satellite lesions as small as 2 mm, including seven (14%) who had nonvisualized palpable lesions at or beyond the planned stapler site.WHAT IS KNOWN ALREADYBoth laparoscopy and laparotomy for bowel resection are standard of care in Europe and the USA. Reoperation rates after laparoscopic bowel procedures are 1–16%. Endometriotic lesions at the stapler margin of bowel resections are associated with increased repeat surgery. Nodules of 0.1 mm to 1 cm in size were not recognized during laparoscopic bowel surgery but were recognized on histological examination. Up to 20 nodules not visualized at laparoscopy have been recognized and excised at laparotomy. Tenderness is found at up to 27 mm from a recognized lesion. The size of a lesion does not always predict its symptoms or behavior.STUDY DESIGN, SIZE, DURATIONThis single-arm, observational study focused on the presence of nonvisualized palpable satellite lesions of the bowel. Fifty-one patients scheduled for laparoscopic-assisted bowel resection for deep infiltrating endometriosis with suprapubic incision for placement of the stapler’s anvil and removal of the specimen in the course of routine clinical care were included. There were no additional inclusion or exclusion criteria.PARTICIPANTS/MATERIALS, SETTING, METHODSLaparoscopic-assisted segmental bowel resection for endometriosis was performed in a private referral center on women aged 24–49 years.MAIN RESULTS AND THE ROLE OF CHANCEForty-nine (96.1%) of the 51 patients underwent segmental resection of the sigmoid or rectum, and 14 (27.5%) underwent segmental resection of the ileum for large nodule(s) recognized on MRI. Twelve patients underwent both procedures. Eleven (22.4%) of the 49 patients with recognized sigmoid or rectal lesions and 5 (35.7%) of the 14 patients with recognized ileal lesions had nonvisualized, palpable, satellite lesions. All the large lesions and none of the satellite lesions had been recognized preoperatively on MRI. Five (10%) of 49 patients with lesions of the large bowel and 4 (28.6%) of the 14 patients with lesions of the ileum had nonvisualized palpable satellite lesions at or beyond the planned stapler site. Lesions as small as 2 mm were palpable.LIMITATIONS, REASONS FOR CAUTIONThis is an observational study. It is not known if the small lesions of this study contributed to the symptoms or were progressive, stable or regressive. This study analyzed lesions in the bowel segment proximal to the primary large bowel lesion, but not in the distal segment as that would have required a change in standard of care surgical technique. This study protocol did not include shaving or disk resection or patients in whom no lesions were visualized. The use of additional techniques for recognition, such as hand-assisted laparoscopy or rectal probes, was not investigated.WIDER IMPLICATIONS OF THE FINDINGSThis study confirms that some nonvisualized satellite lesions as small as 2 mm are palpable and that an increased length of resection can be used to remove lesions recognized by palpation and to avoid lesions at and beyond the stapler site. This may decrease recurrent surgery in 1–16% of the women undergoing surgery for bowel endometriosis. Knowledge of the occurrence of these small lesions may also be particularly useful in plans for repeat surgery or for women with clinically significant bowel symptoms and no visible lesions at laparoscopy. Moreover, small lesions are considered to be important as there is no current technique to determine whether a large primary lesion, smaller lesions, an associated adjacent tissue reaction or a combination of those cause symptoms.STUDY FUNDING/COMPETING INTEREST(S)This CIRENDO cohort was supported by the G4 Group (the University Hospitals of Rouen, Lille, Amiens and Caen) and the ROUENDOMETRIOSE association. No specific funding was received for the study. H.R. reports receiving personal fees from Plasma Surgical Inc., Ethicon Endosurgery, Olympus and Nordic Pharma for presentations related to his experience with endometriosis surgery. D.C.M. reports being given access to Lumenis Surgical CO2 Lasers’ lab at a meeting. None of the other authors have conflicts of interest to disclose.TRIAL REGISTRATION NUMBERN/A

Pure Vs. Hand-Assisted Laparoscopic Hepatectomy in HPB Center of Argentina

Hand-assisted laparoscopic (HAL) and pure laparoscopy (PL) are two effective methods to perform mini invasive laparoscopy liver surgery. The aim of this study was to assess the advantage of one technique over the other one. Retrospective analysis of clinical outcomes for patients who underwent a laparoscopic hepatectomy (LH) between August 2010 and January 2020. 112 LH were performed: 47 PL (42%) and 65 HAL (58%). Variables included were: demographics, diagnostic, benign or malignant disease, operative time (OT), hospital stay (HS), postoperative 90-day mortality and complications. To overcome selection bias, a 1:1 propensity score matching (PSM) analysis was performed, each group containing 27 LH. After PSM, there were no significant differences in age (PL 53+15 vs HAL 55+16), sex (16 females in each group), benign/malignant disease (PL 14/10 vs HAL13/17) and major hepatectomy (PL 7 vs HAL 9). There were no statistical difference in OT between PL and HAL (PL: 225 min + 90 vs HAL, 262 min + 111) (p=0.17). Global and major complication were also similar for both groups:3 complications for the PL group (all minor) and 5 for the HAL, 3 of which were major (Dindo-Clavien IIIb-IV) (p=NS). 90-day mortality was 0% in both groups. There was a significantly shorter HS in the PL group (2,8+1 vs HAL 4,81+3,7) (p=0.002). We observed that ower result suggests that PL had shorter HS, probably due to a lower number of complications. We could not find any significant differences in this study probably due to the small patient sample size.

Comparison of Minimally Invasive Surgical Approaches in the Management of Small Renal Masses at a Safety Net Hospital

Partial nephrectomy can be performed with traditional straight laparoscopy (SL), hand- assisted laparoscopic (HAL) and robotic-assisted laparoscopic (RAL) techniques. The purpose of this study is to analyze trends in surgical technique and compare the intra- and post-operative outcomes at a safety net hospital. We performed a single-institution retrospective review of intra- and post-operative outcomes in partial nephrectomy cases between 2012 and 2018. We analyzed the impact of patient demographics, tumor characteristics, and RENAL nephrometry score on surgical outcomes and post-operative complications among the three surgical approaches to partial nephrectomy. Of the 164 partial nephrectomies, 36 were SL, 65 HAL, and 63 RAL. Most SL was performed in the early years, whereas most RAL was performed in the later years, and HA was evenly distributed throughout the years. There was no difference in demographics, intra-operative complications, estimated blood loss, or positive margin rates between SL, HAL, and RAL. HAL partial nephrectomies had a higher RENAL nephrometry score and had statistically significant less warm ischemia and operative times when compared to RAL. HAL is a worthwhile technique in larger and more complex masses and especially in settings where robotic surgery is unable to be performed.

Living-donor nephrectomy at Singapore General Hospital: Evolution of surgical techniques over the last two decades

Background:Laparoscopic living-donor nephrectomy is the current epitome of living kidney donation surgery. We review our experience in living-donor nephrectomies over the last 19 years, transitioning from open surgery to hand-assisted laparoscopy to full laparoscopic techniques.Methods:We retrospectively identified all living-donor nephrectomies performed at our institution from 1976 to 2018. The donors were categorised according to surgical techniques: open (ODN), hand-assisted laparoscopy (HALDN) and full laparoscopy (LDN). We reviewed changes in donor demographics over the years. Surgical outcomes between groups were compared from 2000 to 2018. We also compared the outcomes of LDN between different time periods to evaluate our learning curve.Results:A total of 214 living-donor nephrectomies were performed between 2000 and 2018. The majority were left sided (93%) and had single renal artery anatomy (90%). There were 22 ODN, 20 HALDN and 163 LDN cases. The mean operating time was 84±43, 151±32 and 179±37 minutes for ODN, HALDN and LDN, respectively ( p&lt;0.001). There were no statistically significant differences in mean warm ischaemia times ( p=0.921) and length of hospital stay ( p=0.114) between groups. The overall 30-day surgical morbidity rate was 9.3%, with a major complications rate of 0.9%. The mean warm ischaemia time for LDN was significantly different ( p&lt;0.001) between time periods: 281±260, 184±94 and 140±42 seconds for the periods between 2005–2009, 2010–2014 and 2015–2018, respectively.Conclusion:This study confirms the safety of living-donor nephrectomies performed at our institution, a centre with a modest volume of kidney transplants.

Palpation to Identify Non-Visualized Bowel Endometriosis during Laparoscopic-Assisted Rectal or Sigmoid Segmental Resection

Study Objective To determine the prevalence of palpable non-visualized bowel endometriotic nodules in women having a laparoscopic-assisted segmental bowel resection for large endometriotic lesions and to compare the operative findings and early postoperative complications with and without palpable non-visualized lesions. Design Observational with follow-up of 2.8 months to 1.2 years. Setting Multispecialty center. Patients or Participants Forty-nine patients with large endometriotic lesions of the rectum or sigmoid colon who underwent segmental resection. Interventions The patients underwent laparoscopic dissection and placement of the distal stapling devise and then exteriorization of the specimen through a small suprapubic incision. The proximal stapler was applied after a modification of the standard procedure that consisted of palpation anticipating small palpable lesions and to include those in the specimen. Hand-assisted laparoscopy and using rectal probes for recognition were not studied. Measurements and Main Results Eleven (22.4%) of the 49 patients who underwent sigmoid or rectal resection were found to have palpable non-visualized lesions of 2 mm to 10 mm. The median length of the proximal resected segment increased by 10 mm (range 5-30 mm) compared to the group with no such lesions. The was no difference in the short-term complication rate between the two groups. Conclusion This suggests that palpation for recognition, diagnosis, and treatment is useful in 22.4% of women undergoing laparoscopic-assisted colon resection for stapler placement. The presence of palpable, non-visualized endometriotic lesions adds to the controversy about the type of surgery needed for symptomatic endometriosis of the rectum and sigmoid colon. Although only 1% to 5% of patients have repeat surgery for symptomatic recurrence, the use of focused palpation may lower that further. The use of hand-assisted laparoscopy or rectal probes for recognition also need investigation.

Multimodal approach to portal hypertension and gastric varices before hepatic resection for hepatocellular carcinoma: a case report

BackgroundLiver cirrhosis occurs in approximately 80–90% of patients with hepatocellular carcinoma (HCC), and hepatic resection may be dangerous because of well-documented liver cirrhosis, which may be accompanied by portal hypertension (PH). Here we report a patient with advanced HCC with gastric varices and PH who experienced a good clinical course after undergoing balloon-occluded retrograde transvenous obliteration (BRTO), percutaneous transhepatic portal vein embolization (PTPE), hand-assisted laparoscopic (HALS) splenectomy, and right lobectomy of the liver.Case presentationA 72-year-old man had two HCCs with gastric varices. CT revealed one tumor (4.5 cm) located in segment 7, involving the right hepatic vein, adjacent to the middle hepatic vein. Another tumor (2.7 cm) was located in segment 6. He first underwent BRTO for gastric varices and PTPE for planned right lobectomy of the liver. To reduce PH, HALS splenectomy was performed, and uncomplicated right lobectomy of the liver was performed 10 weeks after the first visit. He has remained free of recurrence for at least 1 year.ConclusionsOur patient underwent uncomplicated BRTO, PTPE, HALS splenectomy, and right lobectomy of the liver for advanced HCC with PH. Controlling portal pressure is important when hepatic resection is required to treat HCC with PH.

Elective surgery for tumours of the splenic flexure: a French inter-group (AFC, SFCD, FRENCH, GRECCAR) survey.

In an elective setting, there is no consensus regarding the type of colectomy that is best for patients with tumors of the splenic flexure: segmental left colectomy (or splenic flexure colectomy), left hemicolectomy or subtotal colectomy (or extended right hemicolectomy). In the United Kingdom, extended right hemicolectomy is preferred by surgeons. The aim of the present survey was to report on the practices in France for this particular tumor location. Between 15/07/17 and 15/10/17, members of two French surgical societies [the French Association of Surgery (AFC) and the French Society of Digestive Surgery (SFCD)] and two French surgical cooperative groups [the French Federation of Surgical Research (FRENCH) and the French Research Group of Rectal Cancer Surgery (GRECCAR)] were solicited by email to answer an online anonymous questionnaire. A total of 190 out of 420 surgeons participated in this study (response rate 45%). The preferred procedure was splenic flexure colectomy (70%), followed by left hemicolectomy (17%) and subtotal colectomy (13%). The most used surgical approach was laparoscopy (63%), followed by laparotomy (31%) and hand-assisted laparoscopy (6%). Lymph node dissection was extended to the middle colic artery in 29% of splenic flexure colectomies and in 33% of left hemicolectomies. Twenty-nine percent of responders thought that tumors of the splenic flexure had a worse prognosis in comparison with other colonic sites, because of insufficient lymph node dissection (73%) or a more advanced stage (50%) at diagnosis. However, this opinion did not change the type of colectomy performed. There is a strong consensus in France to operate tumors of the splenic flexure with a splenic flexure colectomy and lymph node dissection limited to the left colic artery.

Hand-assisted Laparoscopic Left Donor Nephrectomy Without a Hand-assisted Device: Is it Possible?

BackgroundLive donor nephrectomy is an important donor source. Donor nephrectomy can be performed by laparoscopy or hand-assisted laparoscopy. Different types of hand port devices can be used for assistance. In the literature there are few studies about hand-assisted laparoscopy without a hand port. In this study, we aimed to evaluate the impact of not using a hand port for hand-assisted laparoscopic donor nephrectomy for kidney transplantation. MethodsPatients who were operated on for kidney donation between January 2011 and June 2018 evaluated retrospectively. The patients were divided into 2 groups: group A, on whom a hand port was used, and group B, whose surgeries did not involve a hand port. The groups were compared for sex, age, body mass index, amount of intraoperative bleeding, warm ischemia time, duration of surgery, perioperative complications, duration of hospital stay, and postoperative complications. ResultsThere were 159 patients in group A and 146 patients in group B. There was no difference between the groups considering intraoperative bleeding, warm ischemia time, duration of surgery and postoperative early complications (P > .05 for all). ConclusionHand-assisted laparoscopic donor nephrectomy without a hand port can be considered an easy and effective method of laparoscopic nephrectomy.

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.

"Peek port": avoiding conversion during laparoscopic colectomy-an update.

To assess the efficacy of a method to avoid conversion to laparotomy in patients considered for laparoscopic colectomy. Patients considered being at high risk for conversion to formal laparotomy were initially approached via a small midline incision ("peek port") with the laparoscopic equipment readily available but unopened. If intraperitoneal conditions were favorable, the procedure was performed using hand-assisted laparoscopy (HALS); if intraperitoneal conditions were unfavorable, the incision was extended to a formal laparotomy. Data from 664 patients from a single surgeon brought to the operating room with the intention of proceeding with laparoscopic colectomy (either via straight laparoscopy or HALS) were retrieved from a prospective database. Comparison of conversion rates between groups was performed using χ2 analysis. The study population consisted of 361 men and 303 women with a mean age of 61years. Inflammatory conditions accounted for 40% of the diagnoses and enteric fistulas were present in 12%. Of the 79 patients who underwent initial "peek port" exploration, 38 (48%) underwent immediate extension to formal laparotomy, whereas 41 (52%) underwent HALS colectomy, with one subsequent conversion from HALS to formal laparotomy. Of the 585 patients initially approached laparoscopically, 14 (2%) required conversion to laparotomy. Of the 626 patients from both groups who underwent laparoscopy, the overall conversion to laparotomy rate was 15/626 (2%). The "peek port" approach to the patients with a potentially hostile abdomen allows for prompt assessment of intraperitoneal conditions and is associated with an overall low rate of conversion from laparoscopy to laparotomy during colectomy. This technique may reduce expense and morbidity for patients who ultimately require laparotomy, while allowing some patients with complex disease to be managed laparoscopically who would not normally be considered for a minimally invasive procedure.