Hand Assisted Research Articles

A comparison of three approaches for laparoscopic single-site (LESS) myomectomy: conventional, robotic, and hand assisted.

The objective of this study is to determine the feasibility and explore criteria for patient selection for three methods of LESS myomectomy: conventional (C-LESS), robotic-assisted (RA-LESS), and hand-assisted (HA-LESS). This was a retrospective case review of 72 patients with uterine myomas, conducted in a large academic tertiary care hospital between March 1, 2015, and November 7, 2018. LESS myomectomy via conventional, robotic, and hand-assisted routes. 43 patients underwent C-LESS, 15 underwent RA-LESS, and 14 underwent HA-LESS, with no conversions to open abdominal myomectomy. The operative outcomes were compared across the three approaches. The HA-LESS group had the largest mean number (HA: 6.9; C: 3.7; RA: 2.9, P=0.001), diameter (HA: 11.3 cm; C: 9.3 cm; RA: 7.1 cm, P=0.035), and weight (HA: 850.1 g; C: 320.7 g; RA: 181.1 g, P=0.003) of myomas removed per patient. The use of this method was also found to have a direct correlation with estimated preoperative uterine size (HA: 20.1 weeks; C: 16.2 weeks; RA: 12.0 weeks, P=0.001. Operative time and postoperative stay were found to be not statistically different across groups. We conclude that all three types of LESS myomectomy are feasible with comparable surgical outcomes. Most importantly, our findings indicate that hand assistance can be combined with C-LESS myomectomy for large or multi-fibroid uterus without compromising operating time or patient recovery. Notably, we found that uterine size could be a useful tool for the determination of the surgical approach.

Novel technical modifications of hand-assisted laparoscopic dissection of a large obturator mass: A case report and literature review.

Laparoscopic lateral pelvic tumor dissection (LLPTD) for transobturator tumors may be technically challenging due to the requirement for sufficient operative space. The present study discusses a technique modification with combination of the laparoscopic approach and hand-assisted (HA) open surgery for patients with large obturator masses. LLPTD was performed using the combined approach, defined as HA-LLPTD, with one case treated. According to this technique, a combined working space is constructed based on the outreached laparoscopic space and open extraperitoneal approach, followed by HA-LLPTD. Finally, a literature review was performed to retrospectively evaluate 17 cases of obturator tumors, in terms of tumor type and operative approach. The tumor in the present case was successfully and completely resected, without any obvious intra- and post-operative complications. Based on the literature review, the majority of the cases were benign (~75%) and originated from neurological tissue (~50%). The selection of the operative approach was either open or minimally invasive (50% each). HA-LLPTD allows experienced urological laparoscopic surgeons to safely and completely perform obturator surgery without obstruction of the obturator foramen or formation of intraperitoneal adhesions and associated complications. Therefore, HA-LLPTD may be more useful for transobturator tumor resection compared with the conventional intraperitoneal approach.

Splenic flexure mobilization for sigmoid and low anterior resections in the minimally invasive era: How often and at what cost?

BackgroundSplenic flexure mobilization (SFM) increases left colonic reach for a better vascularized and tension-free anastomosis. Open SFM is challenging due to anatomic position. Minimally invasive SFM improves visualization and minimizes splenic traction. MethodsWe retrospectively reviewed all sigmoid and low anterior resections (LAR) by a colorectal surgical group over 10-year period. We analyzed indications, surgical methods and perioperative outcomes of open and MIS SFM cohorts. Results793 patients were included; 122 (15.5%) open, 671 (84.5%) MIS (60% laparoscopic-assisted (LA), 40% hand-assisted (HA)). Overall, indications were cancer (56%), diverticulitis (31%), and other benign diseases (13%). Compared to MIS, open cases had more complex disease (45% vs. 18%, p < 0.01), with fewer SFM performed (40% vs. 86%, p < 0.01), required more frequent diversion (30% vs. 21%, p = 0.02) and were complicated by higher leak/abscess (7% vs. 3%, p = 0.06) and reoperation rates (10% vs. 6%, p = 0.11). 1% of SFM required conversion (LA to HA 0.5%, MIS to open 0.5%). There were no open SFM complications. There were 26 (5%) MIS SFM complications; bleeding (18; 12 splenic capsular tears (0 splenectomy/splenorraphy), 6 mesenteric) and organ injury (bowel (3), pancreatic (4), renal (1)). ConclusionsOur SFM rate was high in the MIS group, with a low overall complication rate. Of note, the anastomotic leak/abscess rate was 3%, and may be related to the high SFM rate. It is the authors’ opinion that a major advantage of MIS is to facilitate SFM, hence SFM is more likely to be performed with these methods compared to open procedures.

Evolution of Living Donor Nephrectomy at a Single Center

The development of minimally invasive surgical approaches to donor nephrectomy (DN) has been driven by the potential advantages for the donor, with questions remaining about long-term outcomes. All living DN performed from June 1963 through December 2014 at the University of Minnesota were reviewed. Outcomes were compared among 4 DN techniques. We performed 4286 DNs: 2759 open DN (ODNs), 1190 hand-assisted (HA) laparoscopic DNs (LDNs), 203 pure LDN (P-LDNs), and 97 robot-assisted-LDN. Laparoscopic DN was associated with an older (P < 0.001) and heavier (P < 0.001) donor population. Laparoscopic DN was associated with a higher probability of left kidney procurement (P < 0.001). All 3 LDN modalities required a longer operative time (P < 0.001); robot-assisted-LDN took significantly longer than HA-LDN or P-LDN. Laparoscopic DN decreased the need for intraoperative blood transfusion (P < 0.001) and reduced the incidence of intraoperative complications (P < 0.001) and hospital length of stay (P < 0.001). However, LDN led to a significantly higher rate of readmissions, both short-term (<30 day, P < 0.001) and long-term (>30 day, P < 0.001). Undergoing HA-LDN was associated with a higher rate of an incisional hernia compared with all other modalities (P < 0.001). For recipients, LDN seemed to be associated with lower rates of graft failure at 1 year compared with ODN (P = 0.002). The odds of delayed graft function increased for kidneys with multiple arteries procured via P-LDN compared with HA-LDN (OR 3 [1,10]) and ODN (OR 5 [2, 15]). In our experience, LDN was associated with decreased donor intraoperative complications and hospital length of stay but higher rates of readmission and long-term complications.

The Utility of Hand-Assisted Laparoscopic Surgery (HALS) in Giant Pelvic Masses.

The purpose of this study was to report the outcomes of a series of patients who underwent hand-assisted laparoscopy surgery for benign giant pelvic masses, including ovarian cysts and uterine myomas. We reviewed the records of all patients who underwent laparoscopic or hand-assisted laparoscopy surgery for a variety of benign gynecological conditions. Demographic, clinical, pathologic, and follow-up information was analyzed. Twelve patients have undergone hand-assisted laparoscopy for giant pelvic mass, including four hand-assisted laparoscopic myomectomy, four oophorocystectomy, and four salpingo-oophorectomy. The median age was 35.5 (19-55). The median BMI was 22.05 (19.8-26.7kg/m(2)). The median diameter of adnexal mass was 21 (17-24cm). The median diameter of uterine myoma was 18.5 (16-19cm). The median length of hand-assisted (HA) incision was 5cm (2-6cm). The median operation time was 100min (70 to 180 minutes), and median estimated blood loss was 60mL (30 to 800mL). The median length of stay was 3days (3-5days). There was no case of intraoperative and postoperative complications. Hand-assisted laparoscopic surgery is safe and feasible in the management of patients with benign giant pelvic masses. Additional studies are needed to further investigate potential advantages and outcomes of the technique.

Hand Assisted Retroperitoneoscopic Live Donor Nephrectomy With No Side/anatomy Exclusions: Single Centre Experience With 139 Cases.

BACKGROUND: Our study reports last 139 consecutive hand assisted retroperitoneoscopic live donor nephrectomies (HARS) performed at our institution since 6/2011. HARS nephrectomy technique has been introduced by the author in Prague/Czech Republic in January 2003, since June 2011 is being used for all the donors including right sided and complex anatomy cases (mutliple vessels and ureters, retroaortic renal vein, renal artery diseases, etc). The main benefit of HARS approach is increased safety for the donor. Risk of bleeding and intraabdominal injury is low thanks to hand assistance and extraperitoneal approach. METHODS: Data were collected prospectively. The operation is performed in the manner described by Wadström et al 2002, with minor modifications. Tere were all anatomical variations accepted for surgery, including right sided cases when indicated. RESULTS: There was no conversion to open nephrectomy, one donor was re-operated on the first postoperative day for bleeding from paraaortic lymphatics, this donor was also given two units of blood. The median blood loss was zero otherwise, meaning no use of suction or no blood in container. The median post-operative hospital stay was 2 days. We observed few minor complications including one wound infection, one wound seroma and three wound haematomas. There was one case of postoperative bleeding from paraaortic lyphatics mentioned above which required retroperitoneoscopic re-operation, there was one case of incisional hernia which occured some 8 months after surgery. All donors have life-long long follow up. There was one case of delayed graft function due to early rejection observed, all the other patients had immediate graft function. CONCLUSIONS: HARS is a safe way of performing living-donor nephrectomy with low risk of severe complications, minimal morbidity and fast recovery. It is safe alternative to the transperitoneal miniinvasive as well as other nephrectomy techniques. It can be used safely for all the anatomical variations as well as right sided cases.

Hand-assisted laparoscopic transhiatal approach for mediastinal esophageal duplication cyst resection

Esophageal duplication cyst is a rare congenital esophageal disorder. Although these cysts are usually resected via thoracotomy, a minimally invasive approach has recently been suggested to avoid a long hospital stay. Here, we report a case of mediastinal esophageal duplication cyst that was successfully treated using a laparoscopic transhiatal approach. The patient was a 68-year-old male who had previously undergone renal transplantation (3 years ago). At that time, a computed tomography scan showed a cystic lesion in the lower thoracic esophagus, and an esophageal duplication cyst was suspected. During the follow-up, the tumor gradually increased in size, reaching around 35 mm in size. Therefore, we resected the mediastinal esophageal duplication cyst via a laparoscopic transhiatal approach. With the patient in a supine position, an upper abdominal incision (70 mm) was made, and Lap Discs were put in place and used for hand assistance. Three 12 mm ports were inserted in both flanks and the left hypochondrium. One 5 mm port for a videoscope was inserted into the lower abdomen. Using hand assisted laparoscopic surgery, the esophageal hiatus was divided, and carbon dioxide was introduced into the mediastinum. After the abruption of the distal esophagus with a blunt tip dissector, an esophageal duplication cyst with a smooth surface was detected. We carefully exfoliated it from the surrounding tissues and extracted it via a transhiatal approach without injuring the adventitia of the esophagus. The operative time was 245 min, and 30 ml of intra-operative bleeding were observed. The patient was discharged at 8 days after the operation without complications. The histopathological findings were compatible with esophageal duplication cyst. Our surgical procedure produced a good surgical view and made it possible to resect the esophageal duplication cyst via a transhiatal approach and decrease surgical stress.

Evaluation of serum cytokine release in response to hand-assisted, laparoscopic, and open surgery in a porcine model

Background Although the immunologic benefits of laparoscopic surgery have been established, effects from hand-assisted (HA) surgery have not been investigated thoroughly. We hypothesized that the HA approach maintains the immunologic advantage of laparoscopic surgery compared with the open (O) approach. Methods Six O, HA, and laparoscopic (L) transabdominal left nephrectomies were performed on pigs. Blood samples were taken preoperatively, perioperatively, and postoperatively, and serum interleukin-6 and C-reactive protein levels were measured. Results At 24 hours after surgery, interleukin-6 levels were significantly higher in the O group vs the HA and L groups (82.2 vs 37.5 and 29.9 pg/mL, respectively; P < .05). Similar trends were seen at all time periods for both IL-6 and C-reactive protein. No significant differences in postoperative cytokine levels were detected between the HA and L groups. Conclusions The HA approach mimics the immunologic effects of laparoscopic surgery. These data suggest that the HA technique resulted in a reduced systemic immune activation in the early perioperative period when compared with open surgery. In addition to clinical benefits of minimal access, the HA approach also may afford patients an immunologic advantage over laparotomy.

National Survey of Laparoscopic Live Donor Nephrectomy in Japan From 2002 to 2008

Laparoscopic nephrectomy (LN) has been accepted for live donor kidney transplantation. Continuous surveys on the status of LN in live donors were made from 2002 to 2008 in Japan. At first, we reported the status in 2008 at 148 Japanese kidney transplantation centers. Of 148 centers, 109 responded, and 58 performed LN. These centers performed 764 live donor nephrectomies, including 659 LN and 105 open nephrectomies. In 58 centers, 20 were performed as hand-assisted (HA) LN, 27 as non-HA (pure laparoscopic), 2 as both HA and non-HA, and 8 as laparoscope-assisted. There were 24 centers that carried out a peritoneal approach and 34 had a retro-peritoneal approach. Among 764 LN donors, not 1 had a life-threatening complication. Blood transfusions were performed in only 1 donor. Open conversions from LN were required in 13 (2.0%) cases. Minor complications not requiring a prolonged hospital stay were reported in 20 cases. The mortality after LN was 0. Among 659 recipients, 1 case was reported as primary nonfunction, but ten recipients (1.5%) needed hemodialysis after transplantation because of delayed graft function. Urinary tract complications were noted in 18 recipients (2.7%). We have discussed the trends in LN from 2002 to 2008 in Japan. At the beginning of LN, many surgeons performed LN, so the open conversion rate was low and the blood transfusion rate was high. But in the later years, surgeons performed LN in the same manner as general laparoscopic surgeries with high intention for donor safety.

La asistencia manual es una alternativa a la conversión a laparotomía durante la sigmoidectomía laparoscópica

Introduction Laparoscopic surgery in the treatment of diverticular disease offers multiple benefits compared with its open surgery counterpart. There are two distinct techniques, the laparoscopically assisted and the laparoscopic hand assisted approach. The purpose of this study is to demonstrate that the hand assisted approach can be used if, during a laparoscopically assisted approach, there is difficulty in dissection and/or exposure, and before performing a laparotomy. Material and methods This study is a retrospective cohort series that was performed in a private tertiary hospital in Mexico City. Patients with the diagnosis of diverticular disease who underwent a laparoscopically assisted sigmoidectomy were selected. These included patients who, during their procedure required conversion to a hand assisted approach. Results A total of 47 sigmoid colectomies began with assisted laparoscopy, of which 33 were completed, 4 required laparotomy, and 10 where completed using hand assistance (none required laparotomy). There were no statistically significant differences in return of bowel function (P=0.879) and postoperative hospital stay (P=0.679) between the group that was completed by assisted laparoscopy vs. hand assisted. Conclusions If there is difficulty in exposure or dissection during a laparoscopically assisted sigmoid colectomy, the hand assisted approach is an alternative before the laparotomy.

Hand assistance is an alternative to conversion to laparotomy during laparoscopic sigmoidectomy

IntroductionLaparoscopic surgery in the treatment of diverticular disease offers multiple benefits compared with its open surgery counterpart. There are 2 distinct techniques, the laparoscopically assisted and the laparoscopic hand assisted approach. The purpose of this study is to demonstrate that the hand assisted approach can be used if, during a laparoscopically assisted approach, there is difficulty in dissection and/or exposure, and before performing a laparotomy. Material and methodsThis study is a retrospective cohort series that was performed in a private tertiary hospital in Mexico City. Patients with the diagnosis of diverticular disease who underwent a laparoscopically assisted sigmoidectomy were selected. These included patients who, during their procedure required conversion to a hand assisted approach. ResultsA total of 47 sigmoid colectomies began with assisted laparoscopy, of which 33 were completed, 4 required laparotomy, and 10 where completed using hand assistance (none required laparotomy). There were no statistically significant differences in return of bowel function (P=.879) and postoperative hospital stay (P=.679) between the group that was completed by assisted laparoscopy versus hand assisted. ConclusionsIf there is difficulty in exposure or dissection during a laparoscopically assisted sigmoid colectomy, the hand assisted approach is an alternative before the laparotomy.

Outcome of Laparoscopic Living Donor Nephrectomy in 2007: National Survey of Transplantation Centers in Japan

Laparoscopic nephrectomy (LN) has been accepted for a donor in living donor kidney transplantation. However, the current status of LN in living donors is not yet clarified in Japan. In this study, we surveyed 138 Japanese kidney transplantation centers to investigate the outcomes of living donor LN in 2007. Of 138 centers, 107 responded, and 48 performed LN. These centers performed 840 living donor nephrectomies, including 623 LN and 217 open nephrectomies. Among 47 centers, 23 performed hand-assisted (HA) LN, 18 non-HA (pure laparoscopic), 3 both HA and non-HA, and 3 laparoscope-assisted. Seventeen centers utilized a peritoneal approach, 26 a retroperitoneal approach, and 4 both approaches. Among 623 LN donors, the 2 who had the life-threatening complications of bleeding and intestinal injury both survived. Blood transfusions were performed in 5 donors (0.8%). There were 8 (1.3%) open conversions from LN. Minor complications not requiring a longer hospital stay were reported in 10. There was no donor mortality after LN. However, among the recipients, there was 1 case of primary nonfunction. Thirteen recipients (2.0%) required hemodialysis after transplantation because of delayed graft function. Urinary tract complications were noted in 13 recipients (2.0%). This survey presented the current status of this procedure among donors who provided informed consent.

Outcome of Laparoscopic Living Donor Nephrectomy: Current Status and Trends in Japan

Laparoscopic nephrectomy (LN) has been accepted for donors in living donor kidney transplantation. But the current status of LN in living donors is not clarified yet in Japan. In this study, we surveyed 124 Japanese kidney transplantation centers to investigate the outcomes of living donor LN in 2006. Of 124 centers, 100 responded, and 52 performed LN. These centers performed 831 living donor nephrectomies, including 589 LN, and 242 open procedures. In 52 centers, 20 were performed as hand-assisted (HA) LNs, 23 non-HA (pure laparoscopic), five both HA and non-HA, and four laparoscope-assisted. Eighteen centers used a peritoneal approach, 31 used a retroperitoneal approach and three, both. Among 589 LN donors, three experienced life-threatening complications of bleedings and intestinal injury, but all of them survived. Blood transfusions were performed in nine donors (1.5%), and open conversions of LN in 33 (5.6%). Minor complications not requiring a long hospital stay were reported in 45. The mortality of LN was 0. Among the 589 recipients, there was one case of primary nonfunction after venous injury at the operation. Twenty eight recipients (4.8%) needed hemodialysis after transplantation because of delayed graft function. Urinary tract complications were noted in 11 recipients (2.5%). This survey presented the current status of LN in Japan.

The Impact of Uncomplicated and Complicated Diverticulitis on Laparoscopic Surgery Conversion Rates and Patient Outcomes

The aim of this analysis was to determine the impact of complicated and uncomplicated diverticulitis on conversion rates and complications in patients undergoing laparoscopic surgery (LS) for diverticular disease. Between 1993 and 2004, 125 patients underwent LS [91 laparoscopic-assisted (LA) and 34 hand-assisted (HA) colectomy for diverticular disease, 79 uncomplicated and 46 complicated]. Cases not completed laparoscopically were considered converted. Complicated diverticulitis was defined as diverticular disease associated with abscess, fistula, bleeding or stricture. The mean age was 59 years with 67 (54%) men with a mean follow-up of 23 months. The conversion rate was 26% (33 patients). The only factor independently associated with conversion was a history of previous abdominal surgery (37% vs. 14%, p = 0.004). Among the subset of patients undergoing surgery for uncomplicated diverticulitis, the number of diverticulitis episodes (DE), the time between the first and last DE, and the time between the last DE and surgery, were not significantly associated with conversion. Early complications (<30 days from surgery) occurred in 30 (25%) patients. Twenty-one long-term complications (>30 days from surgery) occurred in 20 patients and the one and two-year cumulative probabilities of these complications were 14% and 22%, respectively. Early complications were significantly higher among patients requiring conversion (44% vs. 24%, p = 0.04) but were not significantly higher among patients with complicated diverticulitis (39% vs. 24%, p = 0.11). The rates of long-term complications were not significantly higher among patients that required conversion or had complicated diverticulitis (one-year rate 23% vs. 11%, p = 0.47; 18% vs. 13%, p = 0.70). A previous history of abdominal surgery was associated with a higher conversion rate in patients undergoing laparoscopic surgery for diverticular disease. Long-term patient outcomes are not adversely impacted by laparoscopic surgery for complicated diverticulitis or laparoscopic surgery requiring conversion to an open procedure.

Outcome of Laparoscopic Live Donor Nephrectomy in 2005: National Survey of Japanese Transplantation Centers

The increased acceptance of laparoscopic nephrectomy (LN) has been a driving force for live donor kidney transplantation. However, the outcomes of LN in live donors has not yet been clarified in Japan. In this study, we surveyed 125 Japanese kidney transplantation centers to investigate the current status of live donor LN. Of 125 centers, the 98 that responded had performed 695 live donor nephrectomies. Among these centers, 43 had performed LN. Among the 695 nephrectomies, 441 donors had undergone LN and 254, open nephrectomies. In 43 centers, 16 were performed as hand-assisted (HA) LN; 20, non-HA; 3, both HA and non-HA; and 5 laparoscope-assisted. Ten centers used a peritoneal approach; 30, a retroperitoneal; and 3, both. In 441 LN donors, 1 had a life-threatening complication of deep venous thrombosis and survived. Blood transfusions were performed in 7 donors. Open conversions from LN were necessary in 24. Minor complications not requiring prolonged hospital stay were reported in 52. The mortality of LN was zero. In contrast, among the 441 recipients, 1 case was reported as primary nonfunction after venous misadventure in the operation and 30 recipients needed hemodialysis after transplantation because of delayed graft function. Urinary tract complications were noted in 11 recipients. This survey presented the current status of the procedure, providing a base for informed consent from potential donors.

Objective assessment comparing hand-assisted and conventional laparoscopic surgery

Although several reports have subjectively highlighted the benefits of hand-assisted as compared with conventional laparoscopic surgery, there has been little objective analysis comparing these two techniques. For this study, 12 trained laparoscopic surgeons completed standardized knot-tying and dissection tasks in a laparoscopic trainer using both hand-assisted (HandPort) and traditional laparoscopic techniques. Motion analysis with the Imperial College Surgical Assessment Device was used to assess performance, measuring the number of movements made, the path length of hand travel, and the time taken. Mann-Whitney U tests were used to compare hand-assisted (HA) and conventional laparoscopic (L) performance. A p value less than 0.05 was deemed significant. Means and standard deviations are shown in the results. In knot tying, for both the dominant and nondominant hands, hand-assisted rather than conventional laparoscopic techniques resulted in reduced movements (dominant: HA [114 +/- 50] vs L [321 +/- 118, p < 0.001], nondominant: HA [89 +/- 36] vs L [296 +/- 96, p < 0.001]); path length (dominant: HA [1,083 +/- 680 mm] vs L [3,637 +/- 1,852 mm, p < 0.001], nondominant: HA [549 +/- 339 mm] vs L [2,556 +/- 1,042 mm, p < 0.001]); and time taken (HA [162 +/- 50 s] vs L [460 +/- 179 s, p < 0.001]). However, there was no statistical difference for any measured variable with respect to the dissection task. Hand-assisted surgery significantly improves the knot-tying ability among trained laparoscopic surgeons. However, there appears to be no improvement in performance for this specific dissection task.

Immunologic effects of hand-assisted surgery on peritoneal macrophages: Comparison to open and standard laparoscopic approaches

Exaggerated activation of peritoneal immunity after major abdominal surgery activates peritoneal macrophages (PMs), which may lead to a relative local immunosuppression. Although laparoscopy (L) is known to elicit a smaller attenuation of peritoneal host defenses, compared with open (O) surgery, effects of the hand-assisted (HA) approach have not been investigated to date. Eighteen pigs underwent a transabdominal nephrectomy via O, HA, or L approach. PMs were harvested at 4, 12, and 24 hours through an intraperitoneal drain and stimulated in vitro with lipopolysaccharide. The production of interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) by the purified macrophage cultures was measured with the use of a standard enzyme-linked immunosorbent assay technique. Statistical comparison was performed by using analysis of variance and Student t test. In vitro lipopolysaccharide-induced IL-6 and TNF-alpha production by PMs increased over the 24-hour period in all 3 groups. Stimulated PMs harvested at 12 and 24 hours postoperatively secreted higher levels of IL-6 in the O group, compared with both the HA group (P = .02, P = .01) and L group (P = .04, P = .001). PMs harvested at 4, 12 and 24 hours postoperatively also produced more TNF-alpha in O group, compared with both the HA group (P = .03, P = .03, and P = .01) and L group (P = .01, P = .05 and P = .03). There was no significant difference between H and L groups in production of either cytokine. Abdominal surgery attenuates peritoneal host defenses regardless of the surgical approach employed. However, for the first time, we demonstrated that the HA approach, similar to laparoscopy, is superior to open surgery in the degree of PM activation. Overall, in addition to clinical benefits of minimal access, HA surgery may confer an immunologic advantage over laparotomy.

100-MINUTE RETROPERITONEOSCOPIC RADICAL NEPHRECTOMY: A NEW RETROPERITONEAL APPROACH WITH A HAND ASSISTED METHOD

A new approach for retroperitoneoscopic radical nephrectomy is introduced. The point of our surgical method is the application of a combination of hand assistance and pure laparoscopic procedures with appropriate surgical steps via the retroperitoneal approach. In our early series we had good surgical results and we completed radical nephrectomy in about 100 minutes using this procedure. A total of 20 consecutive patients with renal cell carcinoma (cT1-2) who were operated on with this surgical method were analyzed. Surgical procedures occurred in 5 steps. In step 1 the retroperitoneal space was created manually from a pararectal incision at the umbilicus level. In step 2 the lateroconal fascia was incised and the renal hilar area was exposed with hand assistance. In step 3 hilar dissection was performed by pure laparoscopic procedure with another surgical instrument inserted from the hand device. Step 4 involved the application of hand assistance again for the quick mobilization of the kidney and adrenal gland. In step 5 the intact surgical specimen was retrieved from the hand device. Mean operative time and estimated blood loss were 103 +/- 21 minutes (range 70 to 145) and 49 +/- 85 ml (range 5 to 360), respectively. Mean days to oral intake and ambulation were 1.0 and 1.1, respectively. Operative times of the steps of hilar dissection and mobilization of the kidney and adrenal were shorter than in other series performed by standard retroperitoneoscopic radical nephrectomy. Major complications were not experienced. At this point, no metastasis has been experienced. Our surgical method may have the benefits of the retroperitoneal approach and hand assistance. The retroperitoneoscopic hand assisted method may be another important option in the 3 major approaches for laparoscopic radical nephrectomy, although longer-term followup is clearly required.

THE HAND-ASSISTANCE ADVANTAGE OVER INTEGRAL RETROPERITONEOSCOPIC KIDNEY HARVESTING. THE INITIAL EXPERIENCE

A56 Aims: Hand assistance makes retroperitoneoscopic kidney harvesting a safe and effective procedure; a promise for a new standard. It gives a quick way in, a large working space, tactile discrimination and a quick way out for the harvested kidney. A proper hand assisted approach gives a clear-cut advantage for retroperitoneal laparoscopy. The aim of this study is to assess the hand assisted retroperitoneoscopic kidney harvesting. Methods: We assessed the initial results obtained with 10 hand-assisted retroperitoneoscopic kidney harvesting (HARH) compared with 25 standard retroperitoneoscopic procedures (RH). We have harvested only the left kidney. Vascular anomalies were accepted and corrected in bench surgery. The hand assistance is performed throw a 6 cm incision along the lateral side of the rectus abdominis muscle, beneath the umbilicus. A large working space is created by manual blunt dissection with subsequent extensive detachment of the peritoneum. The working trocar is placed at the tip of the XIIth rib and the telescope is placed above the iliac crest. Additional ports are placed as necessary. The dissection is easier and the kidney is immediately removed through hand assistance entrance. Results: All harvestings were successful. Mean operative time was shorter in HARH group (114.5 min. vs. 166.4 min). Cold ischemia time was minimal: 2.3 min. All grafts were functional after transplantation Conclusions: Hand assisted retroperitoneoscopic kidney harvesting promise to become the new standard in living donation.

Hand assisted laparoscopic radical cystectomy for cancer bladder.

To evaluate the efficacy, safety and feasibility of hand assistance in performing laparoscopic radical cystectomy and to describe our point of technique of hand assisted laparoscopic radical cystectomy (HALRC) with extra-corporeal ileal conduit reconstruction for muscle invasive bladder cancer. This is the second case report of HALRC in the world literature. A five-port transperitoneal laparoscopic approach with an indigenous hand port was used to perform the radical cystectomy in a patient with muscle invasive TCC of bladder. After specimen retrieval, ileal conduit reconstruction was performed extra-corporeally through the site of hand port incision. HALRC was successfully completed in 4.3 hrs and the patient was discharged on the 7th day. The blood loss was 500 ml, and patient was transfused 2 units of blood, as the pre operative hemoglobin was 9 gms%. The analgesic requirement was 350 mgs of Pethidine (equivalent to 35 mgs of Morphine) and 450 mgs of oral Diclofenac Sodium. It took about 23 days for patient to resume normal activity. The histopathology was reported as T3b, left perivesical margin was positive and 2/5 of left pelvic lymph nodes were also involved. However, 7 lymph nodes removed from the right side did not show any disease. In view of histopathology report patient was given 4 cycles of postoperative chemotherapy, At the current follow up of 25 months the patient is free of any recurrence of disease. This case demonstrates the applicability of hand port assistance in to the laparoscopic field inside the abdomen, which helps in retraction and performing blunt dissection coupled with tactile sensation. It is feasible to use hand during laparoscopic radical cystectomy. Its usefulness has to be weighed against the standard laparoscopic radical cystectomy and additional time required for set up and the added cost. The technical success rate currently for standard laparoscopic radical cystectomy clearly demonstrates that hand assistance is not necessary. But, just as its applicability is being investigated, its role should be assessed in larger series of laparoscopic radical cystectomy.