Hand-assisted Laparoscopy Research Articles

Hand-assisted urological laparoscopy.

Hand-assisted laparoscopy has been successfully applied to various applications within the field of urology. Many authors have proved the safety and efficacy of this technique, as well as demonstrating improved patient recovery for such procedures as radical nephrectomy, radical nephroureterectomy and donor nephrectomy. The recent literature regarding this topic is reviewed and evaluated here.

Prospective comparison of hand-assisted laparoscopic devices

Objectives. To evaluate and compare the three commercially available first-generation hand-assisted laparoscopic (HAL) devices in a prospective, randomized fashion. HAL nephrectomy has become an increasingly popular surgical modality. Methods. Sixty-seven board-certified urologists each performed two HAL nephrectomies in a porcine laboratory, using two different hand devices, at a learning course sponsored by the American Urological Association. At the completion of the laboratory session, each surgeon was asked to complete a 12-question survey designed to evaluate the different hand-assist devices. Results. Thirty-nine surgeons used the HandPort, 47 used the Intromit, and 47 used the Pneumosleeve. No statistical differences were found in the ratings among the three devices within any category. No device scored better than 8.1 in any category, and the overall satisfaction was less than 7.7 in all three groups. Although not statistically significant, the Intromit device had the highest ratings in the following categories: instructions, maintenance of pneumoperitoneum, exchange of laparotomy pads, retrieval of specimens, sturdiness, and overall satisfaction. The HandPort had the highest failure rate. Conclusions. HAL relies heavily on devices that allow the hand to be introduced into the laparoscopic environment. The three available devices are all effective, yet each have their specific advantages and disadvantages. In terms of overall satisfaction, no device scored greater than 7.7. The results of this study suggest that the need for improvement by all three manufacturers is significant and have helped to better identify these areas.

Laparoscopic donor nephrectomy: an update.

Laparoscopic donor nephrectomy was developed primarily to increase the number of kidneys available for donation. Further evidence of the safety and efficacy of laparoscopic donor nephrectomy has been reported in the literature, as have studies on the cost-effectiveness of this procedure and its role in removing disincentives for renal donation. Specific technical modifications have been developed and refined that improve outcomes when performing laparoscopic harvesting of right kidneys. Other technical modifications have been developed for use in obese patients. With the adoption of these modified techniques, equivalent results to open donor nephrectomy have been reported. Recently, a wide range of alternative approaches (hand-assisted, retroperitoneal, and gasless laparoscopy) have been utilized for laparoscopic donor nephrectomy.

Making hand-assisted laparoscopy easier: preventing CO2 leak.

Hand assistance has been a significant advance in making laparoscopy an easier and safer method for certain procedures such as nephrectomy. The value of this technique is realized when comparing patient outcomes (e.g., less postoperative pain, shorter hospital stay, quicker recovery time) with those of the standard open approaches. One reported disadvantage of the Pneumo Sleeve device for hand-assisted laparoscopy is leakage of CO2 gas from around the ring base. We describe in detail our technique to secure the Pneumo Sleeve to the abdomen in such a way as to prevent leakage of intraperitoneal gas and fluid.

The feasibility of hand-assisted laparoscopic aortic bypass using a low transverse incision.

Hand-assisted laparoscopy can be used to perform aortoiliac reconstructive procedures. This study aimed to evaluate the safety and feasibility of a hand-assisted aortofemoral bypass in patients with occlusive disease using a low abdominal transverse incision to reduce postoperative respiratory problems. In 18 patients, a modified Pfannenstiel incision was performed. A hand-assist device was inserted, and the aorta was exposed using transperitoneal laparoscopy. Tunneling was performed under laparoscopic control. The anastomosis was always performed proximally to the inferior mesenteric artery. In three patients, the proximal anastomosis had to be performed laparoscopically. The indication for surgery was occlusive disease in 16 patients and a combination of an aneurysm and aortoiliac occlusion in 2 patients. Conversion was required in one patient (1/18). In 13 patients (13/18), the total operating time did not exceed 180 min, and 61% of the patients (11/18) could be discharged by postoperative day 5. None of the patients died perioperatively (0/18). Complications were observed in six patients (6/18). Only one of these patients had respiratory problems (1/18). The remaining five patients had local complications such as wound healing problems. The anastomosis was sutured laparoscopically in three patients (3/18). Hand-assisted laparoscopy can be performed safely using a low transverse abdominal incision. In our experience this laparoscopic access can reduce the incidence of postoperative respiratory problems and incision-related complications.

Hand-assisted laparoscopic nephroureterectomy: Initial case report

Nephroureterectomy with removal of a bladder cuff was performed successfully on a 47-year-old man for transitional cell carcinoma of the right renal pelvis using hand-assisted laparoscopy. The results showed that hand-assisted laparoscopic nephroureterectomy is an efficacious alternative to open surgery and provides the urologist new to laparoscopy a shorter learning curve compared with standard laparoscopy.

Technique of Right Laparoscopic Donor Nephrectomy: A Single Center Experience

The majority of laparoscopic donor nephrectomies (LDNs) are limited to the left side due to technical and allograft concerns in using the right. We review our experience with right LDNs. Since June 1997, 15 right LDNs were performed and the records retrospectively reviewed for demographics, operative time, transfusions, complications, and length of stay. Recipient records were also reviewed for delayed graft function, complications, and serum creatinine levels. Overall donor, recipient and graft survivals at 6 months are 100%. Mean operative time was 317 +/- 11.0 min, length of stay was 4.2 +/- 0.2 d, and mean serum creatinine levels at discharge, 1, 3, and 6 months were 1.74 +/- 0.19, 1.59 +/- 0.13, 1.72 +/- 0.13, and 1.68 +/- 0.13 mg/dL, respectively. No transfusions were required. There were no operative or hospital complications. Two recipients (13.3%) experienced delayed graft function, defined as requiring hemodialysis post-transplantation. With hand-assisted laparoscopy, the right laparoscopic donor nephrectomy is safe and allows excellent allograft function.

HAND ASSISTED LAPAROSCOPIC DONOR NEPHRECTOMY: A COMPARISON WITH THE OPEN APPROACH

Hand assisted laparoscopy combines aspects of open and laparoscopic surgery. A hand in the abdomen may facilitate laparoscopic live donor nephrectomy, allowing more urologists to participate. We report and compare our initial series of hand assisted laparoscopy donor nephrectomy with nephrectomy performed by standard open methods. In the last 18 months 60 patients at 2 institutions underwent hand assisted laparoscopy donor nephrectomy. This cohort was compared to a contemporary group of 31 patients who underwent open donor nephrectomy via a flank incision at our 2 institutions. Demographic and outcome data were compared retrospectively in a nonrandomized fashion in the 2 groups. Demographic data on patient age, male-to-female ratio and body mass index were similar in the 2 groups. Operative time, transfusion rate, time to oral intake and complications were also similar. However, estimated blood loss, change in hematocrit preoperatively to postoperatively, hospitalization, parenteral and oral narcotic requirement, and donor convalescence were significantly less in the hand assisted laparoscopy versus open groups. In terms of allograft function, nadir creatinine, time to nadir creatinine, creatinine clearance at 6, 12, and 18 months, delayed graft function, episodes of acute rejection and ureteral stricture were similar in the groups. Hand assisted laparoscopy is safe, efficacious and reproducible for living related donor nephrectomy. Compared with the open technique hand assisted laparoscopy provides the donor with significantly decreased postoperative morbidity, while enabling excellent allograft function. Further randomized prospective studies are warranted.

LAPAROSCOPIC PARTIAL NEPHRECTOMY WITH A MICROWAVE TISSUE COAGULATOR FOR SMALL RENAL TUMOR

LAPAROSCOPIC PARTIAL NEPHRECTOMY WITH A MICROWAVE TISSUE COAGULATOR FOR SMALL RENAL TUMOR

Hand-Assisted Laparoscopic Bariatric Surgery

Bariatric surgery implies a major life-long rearrangement of the gastrointestinal tract to obtain a controlled weight reduction in a severe but nonmalignant disease. Obesity poses a special challenge to the laparoscopic surgeon. Laparoscopy is known to facilitate the perioperative phase for the patient, but is technically difficult to perform in morbidly obese subjects. Hand-assistance adds extra control in demanding procedures, and Hand-port systems for use in the thick abdominal wall are now available. Here we review the role of hand-assisted laparoscopy for common bariatric procedures and describe our technique for Hand-assisted laparoscopic Roux-en-Y Gastric bypass. Hand-assistance might be the well-blended mix for complex laparoscopic procedures in bariatric work, especially for surgeons working outside highly specialized laparoscopic centers.

Editorial Comment: Retroperitoneal Laparoscopic Nephroureterectomy and Management Options for the Distal Ureter

Journal of EndourologyVol. 15, No. 4 Transitional-cell Carcinoma of the Renal PelvisEditorial Comment: Retroperitoneal Laparoscopic Nephroureterectomy and Management Options for the Distal UreterFray F. MarshallFray F. MarshallSearch for more papers by this authorPublished Online:6 Jul 2004https://doi.org/10.1089/089277901300189411AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail "Editorial Comment: Retroperitoneal Laparoscopic Nephroureterectomy and Management Options for the Distal Ureter." , 15(4), p. 397FiguresReferencesRelatedDetailsCited ByLaparoscopic Approaches to Renal MalignanciesCurrent Problems in Cancer, Vol. 30, No. 4 Volume 15Issue 4May 2001 To cite this article:Fray F. Marshall.Editorial Comment: Retroperitoneal Laparoscopic Nephroureterectomy and Management Options for the Distal Ureter.Journal of Endourology.May 2001.397-397.http://doi.org/10.1089/089277901300189411Published in Volume: 15 Issue 4: July 6, 2004PDF download

Hand-assisted laparoscopic partial nephrectomy.

The indications for partial nephrectomy are expanding as newer and more complete data come forth. A partial nephrectomy has traditionally required a generous flank incision. We report our experience using hand-assisted laparoscopy (HAL) as a less-invasive approach to partial nephrectomies. Between October 1999 and May 2000, we performed 11 HAL partial nephrectomies. The average age of the patients was 55.7 years, the average body mass index was 25.6, and the average ASA class was 2.2. The indications for partial nephrectomy were enhancing solid renal lesions (N = 9) and nonfunctioning renal moiety in a duplicated system (N = 2). In the majority of cases, access to the renal pedicle was obtained prior to the partial nephrectomy. However, in no case did the renal artery or vein require occlusion. Several excisional techniques were employed, but all relied heavily on the Harmonic Scalpel in conjunction with the argon beam coagulator. Different hemostatic agents were applied to the renal defect, including Surgicel, Avitene, and fibrin-soaked Gelfoam activated by thrombin. In several instances, pledget reinforced sutures were placed in the renal capsule to aid with hemostasis. The average operative time was 273 minutes, the estimated blood loss 319 mL, and the change in hematocrit 7.3 points. No patient required a transfusion, and there was one conversion to open. Postoperatively patients, required an average of 35.6 mg of morphine sulfate equivalent and 8.2 narcotic tablets, resumed oral intake in 1.7 days, and were discharged home in 3.3 days. There were no major complications and only two minor complications. Postoperatively, five lesions were found to be benign, four lesions were confirmed to be malignant, and two lesions were consistent with a nonfunctioning duplicated renal moiety. Specimen size averaged 180 cc, and the tumor diameter averaged 1.9 cm. There were no positive surgical margins. Hand-assisted laparoscopic partial nephrectomy is feasible and reproducible. The surgeon's hand in the operative field facilitates dissection, vascular control, hemostasis, and suturing. Further long-term and prospective studies are underway.

Simple Nephrectomy: Hand-Assisted Technique

Chronic inflammation or prior surgical procedures may complicate the laparoscopic performance of simple nephrectomy. In these difficult cases, hand-assisted laparoscopy may be useful. The position of the hand port depends on the particular situation, but the port must allow flexion of the wrist and access to the entire surgical field. The hand-assisted procedure is similar to standard laparoscopy in analgesic use, time to oral intake, length of stay, and time to full recovery. Hand-assisted laparoscopy allows the inexperienced surgeon to perform laparoscopy with the aid of tactile sensation and three-dimensional spatial orientation. For the experienced surgeon, the technique offers an alternative to open conversion when the laparoscopic procedure fails to progress.

LAPAROSCOPIC RADICAL NEPHROURETERECTOMY FOR UPPER TRACT TRANSITIONAL CELL CARCINOMA: THE CLEVELAND CLINIC EXPERIENCE

We report our single institutional experience with retroperitoneal laparoscopic radical nephroureterectomy in patients with upper tract transitional cell carcinoma and compare results to those achieved by the open technique. A total of 77 patients underwent radical nephroureterectomy for pathologically confirmed upper tract transitional cell carcinoma. Of these patients 42 underwent laparoscopic nephroureterectomy from September 1997 through January 2000 and 35 underwent open surgery. All specimens were extracted intact. Of the laparoscopic group the juxtavesical ureter and bladder cuff were excised by our novel transvesical needlescopic technique in 27 and radical nephrectomy was performed retroperitoneoscopically in all 42. Data were compared retrospectively with 35 patients undergoing open radical nephroureterectomy from February 1991 through December 1999. Laparoscopy was superior in regard to surgical time (3.7 versus 4.7 hours, p = 0.003), blood loss (242 versus 696 cc, p <0. 0001), specimen weight (559 versus 388 gm., p = 0.04), resumption of oral intake (1.6 versus 3.2 days, p = 0.0004), narcotic analgesia requirements (26 versus 228 mg., p <0.0001), hospital stay (2.3 versus 6.6 days, p <0.0001), normal activities (4.7 versus 8.2 weeks, p = 0.002) and convalescence (8 versus 14.1 weeks, p = 0.007). Complications occurred in 5 patients (12%) in the laparoscopic group, including open conversions in 2, and in 10 (29%) in the open group (p = 0.07). Followup was shorter in the laparoscopic group (11.1 versus 34.4 months, p <0.0001). The 2 groups were similar in regard to bladder recurrence (23% versus 37%, p = 0.42), local retroperitoneal or port site recurrence (0% versus 0%) and metastatic disease (8.6% versus 13%, p = 1.00). Mortality occurred in 2 patients (6%) in the laparoscopic group and 9 (30%) in the open group. Cancer specific survival (97% versus 87%) and crude survival (97% versus 94%) were similar between both groups (p = 0.59). In patients with upper tract transitional cell carcinoma who are candidates for radical nephroureterectomy the retroperitoneal laparoscopic approach satisfactorily duplicates established technical principles of traditional open oncological surgery, while significantly decreasing morbidity from this major procedure. Short-term oncological and survival data of the laparoscopic technique are comparable to open surgery. Although long-term followup data are not yet available, it appears that laparoscopic radical nephroureterectomy may supplant open surgery as the standard of care in patients with muscle invasive or high grade upper tract transitional cell carcinoma.

Video-assisted aortic surgery

Background: There are several laparoscopic techniques that can be used to perform a total or video-assisted aorto–femoral bypass grafting procedure. Major drawbacks of laparoscopic aortic surgery are the long operating times and the steep learning curve required for these procedures. Hand-assisted laparoscopy is a novel technique that allows surgeons to use their hands and laparoscopic instruments in the operative field while maintaining a pneumoperitoneum. Study Design: A prospective nonrandomized study was conducted in a community medical center. Any patient with aortoiliac occlusive disease or an abdominal aortic aneurysm who was determined to be suitable for a laparoscopic aorto–femoral bypass grafting procedure was included in the study. The main outcomes measured were: operating time, aortic cross-clamp time, incision size, complications, conversion rate to an open procedure, length of stay in the ICU, and postprocedural hospital stay. A concurrent control group of 20 patients was compared with the minimally invasive group. Results: Forty-one consecutive patients were scheduled for the laparoscopic operation. Conversion to an open procedure was necessary in three patients. There were two major complications, including the development of renal failure in one patient who died 28 days postoperatively. The mean postprocedural hospital stay was 4.5 ± 2.5 days (range 2 to 15 days). The mean operating time was 163.1 ± 38.7 minutes, including an aortic cross-clamp time of 38.3 ± 9.7 minutes. Postoperative hospital stay and the time required in the ICU were significantly shorter after the laparoscopic procedure compared with a conventional bypass grafting procedure. Conclusions: Hand-assisted laparoscopy is a minimally invasive technique with operating times and outcomes similar to those of conventional procedures. The possibilities of this technique in patients with aortoiliac disease should be evaluated in a prospective randomized study.

Hand-assisted laparoscopic cholecystectomy at cesarean section

Laparoscopic cholecystectomy at the time of elective cesarean delivery eliminates the need for separate operations. Hand-assisted laparoscopy takes technical advantage of the cesarean abdominal incision to facilitate laparoscopic maneuvers with retention of pneumoperitoneum. A 39-year-old woman with two previous cesarean sections and recurrent cholecystitis throughout her third pregnancy underwent full-term, elective cesarean section, tubal sterilization, and hand-assisted laparoscopic cholecystectomy under general anesthesia. Total operating time was 53 minutes, estimated blood loss was 550 ml, and postoperative hospital stay was 72 hours. The operation and recovery were uneventful.

Hand-assisted laparoscopy for complex hysterectomy

In rare cases of extreme uterine enlargement, hysterectomy by vaginal and laparoscopic-assisted techniques is not feasible and requires a large abdominal incision. Hand-assisted laparoscopy permits the performance of such cases through a much smaller, glove-size abdominal incision while preserving pneumoperitoneum. In a 45-year-old nullipara with a grossly enlarged, impacted uterus and total vaginal obliteration, hysterectomy was safely performed by hand-assisted laparoscopy using the Pneumo Sleeve system through a 7.5-cm transverse suprapubic incision, and a 1-cm laparoscopic incision. The operation lasted 150 minutes, blood loss was 220 ml, and the specimen weighed 3050 g. The patient was discharged in excellent condition on the second postoperative day and had an uneventful recovery.

Divided vertical banded gastroplasty either for correction or as a first-choice operation.

Staple-line disruption may occur after vertical banded gastroplasty (VBG). Since May 1996, the authors have performed the gastric restrictive procedure divided VBG, as described by MacLean, as a first-choice operation and not only as correction for staple-line breakdown. Divided VBG was done in 111 patients, 32 as correction after staple-line disruption and 79 as a first choice, 29 of them by hand-assisted laparoscopy with the dexterity pneumosleeve. Weight loss and nutritional status have been very satisfactory. Operating time for the standardized operation has been no longer than 60 minutes. Divided VBG, especially if done by hand-assisted laparoscopy using the dexterity pneumosleeve, is a valid restrictive procedure.

RETROPERITONEOSCOPIC NEPHROURETERECTOMY FOR RENAL PELVIC TUMORS WITH A SINGLE ILIAC INCISION

Retroperitoneal laparoscopy, by providing direct access to the retroperitoneal cavity, is a useful approach to urological surgery. We applied this technique to nephroureterectomy in patients with tumors of the renal pelvis. Between January 1995 and March 1997 we performed 4 retroperitoneal laparoscopic nephroureterectomies in patients with tumors of the renal pelvis. The patients were placed in the lateral decubitus position. Five trocars were used. Balloon dilation was not contributory. Radical nephrectomy was performed and the kidney was left in the retroperitoneal space. Via an iliac incision ureterectomy with a bladder cuff was performed and the specimen was removed (kidney and ureter) en bloc via this incision without opening the urinary tract. One right and 3 left nephroureterectomies were performed with an average operating time of 220 minutes (range 160 to 300). Average kidney size was 110 mm. (range 100 to 120). Average hospital stay was 5.7 days (range 5 to 7). Blood loss was minimal and postoperative analgesic requirements were moderate. Conversion to open surgery was never necessary. The morbidity rate was zero. The pathological stages were pT2 G2, pT3 G2, pT3G3 and pT3 G2-G3 N+. A local recurrence was observed in a patient with a pT3 G3 tumor. Nephroureterectomy can be performed by retroperitoneal laparoscopy. The perioperative morbidity and hospital stay are reduced. Further followup is required to evaluate long-term results in terms of cancer outcome.

Hand-assisted laparoscopic nephrectomy.

The introduction of hand-assisted laparoscopy should benefit every laparoscopic urologist. Hand assistance will shorten the learning curve for many urologists interested in performing laparoscopic renal procedures, including nephrectomy and nephroureterectomy. Advanced laparoscopists will be able to undertake more challenging procedures, including nephrectomies for inflamed, infected kidneys and live-donor nephrectomies. A step-by-step approach is presented for hand-assisted laparoscopic nephrectomy.