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Drezdzon MK, Calata JF, Peterson CY, Otterson MF, Ludwig KA, Ridolfi TJ. Lending a hand: The utility of hand-assisted laparoscopic surgery in diverticulitis with fistula. Surgery 2024; 175:776-781. [PMID: 37867107 DOI: 10.1016/j.surg.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/10/2023] [Accepted: 08/08/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Current guidelines recommend elective colectomy for the management of diverticulitis-associated fistulas. These cases present considerable operative challenges, and surgical approaches and fistula tract management vary widely. Hand-assisted laparoscopic surgery offers the benefits of minimally invasive surgery while maintaining the tactile advantages of open surgery. This study aims to evaluate outcomes of hand-assisted laparoscopic surgery colectomy for diverticulitis-associated fistulas, fistula tract, and urinary catheter management. METHODS A retrospective review of patients with diverticulitis-associated fistula who underwent elective hand-assisted laparoscopic surgery colectomy between January 2, 2008, and September 8, 2022, was performed. Patients with Crohn disease or who underwent emergency surgery were excluded. RESULTS Seventy patients were included; the mean patient age was 64.1 ± 14.8 years, and the mean body mass index was 30.9 ± 9.1 kg/m2. Colovesical fistulas were most common (n = 48; 68.6%), followed by colovaginal fistulas (n = 22; 31.4%). The median operative time was 186 minutes. Conversion to an open approach occurred in 4 cases (5.7%). The fistula tract remnant was left without intervention in 35 patients (50%), and omental coverage occurred in 23 cases (32.9%). The median duration of the urinary catheter was 3 days (range = 1-63). There were no postoperative urine leaks. Three patients (4.3%) were readmitted in ≤30 days. There were no 30-day mortalities. CONCLUSION The challenges of colectomy for diverticulitis-associated fistulas can be mitigated using the hand-assisted laparoscopic surgery technique. We found a low conversion-to-open rate, falling below rates reported for laparoscopic colectomy. There were no cases of postoperative urine leak, suggesting that no intervention or omental coverage is a safe approach to fistula tract management.
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Affiliation(s)
| | - Jed F Calata
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Carrie Y Peterson
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Mary F Otterson
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Kirk A Ludwig
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Timothy J Ridolfi
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
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Hand-assisted versus straight laparoscopy for colorectal surgery - a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:2309-2319. [PMID: 36319866 PMCID: PMC9640416 DOI: 10.1007/s00384-022-04272-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE Hand-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. METHODS Comprehensive 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. RESULTS A 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. CONCLUSIONS Hand-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.
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Hawkins AT, Wise PE, Chan T, Lee JT, Glyn T, Wood V, Eglinton T, Frizelle F, Khan A, Hall J, Ilyas MIM, Michailidou M, Nfonsam VN, Cowan ML, Williams J, Steele SR, Alavi K, Ellis CT, Collins D, Winter DC, Zaghiyan K, Gallo G, Carvello M, Spinelli A, Lightner AL. Diverticulitis: An Update From the Age Old Paradigm. Curr Probl Surg 2020; 57:100862. [PMID: 33077029 PMCID: PMC7575828 DOI: 10.1016/j.cpsurg.2020.100862] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023]
Abstract
For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent. To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether. The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables. Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing. Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known. The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner. Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy. After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy. For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”. Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary. For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents. Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance. Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key. Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease. While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined. Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.
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Affiliation(s)
- Alexander T Hawkins
- Section of Colon & Rectal Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN.
| | - Paul E Wise
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Tiffany Chan
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Janet T Lee
- Department of Surgery, University of Minnesota, Saint Paul, MN
| | - Tamara Glyn
- University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Verity Wood
- Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Timothy Eglinton
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Frank Frizelle
- Department of Surgery, University of Otago, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Adil Khan
- Raleigh General Hospital, Beckley, WV
| | - Jason Hall
- Dempsey Center for Digestive Disorders, Department of Surgery, Boston Medical Center, Boston, MA
| | | | | | | | | | | | - Scott R Steele
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Oh
| | - Karim Alavi
- Division of Colorectal Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA
| | - C Tyler Ellis
- Department of Surgery, University of Louisville, Louisville, KY
| | | | - Des C Winter
- St. Vincent's University Hospital, Dublin, Ireland
| | | | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Michele Carvello
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Antonino Spinelli
- Colon and Rectal Surgery Unit, Humanitas Clinical and Research Center IRCCS, Department of Biomedical Sciences, Humanitas University, Milano, Italy
| | - Amy L Lightner
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
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Siddiqui J, Young CJ. Thirteen-year experience with hand-assisted laparoscopic surgery in colorectal patients. ANZ J Surg 2019; 90:113-118. [PMID: 31828890 DOI: 10.1111/ans.15578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 10/26/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND We report outcomes on 324 consecutive cases of hand-assisted laparoscopic surgery (HALS) in colorectal patients over 13 years performed by a single surgeon. METHODS A prospectively maintained database was used to identify all patients undergoing HALS colorectal procedures for benign or malignant indications from September 2004 to February 2018, at two major tertiary centres in Sydney, Australia. RESULTS Median age was 64 years, 51% were female and median body mass index was 26. Colorectal cancer (55%), diverticular disease (13%) and polyp related conditions (13%) were common indications. Anterior resection (65%) and right hemicolectomy (18%) were most commonly performed. Median operative time was 244 min (190-300) and 75% of Gelport incisions were Pfannenstiel. Sixty-three percent of colorectal cancer patients had a T3 or T4 cancer. Median tumour size was 35 mm (25-45). Seven percent required conversion to open and 4% a re-operation in the early post-operative period. Thirty-six percent had a post-operative complication, and 11% were major complications. Follow-up extended to 12.8 years and there were 33 late deaths. Being in a high dependency unit or intensive care unit was significant for late mortality (odds ratio 2.8, 95% confidence interval 1.06-7.78, P = 0.037). Three percent developed an incisional hernia and 6% had small bowel obstruction at long-term follow-up. CONCLUSION HALS is an effective technique for both benign and malignant colorectal indications with the added advantage of tactile feedback and a lower rate of conversion to open.
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Affiliation(s)
- Javariah Siddiqui
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Christopher J Young
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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"Peek port": avoiding conversion during laparoscopic colectomy-an update. Surg Endosc 2019; 34:3944-3948. [PMID: 31586252 DOI: 10.1007/s00464-019-07165-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 09/24/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE 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. METHODS 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. RESULTS The study population consisted of 361 men and 303 women with a mean age of 61 years. 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%). DISCUSSION 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.
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Feasibility of hand-assisted laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancy. Surg Endosc 2019; 33:52-57. [PMID: 29926165 DOI: 10.1007/s00464-018-6265-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 06/07/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND In light of the modern surgical trend towards minimally invasive surgery, we aim to assess the feasibility of hand-assisted laparoscopic (HAL) cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in peritoneal surface malignancy (PSM). METHODS Patients with PSM secondary to colorectal cancer or pseudomyxoma peritonei with peritoneal cancer index (PCI) of ≤ 10 were considered for HAL CRS and HIPEC. One patient had PCI of 15 but based on the disease distribution laparoscopic-assisted CRS and HIPEC was thought to be feasible, thus was also included. These patients were compared to matched controls who underwent open CRS and HIPEC for similar pathologies. Matching was performed on age and PCI to reflect a comparable complexity of the operation, and tumor grade for comparable risk of disease recurrence. RESULTS Eleven patients were included in each group. In both groups, mean PCI was 4.1, mean age was 58.5 years, and 81.8% were well-moderately differentiated tumors. Complete cytoreduction was achieved in all patients. Upon comparison, HAL patients had significantly less blood loss and 3-day shorter hospitalization. No difference was demonstrated in operative time, number of visceral resections, and rate of omentectomy/peritonectomy. Also, no difference was detected in morbidities and 30-day readmission rates. No intraperitoneal recurrences have been reported in the HAL group after a median follow-up of 11 months. CONCLUSION HAL CRS and HIPEC is a feasible procedure and can be considered for PSM with low PCI. It offers very acceptable and comparable short-term outcomes to the conventional open approach.
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Hand-assisted Laparoscopy: Expensive but Considerable Step Between Laparoscopic and Open Colectomy. Surg Laparosc Endosc Percutan Tech 2018; 28:214-218. [PMID: 29912135 DOI: 10.1097/sle.0000000000000545] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Hand-assisted laparoscopic colectomy (HALC) and laparoscopic-assisted colectomy (LAC) have been shown to have comparable short-term outcomes while there are limited data regarding costs. The aim of our study was to compare the short-term outcomes and costs of HALC and LAC. MATERIALS AND METHODS In total, 46 patients who underwent HALC or LAC for benign or malignant disease between January 2011 and December 2014 at our institution were included in the study. Patients were randomized into HALC or LAC group. Patients' demographics and characteristics, operative details, short-term outcomes, and costs were evaluated. RESULTS There were 25 patients in LAC group and 21 patients in HALC group. Patient's demographics and characteristics and short-term outcomes were comparable between the LAC and HALC groups. Conversion rate was significantly lower in the HALC group (4.7% vs. 28%, P=0.03) while surgical costs ($1706.83±203.70 vs. $1304.93±305.67, P=0.038) and total costs ($2427.18±254.27 vs. $2044.03±215.22, P=0.021) were significantly higher in HALC group. CONCLUSIONS HALC is associated with increased surgical and total hospital costs, and decreased rate of conversion. Although it is more expensive, HALC may be helpful by providing a step between LAC and open surgery before considering conversion.
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Jung KU, Yun SH, Cho YB, Kim HC, Lee WY, Chun HK. The Role of Hand-Assisted Laparoscopic Technique in the Age of Single-Incision Laparoscopy: An Effective Alternative to Avoid Open Conversion in Colorectal Surgery. J Laparoendosc Adv Surg Tech A 2018; 28:415-421. [DOI: 10.1089/lap.2017.0553] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Kyung uk Jung
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University of School of Medicine, Seoul, Republic of Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University of School of Medicine, Seoul, Republic of Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University of School of Medicine, Seoul, Republic of Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University of School of Medicine, Seoul, Republic of Korea
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University of School of Medicine, Seoul, Republic of Korea
| | - Ho-Kyung Chun
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University of School of Medicine, Seoul, Republic of Korea
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Gaitanidis A, Simopoulos C, Pitiakoudis M. What to consider when designing a laparoscopic colorectal training curriculum: a review of the literature. Tech Coloproctol 2018; 22:151-160. [PMID: 29512045 DOI: 10.1007/s10151-018-1760-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 12/03/2017] [Indexed: 12/27/2022]
Abstract
Multiple studies have demonstrated the benefits of laparoscopic colorectal surgery (LCS), but in several countries it has still not been widely adopted. LCS training is associated with several challenges, such as patient safety concerns and a steep learning curve. Current evidence may facilitate designing of efficient training curricula to overcome these challenges. Basic training with virtual reality simulators has witnessed meteoric advances and may be essential during the early parts of the learning curve. Cadaveric and animal model training still constitutes an indispensable training tool, due to a higher degree of difficulty and greater resemblance to real operative conditions. In addition, recent evidence favors the use of novel training paradigms, such as proficiency-based training, case selection and modular training. This review summarizes the recent advances in LCS training and provides the evidence for designing an efficient training curriculum to overcome the challenges of LCS training.
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Affiliation(s)
- A Gaitanidis
- Second Department of Surgery, University General Hospital of Alexandroupoli, Democritus University of Thrace Medical School, 68100, Alexandroupoli, Greece.
| | - C Simopoulos
- Second Department of Surgery, University General Hospital of Alexandroupoli, Democritus University of Thrace Medical School, 68100, Alexandroupoli, Greece
| | - M Pitiakoudis
- Second Department of Surgery, University General Hospital of Alexandroupoli, Democritus University of Thrace Medical School, 68100, Alexandroupoli, Greece
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Zhang X, Wu Q, Hu T, Gu C, Bi L, Wang Z. Hand-Assisted Laparoscopic Surgery Versus Conventional Laparoscopic Surgery for Colorectal Cancer: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2017; 27:1251-1262. [PMID: 28813634 DOI: 10.1089/lap.2017.0210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AIM This meta-analysis aims to compare hand-assisted laparoscopic surgery (HALS) with conventional laparoscopic surgery (LAS) for colorectal cancer (CRC) in terms of intraoperative, postoperative, and survival outcomes. MATERIALS AND METHODS A systematic literature search with no limits was performed in PubMed, Embase, and Medline. The last search was performed on March 31, 2017. The outcomes of interests included intraoperative outcomes (operative time, blood loss, length of incision, transfusion, conversion, and lymph nodes harvested), postoperative outcomes (length of hospital stay, time to first flatus, time to first bowel movement, postoperative complications, mortality, reoperation, ileus, anastomotic leakage, postoperative bleeding, wound infection, intra-abdominal abscess, urinary complication, cardiopulmonary complication, and readmission), and 5-year survival outcomes. RESULTS Nine articles published between 2007 and 2016 with a total of 1307 patients were enrolled in this meta-analysis. HALS was associated with longer length of incision. No differences were found for operative time, blood loss, transfusion, conversion, lymph nodes harvested, length of hospital stay, time to first flatus, time to first bowel movement, postoperative complications, mortality, reoperation, ileus, anastomotic leakage, postoperative bleeding, wound infection, intra-abdominal abscess, urinary complication, cardiopulmonary complication, readmission, or 5-year survival outcomes. CONCLUSION Our meta-analysis demonstrated that HALS is similar to LAS for CRC surgery in terms of intraoperative, postoperative, and survival outcomes except for the longer length of incision.
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Affiliation(s)
- Xubing Zhang
- 1 Department of Gastrointestinal Surgery, West China Hospital, Sichuan University , Chengdu, China .,2 West China School of Medicine, Sichuan University , Chengdu, China
| | - Qingbin Wu
- 1 Department of Gastrointestinal Surgery, West China Hospital, Sichuan University , Chengdu, China .,2 West China School of Medicine, Sichuan University , Chengdu, China
| | - Tao Hu
- 1 Department of Gastrointestinal Surgery, West China Hospital, Sichuan University , Chengdu, China .,2 West China School of Medicine, Sichuan University , Chengdu, China
| | - Chaoyang Gu
- 1 Department of Gastrointestinal Surgery, West China Hospital, Sichuan University , Chengdu, China
| | - Liang Bi
- 1 Department of Gastrointestinal Surgery, West China Hospital, Sichuan University , Chengdu, China .,2 West China School of Medicine, Sichuan University , Chengdu, China
| | - Ziqiang Wang
- 1 Department of Gastrointestinal Surgery, West China Hospital, Sichuan University , Chengdu, China
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The Feasibility of Hand-assisted Laparoscopic and Laparoscopic Multivisceral Resection Compared With Open Surgery for Locally Advanced Colorectal Cancer. Surg Laparosc Endosc Percutan Tech 2017; 27:e57-e65. [DOI: 10.1097/sle.0000000000000428] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Julien M, Dove J, Quindlen K, Halm K, Shabahang M, Wild J, Blansfield J. Evolution of Laparoscopic Surgery for Colorectal Cancer: The Impact of the Clinical Outcomes of Surgical Therapy Group Trial. Am Surg 2016. [DOI: 10.1177/000313481608200825] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The Clinical Outcomes of Surgical Therapy Group (COST) Trial established laparoscopic procedures offer short-term benefits while preserving the same oncologic outcomes in colorectal cancer (CRC) patients compared with open procedures. The aim of this study was to evaluate the trend of laparoscopic resection for CRC before and after the publication of the COST Trial. Retrospective study of surgically treated CRC patients was conducted from January 2000 to December 2009. Surveillance, Epidemiology, and End Results Program and Medicare. Between 2000 and 2009, 147,388 patients underwent resection for CRC, 9,901 resections were performed laparoscopically. In 2000, 1.0 per cent of colorectal resections were performed laparoscopically. There was a dramatic increase in laparoscopic resections in 2009 to 30.4 per cent. During this time period, rates of laparoscopic resections increased for all tumor stages. Right colectomies and early stage tumors had the most significant rise from 3.1 per cent (2004) to 38.7 per cent (2009) and 4.41 per cent (2004) to 39.17 per cent (2009), respectively; whereas, rectal and later stage tumors resection rates were more modest from 2.1 per cent (2004) to 13.2 per cent (2009) and 1.41 per cent (2004) to 17.10 per cent (2009), respectively. This study demonstrates the COST Trial had a significant impact on utilization of laparoscopic colorectal resection for CRC. Although laparoscopic colorectal resections have been accepted for all types of CRCs, more difficult procedures are being adopted at slower rates.
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Affiliation(s)
| | - James Dove
- Geisinger Medical Center, Danville, Pennsylvania
| | | | - Kristen Halm
- Geisinger Medical Center, Danville, Pennsylvania
| | | | - Jeffrey Wild
- Geisinger Medical Center, Danville, Pennsylvania
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Benlice C, Costedio M, Stocchi L, Abbas MA, Gorgun E. Hand-assisted laparoscopic vs open colectomy: an assessment from the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted cohort. Am J Surg 2016; 212:808-813. [PMID: 27324382 DOI: 10.1016/j.amjsurg.2016.02.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 02/01/2016] [Accepted: 02/09/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Perioperative outcomes of patients who underwent hand-assisted colorectal laparoscopic (HALS) vs open colectomy were compared using recently released procedure-targeted database. METHODS Review was conducted using the 2012 colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program database. Patients were classified into 2 groups according to final surgical approach: HALS vs open (planned). Groups were matched (1:1) based on age, gender, body mass index, surgical procedure, diagnosis, American Society of Anesthesiologists score, and wound classification. Multivariate logistic regression analysis was conducted for group comparison. RESULTS Of 7,303 patients, 1,740 patients were matched in each group. Open group had higher proportion of patients with preoperative dyspnea (P = .01), ascites (P = .01), weight loss (P < .001), smoking history (P = .04), and increased work relative value units (P < .001). After adjusting for difference in baseline comorbidities, overall morbidity, superficial, deep, and organ-space surgical site infection, urinary tract infection, ileus, reoperation, readmission, and hospital stay were significantly higher in open group (P < .05). CONCLUSIONS National Surgical Quality Improvement Program targeted-data demonstrated several advantages of HALS compared with open colonic resection including shorter hospital stay and lower complication rate. Further adoption of HALS technique as a bridge to straight laparoscopy or tool in difficult cases can positively impact the short-term outcomes after colectomy when compared with open technique.
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Affiliation(s)
- Cigdem Benlice
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A-30, Cleveland, OH 44195, USA
| | - Meagan Costedio
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A-30, Cleveland, OH 44195, USA
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A-30, Cleveland, OH 44195, USA
| | - Maher A Abbas
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A-30, Cleveland, OH 44195, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A-30, Cleveland, OH 44195, USA.
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Silva-Velazco J, Stocchi L, Costedio M, Gorgun E, Kessler H, Remzi FH. Is there anything we can modify among factors associated with morbidity following elective laparoscopic sigmoidectomy for diverticulitis? Surg Endosc 2015; 30:3541-51. [PMID: 26541732 DOI: 10.1007/s00464-015-4651-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/27/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Laparoscopic sigmoidectomy for diverticulitis is widely accepted, using either endolinear staplers or traditional linear staplers under direct vision through the extraction site to transect the rectum. The aim of this study was to assess modifiable factors affecting perioperative morbidity after elective laparoscopic sigmoidectomy for diverticulitis. METHODS Potential associations between perioperative morbidity and demographic, disease-related, and treatment-related factors were assessed on all consecutive patients included in a prospectively collected database undergoing elective laparoscopic sigmoidectomy for diverticulitis between 1992 and 2013. Rectal transection with a linear stapler under direct vision through the extraction site was considered compatible with laparoscopic technique. RESULTS There were two deaths out of 1059 patients (0.19 %). Conversion rate was 13.1 %, overall morbidity 28 %, and anastomotic leak 3.7 %. Independent factors associated with morbidity in an intent-to-treat analysis were ASA 3 (OR 1.53, p = 0.006), conversion (OR 1.71, p = 0.015), and rectal transection without endolinear stapling (traditional linear stapler: OR 1.75, p = 0.003; surgical knife: OR 2.09, p = 0.002). The same factors along with complicated diverticulitis (OR 1.56, p = 0.013) were independently associated with overall morbidity among laparoscopically completed cases. BMI ≥ 35 (OR 2.3, p = 0.017), complicated diverticulitis (OR 2.37, p = 0.002), and rectal transection with a traditional linear stapler (OR 2.19, p = 0.018) were independently associated with abdomino-pelvic infections, both in an intent-to-treat analysis and among laparoscopically completed cases. The number of endolinear stapler firings was not associated with morbidity. CONCLUSIONS Most factors associated with morbidity of laparoscopic sigmoidectomy for diverticulitis cannot be easily modified. With the limitation of a retrospective analysis, modifiable factors to minimize morbidity are laparoscopic completion and endolinear stapling.
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Affiliation(s)
- Jorge Silva-Velazco
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA.
| | - Meagan Costedio
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA
| | - Hermann Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA
| | - Feza H Remzi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, 9500 Euclid Ave/A30, Cleveland, OH, 44195, USA
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Bae SU, Park JS, Choi YJ, Lee MK, Cho BS, Kang YJ, Park JS, Kim CN. The role of hand-assisted laparoscopic surgery in a right hemicolectomy for right-sided colon cancer. Ann Coloproctol 2014; 30:11-7. [PMID: 24639965 PMCID: PMC3953162 DOI: 10.3393/ac.2014.30.1.11] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Accepted: 08/21/2013] [Indexed: 12/17/2022] Open
Abstract
Purpose The purpose of this study is to evaluate the perioperative and long-term oncologic outcomes of hand-assisted laparoscopic surgery (HALS) and standard laparoscopic surgery (SLS) and assess the role of HALS in the management of right-sided colon cancer. Methods The study group included 53 patients who underwent HALS and 45 patients who underwent SLS for right-sided colon cancer between April 2002 and December 2008. Results The patients in each group were similar in age, American Society of Anesthesiologist (ASA) score, body mass index, and history of previous abdominal surgeries. Eight patients in the HALS group and no patient in the SLS group exhibited signs of tumor invasion into adjacent structures. No differences were noted in the time to return of normal bowel function, time to toleration of diet, lengths of hospital stay and narcotic usage, and rate of postoperative complications. The median incision length was longer in the HALS group (HALS: 7.0 cm vs. SLS: 4.8 cm, P < 0.001). The HALS group had a significantly higher pathologic TNM stage and significantly larger tumor size (HALS: 6.0 cm vs. SLS: 3.3 cm, P < 0.001). The 5-year overall, disease-free, and cancer-specific survival rates of the HALS and the SLS groups were 87.3%, 75.2%, and 93.9% and 86.4%, 78.0%, and 90.7%, respectively (P = 0.826, P = 0.574, and P = 0.826). Conclusion Although patients in the HALS group had more advanced disease and underwent more complex procedures than those in the SLS group, the short-term benefits and the oncologic outcomes between the two groups were comparable. HALS can, therefore, be considered an alternative to SLS for bulky and fixed right-sided colon cancer.
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Affiliation(s)
- Sung Uk Bae
- Division of Colorectal Surgery, Department of Surgery, Colorectal Cancer Clinic, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Seok Park
- Department of Surgery, Eulji University Hospital, Daejeon, Korea
| | - Young Jin Choi
- Department of Surgery, Eulji University Hospital, Daejeon, Korea
| | - Min Ku Lee
- Department of Surgery, Eulji University Hospital, Daejeon, Korea
| | - Byung Sun Cho
- Department of Surgery, Eulji University Hospital, Daejeon, Korea
| | - Yoon Jung Kang
- Department of Surgery, Eulji University Hospital, Daejeon, Korea
| | - Joo Seung Park
- Department of Surgery, Eulji University Hospital, Daejeon, Korea
| | - Chang Nam Kim
- Department of Surgery, Eulji University Hospital, Daejeon, Korea
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Crapko M, Fleshman J. Minimally invasive surgery for rectal cancer. Ann Surg Oncol 2013; 21:173-8. [PMID: 24002534 DOI: 10.1245/s10434-013-3105-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Indexed: 12/18/2022]
Abstract
Rectal cancer remains a common and complex surgical problem. There is growing evidence that minimally invasive surgery (MIS) can provide ideal care for patients with rectal cancer. This review examines the short- and long-term benefits to MIS for rectal cancer, as well as the current techniques available, and how wider adoption of these techniques may be performed.
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Affiliation(s)
- Matthew Crapko
- Colon and Rectal Surgery, Baylor University Medical Center, Dallas, TX, USA,
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Abstract
BACKGROUND A PubMed search of the biomedical literature was carried out to systematically review the role of laparoscopy in colonic diverticular disease. All original reports comparing elective laparoscopic, hand-assisted, and open colon resection for diverticular disease of the colon, as well as original reports evaluating outcomes after laparoscopic lavage for acute diverticulitis, were considered. Of the 21 articles chosen for final review, nine evaluated laparoscopic versus open elective resection, six compared hand-assisted colon resection versus conventional laparoscopic resection, and six considered laparoscopic lavage. Five were randomized controlled trials. RESULTS Elective laparoscopic colon resection for diverticular disease is associated with increased operative time, decreased postoperative pain, fewer postoperative complications, less paralytic ileus, and shorter hospital stay compared to open colectomy. Laparoscopic lavage and drainage appears to be a safe and effective therapy for selected patients with complicated diverticulitis. CONCLUSIONS Elective laparoscopic colectomy for diverticular disease is associated with decreased postoperative morbidity compared to open colectomy, leading to shorter hospital stay and fewer costs. Laparoscopic lavage has an increasing but poorly defined role in complicated diverticulitis.
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Yang I, Boushey RP, Marcello PW. Hand-assisted laparoscopic colorectal surgery. Tech Coloproctol 2013; 17 Suppl 1:S23-7. [DOI: 10.1007/s10151-012-0933-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 08/20/2012] [Indexed: 02/06/2023]
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Minimally invasive surgery for diverticulitis. Tech Coloproctol 2012; 17 Suppl 1:S11-22. [DOI: 10.1007/s10151-012-0940-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 09/06/2011] [Indexed: 01/19/2023]
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Orcutt ST, Marshall CL, Balentine CJ, Robinson CN, Anaya DA, Artinyan A, Berger DH, Albo D. Hand-assisted laparoscopy leads to efficient colorectal cancer surgery. J Surg Res 2012; 177:e53-8. [PMID: 22841382 DOI: 10.1016/j.jss.2012.02.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 01/16/2012] [Accepted: 02/22/2012] [Indexed: 12/21/2022]
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Ng LWC, Tung LM, Cheung HYS, Wong JCH, Chung CC, Li MKW. Hand-assisted laparoscopic versus total laparoscopic right colectomy: a randomized controlled trial. Colorectal Dis 2012; 14:e612-7. [PMID: 22413783 DOI: 10.1111/j.1463-1318.2012.03028.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Laparoscopic colectomy for colorectal cancer is associated with definite short-term benefits, and is increasingly practised worldwide. The limitations of a pure laparoscopic approach include a relative lack of tactile feedback and long procedural time. Hand-assisted laparoscopic surgery was introduced in an attempt to facilitate operation by improving the tactile sensation. To date, there is no consensus as to which approach is better. Herein we conducted a randomized controlled trial comparing hand-assisted laparoscopic colectomy (HALC) with total laparoscopic colectomy (TLC) in the management of right-sided colonic cancer. METHODS Adult patients with carcinoma of the caecum and ascending colon were recruited and randomized to undergo either HALC or TLC. Measured outcomes included operative time, blood loss, conversion rate, postoperative morbidities, postoperative pain, length of hospital stay, disease recurrence and patient survival. RESULTS Sixty patients (HALC=30, TLC=30) were recruited. The two groups were comparable with regard to age, gender distribution, body mass index and final histopathological staging. No difference was observed between the groups in terms of operating time, conversion rate, operative blood loss, pain score and length of hospital stay. With a median follow-up of 27 to 33 months, no difference was observed in terms of disease recurrence, and the 5-year survival rates remained similar (83%vs 80%, P=0.923). CONCLUSION HALC is safe and feasible, but it does not show any significant benefits over TLC in terms of operating time and conversion rate. Routine use of the hand-assisted laparoscopic technique in right hemicolectomy is therefore not recommended.
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Affiliation(s)
- L W C Ng
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan Hong Kong SAR, China.
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Pitiakoudis M, Michailidis L, Zezos P, Kouklakis G, Simopoulos C. Quality training in laparoscopic colorectal surgery: does it improve clinical outcome? Tech Coloproctol 2012; 15 Suppl 1:S17-20. [PMID: 21887564 DOI: 10.1007/s10151-011-0746-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Laparoscopic colorectal surgery (LCRS) is a safe, effective and cost-efficient option for the treatment of various benign and malignant conditions. However, its implementation to surgical practice is still limited. That is mainly due to its association with a steep learning curve. We performed a review of the literature to determine whether quality training in LCRS can reduce that learning curve and lead to better clinical outcomes. We concluded that a structured training program with pre-clinical phase focused on basic skill acquisition and a clinical phase focused on mentoring from experts can shorten the learning curve and improve clinical outcomes.
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Affiliation(s)
- M Pitiakoudis
- Second Department of Surgery, Democritus University of Thrace, University General Hospital, 68100 Dragana, Alexandroupolis, Greece.
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Liu Z, Wang GY, Chen YG, Jiang Z, Tang QC, Yu L, Muhammad S, Wang XS. Cost Comparison Between Hand-Assisted Laparoscopic Colectomy and Open Colectomy. J Laparoendosc Adv Surg Tech A 2012; 22:209-13. [PMID: 22288882 DOI: 10.1089/lap.2011.0446] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Zheng Liu
- Cancer Center, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Gui-yu Wang
- Cancer Center, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ying-gang Chen
- Cancer Center, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zheng Jiang
- Cancer Center, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qing-chao Tang
- Cancer Center, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lei Yu
- Cancer Center, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Shan Muhammad
- Cancer Center, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xi-shan Wang
- Cancer Center, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
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Orcutt ST, Balentine CJ, Marshall CL, Robinson CN, Anaya DA, Artinyan A, Awad SS, Berger DH, Albo D. Use of a Pfannenstiel incision in minimally invasive colorectal cancer surgery is associated with a lower risk of wound complications. Tech Coloproctol 2012; 16:127-32. [DOI: 10.1007/s10151-012-0808-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 01/23/2012] [Indexed: 12/21/2022]
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Gonzales ER, Alavi K. Evaluation and Treatment of Uncomplicated Diverticular Disease. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ross H, Steele S, Whiteford M, Lee S, Albert M, Mutch M, Rivadeneira D, Marcello P. Early multi-institution experience with single-incision laparoscopic colectomy. Dis Colon Rectum 2011; 54:187-92. [PMID: 21228667 DOI: 10.1007/dcr.0b013e3181f8d972] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE Single-incision laparoscopic colectomy represents a potential advance in minimally invasive surgical approaches to colorectal disease. Although widely promoted, outcome data are virtually absent. A group of highly experienced laparoscopic attending colorectal surgeons convened to standardize technique and prospectively record operative details and outcomes. METHODS Single-incision laparoscopic colectomy was performed by 10 experienced attending colorectal surgeons with minimal or no prior single-incision laparoscopic colectomy experience. Surgeon rating of ergonomics and 15 components of operation conduct was compared with conventional multiple-port laparoscopic colectomy. Patient demographics, operative details, and outcome data were prospectively collected. RESULTS Thirty-nine single-incision laparoscopic colectomies were performed (25 right colectomies, 5 ileocolic resections, 8 sigmoidectomies, and 1 low anterior resection). Underlying pathology included polyps (12), cancer (15), Crohn's disease (5), and diverticulitis (7). Patients were highly selected with a mean body mass index of 25.6 (range, 16-40). Two conversions to open resection occurred, 1 because of fistula and 1 because of adhesions, in patients with a mean body mass index of 34. An additional port was required in 3 patients. Mean incision length was 4.2 cm (range, 2.5-8) and operative time was 120 minutes (range, 68-210). Complications included 1 wound infection and 2 anastomotic bleeds requiring transfusion. Average length of stay was 4.4 days (range, 2-8). Mean lymph node harvest was 19 (range, 12-39). Exposure, instrument conflict, ergonomics, ease of instrumentation, and camera operation were rated significantly more difficult with single-incision laparoscopic colectomy than with multiple-port laparoscopic colectomy. CONCLUSIONS Preliminary data demonstrate that single-incision laparoscopic colectomy can be performed safely in selected patients by experienced surgeons. The benefits of single-incision compared with multiple-port laparoscopic colectomy are not immediately evident. Despite the advanced skills of the faculty, a learning curve of undetermined length still exists in which specific components of single-incision laparoscopic colectomy are more difficult than multiple-port laparoscopic colectomy, and areas of focus remain that require advances to make single-incision laparoscopic colectomy equivalent to multiple-port laparoscopic colectomy. The multi-institutional registry will enable further analysis of single-incision laparoscopic colectomy.
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Affiliation(s)
- H Ross
- Riverview Medical Center, Red Bank, New Jersey 07701, USA.
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Meshikhes AWN, El Tair M, Al Ghazal T. Hand-assisted laparoscopic colorectal surgery: initial experience of a single surgeon. Saudi J Gastroenterol 2011; 17:16-9. [PMID: 21196647 PMCID: PMC3099074 DOI: 10.4103/1319-3767.74444] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND/AIM As totally laparoscopic colorectal surgery is considered challenging and technically demanding with a long steep learning curve, we adopted hand-assisted laparoscopic colorectal surgery as a bridge to totally laparoscopic assisted colorectal surgery. This prospective study aims to highlight the initial experience of a single surgeon with this technique. MATERIALS AND METHODS A prospective analysis of the first 25 cases of hand-assisted laparoscopic colorectal resections which were performed by a single surgeon over a 15-month period. There were 15 males and 10 females with a mean age of 55.5 (range 20-82) years. RESULTS The indication in majority of cases was cancer (76%). The procedures consisted of 18 (72%) various colectomies and 7 (28%) anterior resections. The operative time ranged between 110-400 (mean 180) min. There was one conversion (4%) and the mean operative blood loss was 80 (range 60-165) ml. The number of lymph nodes retrieved in the cancer cases was 5-31 (mean 15) nodes. The mean length of hospital stay was five (range 3-10) days. The total number of short-term complications was six (24%) and there was one death due to anastomatic leak and multiorgan failure. Long-term complications after a maximum follow up of 30 months were two incisional hernias at the hand port site, but none of the patients developed adhesive small bowel obstruction or late anastomotic stricture. Currently all our colorectal procedures are conducted laparoscopically. CONCLUSION Hand-assisted laparoscopic colorectal procedures are easy to learn as a good bridge to master totally laparoscopic colorectal surgery.
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Affiliation(s)
- Abdul-Wahed N. Meshikhes
- Department of Surgery, King Fahad Specialist Hospital, Dammam - 31444, Eastern Province, Saudi Arabia,Address for correspondence: Dr. Abdul-Wahed Meshikhes, Department of Surgery, King Fahad Specialist Hospital, Dammam - 31444, Eastern Province, Saudi Arabia. E-mail:
| | - Mokhtar El Tair
- Department of Surgery, King Fahad Specialist Hospital, Dammam - 31444, Eastern Province, Saudi Arabia
| | - Thabit Al Ghazal
- Department of Surgery, King Fahad Specialist Hospital, Dammam - 31444, Eastern Province, Saudi Arabia
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Meshikhes AWN. Controversy of hand-assisted laparoscopic colorectal surgery. World J Gastroenterol 2010; 16:5662-8. [PMID: 21128315 PMCID: PMC2997981 DOI: 10.3748/wjg.v16.i45.5662] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 08/18/2010] [Accepted: 08/25/2010] [Indexed: 02/06/2023] Open
Abstract
Laparoscopically assisted colorectal procedures are time-consuming and technically demanding and hence have a long steep learning curve. In the technical demand, surgeons need to handle a long mobile organ, the colon, and have to operate on multiple abdominal quadrants, most of the time with the need to secure multiple mesenteric vessels. Therefore, a new surgical innovation called hand-assisted laparoscopic surgery (HALS) was introduced in the mid 1990s as a useful alternative to totally laparoscopic procedures. This hybrid operation allows the surgeon to introduce the non-dominant hand into the abdominal cavity through a special hand port while maintaining the pneumoperitoneum. A hand in the abdomen can restore the tactile sensation which is usually lacking in laparoscopic procedures. It also improves the eye-to-hand coordination, allows the hand to be used for blunt dissection or retraction and also permits rapid control of unexpected bleeding. All of those factors can contribute tremendously to reducing the operative time. Moreover, this procedure is also considered as a hybrid procedure that combines the advantages of both minimally invasive and conventional open surgery. Nevertheless, the exact role of HALS in colorectal surgery has not been well defined during the advanced totally laparoscopic procedures. This article reviews the current status of hand-assisted laparoscopic colorectal surgery as a minimally invasive procedure in the era of laparoscopic surgery.
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Ozturk E, da Luz Moreira A, Vogel JD. Hand-assisted laparoscopic colectomy: the learning curve is for operative speed, not for quality. Colorectal Dis 2010; 12:e304-9. [PMID: 20070328 DOI: 10.1111/j.1463-1318.2010.02205.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM We aimed to define the learning curve for hand-assisted laparoscopic colectomy (HALC). METHOD A retrospective analysis of prospectively recorded data was performed. Consecutive segmental and total HALC performed by a single surgeon with no prior HALC experience was included. Operative time and quality-related outcomes, including conversions, operative and postoperative complications, length of stay, reoperations and readmissions were compared for consecutive cohorts of 25 HALC. A subgroup analysis of right, left, total and proctocolectomy performed in each cohort of 25 HALC was also performed. RESULTS From December 2005 to February 2009, 200 HALC were performed. When evaluated in cohorts of 25 consecutive cases, operative times (155-206 min), operative complications (4-12%), postoperative complications (8-36%), length of stay (4-5 days), reoperations (0-8%) and readmissions (0-16%) were similar. In the subgroup analysis, there were no changes in the quality-related measures for any colectomy type or the operative time for right and proctocolectomy as experience was gained. Operative time decreased for left (183-127 min) and total HALC (259-218 min) after experience with 50 cases (P < 0.05). CONCLUSION HALC operative times decreased with surgeon experience. For quality-related outcomes, there was no learning curve for HALC.
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Affiliation(s)
- E Ozturk
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Hall J, Hammerich K, Roberts P. New paradigms in the management of diverticular disease. Curr Probl Surg 2010; 47:680-735. [PMID: 20684920 DOI: 10.1067/j.cpsurg.2010.04.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jason Hall
- Department of Colon and Rectal Surgery, Tufts University School of Medicine, Burlington, Massachusetts, USA
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Yun HR, Cho YK, Cho YB, Kim HC, Yun SH, Lee WY, Chun HK. Comparison and short-term outcomes between hand-assisted laparoscopic surgery and conventional laparoscopic surgery for anterior resections of left-sided colon cancer. Int J Colorectal Dis 2010; 25:975-81. [PMID: 20414781 DOI: 10.1007/s00384-010-0948-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hand-assisted laparoscopic surgery has been introduced as an alternative to conventional laparoscopic surgery. This study compared the efficacies and short-term clinical outcomes between hand-assisted laparoscopic anterior resection (HAL-AR) and conventional laparoscopic anterior resection (CL-AR) for treating left-sided colon cancer. MATERIALS AND METHODS We retrospectively analyzed 248 patients who underwent anterior resection for colon cancer (118 HAL-AR and 128 CL-AR) between May 2000 and December 2006. The collected data included the perioperative and short-term oncologic outcomes. RESULTS There were no significant differences between the HAL-AR and CL-AR groups, except for the operation time and the size of the primary tumor. The operation time of the HAL-AR group was significantly shorter than that of the CL-AR group (p = 0.004), and the size of the primary tumor in the HAL-AR group was significantly larger than that of the CL-AR group (p = 0.019). The operating time of the HAL-AR group reached an earlier mean plateau than did that of the CL-AR group. Before and after reaching the plateau, there were no differences in the perioperative results between the two groups. The operating time for the HAL-AR group was significantly shorter than that of the CL-AR group after reaching a plateau (p = 0.012). The short-term outcomes for both groups were similar in terms of survival and recurrence (p = 0.996 and p = 0.476, respectively). CONCLUSION Hand-assisted laparoscopic anterior resection has a shorter operative time than does CL-AR and is more successful than CL-AR for resecting larger tumors, while both procedures result in similar short-term oncologic outcomes. Hand-assisted laparoscopic anterior resection is thought be a comparable operative technique for anterior resection of left-sided colon cancer.
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Affiliation(s)
- Hae Ran Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Oncel M, Akin T, Gezen FC, Alici A, Okkabaz N. Left inferior quadrant oblique incision: a new access for hand-assisted device during laparoscopic low anterior resection of rectal cancer. J Laparoendosc Adv Surg Tech A 2010; 19:663-6. [PMID: 19845455 DOI: 10.1089/lap.2008.0375] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although long-term results are not clear, laparoscopic resection of rectal cancer may be feasible, and the use of hand-assisted technique may ease the procedure. This article aims to describe the details of left inferior quadrant oblique incision (LIQOI) and to discuss the results of patients who underwent laparoscopic hand-assisted low anterior resection using LIQOI. MATERIALS AND METHODS All rectal cancer patients who underwent a hand-assisted low anterior resection through a LIQOI at our department between November 2006 and May 2008 were retrospectively evaluated. The details of the procedures were assessed. RESULTS AND DISCUSSION At the time of laparoscopic rectal cancer surgery, LIQOI was used on 23 patients (13 males; 56.5%) with a mean age of 55.2; standard deviation was 12.8 years. Conversion to open surgery was necessitated in 1 patient (4.4%), who was suspected to have a T4 tumor, and another case (4.4%) with a severe cardiac illness died 7 days after surgery. The right and left hands were used to help the mobilization of splenic flexure and rectum, respectively, after the insertion of the hand-assisted device through LIQOI. CONCLUSION This incision may allow the uncomplicated mobilization of splenic flexure and rectum and thus ease the hand-assisted low anterior resection procedure.
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Affiliation(s)
- Mustafa Oncel
- Department of General Surgery, Kartal Education and Research Hospital, Istanbul, Turkey.
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Murillo Zolezzi A, Murakami Morishige PD, Toledo Valdovinos SA, Maydon González H, Belmonte Montes C. [Hand assistance is an alternative to conversion to laparotomy during laparoscopic sigmoidectomy]. Cir Esp 2009; 86:346-50. [PMID: 19875109 DOI: 10.1016/j.ciresp.2009.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2009] [Revised: 08/07/2009] [Accepted: 08/13/2009] [Indexed: 10/20/2022]
Abstract
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.
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Roslani AC, Koh DC, Tsang CB, Wong KS, Cheong WK, Wong HB. Hand-assisted laparoscopic colectomy versus standard laparoscopic colectomy: a cost analysis. Colorectal Dis 2009; 11:496-501. [PMID: 18662242 DOI: 10.1111/j.1463-1318.2008.01647.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE There is a relative dearth of literature comparing hand-assisted (HALC) to standard (SLC) laparoscopic colectomies. HALC seems beneficial in terms of shorter operative times and lower conversion rates, but this is counterbalanced by a greater inflammatory response, larger incisions and higher direct costs. Nevertheless, these results are not consistent throughout existing studies and there are to date no detailed cost comparisons. Our hypothesis was that HALC would not incur significantly higher institutional costs compared with standard laparoscopic techniques. METHOD Patients undergoing either SLC or HALC between August 2004 and September 2006 were retrospectively reviewed. All patients were managed using a standard protocol. Outcomes assessed included operative times, conversion rates, pain scores, time to resolution of ileus, length of stay and complications. Total costs were calculated from the day of surgery. Statistical analyses included chi(2), Fisher's exact test, the Mann-Whitney U-test or nonparametric bootstrapping method. RESULTS Seventy-three patients underwent SLC while 101 had HALC. Demographics and indications for surgery in both groups were similar; the majority were performed for colorectal cancers. Operative times were shorter (147.5 vs 172.5 min, P < 0.05) and complication rates lower (28.7%vs 45.2%, P < 0.025) for HALC. There was no significant difference in the other clinical outcomes. Operative costs and cost of consumables were higher for HALC (US$4024.2 vs US$3568.1, P = 0.01 and US$1724.7 vs US$1302.7, P < 0.001, respectively). However, total costs were not significantly different (HALC US$8999.8, SLC US$7910.7, P = 0.11). CONCLUSION Institutional costs are not significantly higher for HALC compared with SLC.
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Affiliation(s)
- A C Roslani
- Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore
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Ozturk E, Kiran RP, Geisler DP, Hull TL, Vogel JD. Hand-assisted laparoscopic colectomy: benefits of laparoscopic colectomy at no extra cost. J Am Coll Surg 2009; 209:242-7. [PMID: 19632601 DOI: 10.1016/j.jamcollsurg.2009.03.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Revised: 03/10/2009] [Accepted: 03/11/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Comparison studies of hand-assisted and laparoscopic-assisted colectomy have indicated that short-term outcomes are similar. Although a few of these studies have compared costs, none has reported on the costs of hand-assisted colectomy performed in the US. Our aim was to determine the short-term outcomes and direct costs associated with hand-assisted and laparoscopic-assisted colectomy performed in the US. STUDY DESIGN One hundred hand-assisted laparoscopic colectomies were matched to 100 laparoscopic-assisted colectomies performed concurrently. Matching criteria were age (+/- 10 years), gender, diagnosis, American Society of Anesthesiologists score, earlier abdominal operation, colectomy type, and conversion. Operative time, morbidity, length of stay, reoperation, and readmission were assessed. Direct costs for the operating room, nursing care, intensive care, anesthesia, laboratory, pharmacy, radiology, emergency services and consultations, and professional and ancillary services related to the initial hospitalization and readmissions were compared. RESULTS From June 2005 to August 2008, 176 hand-assisted and 845 laparoscopic-assisted segmental and total colectomies were performed. Of 100 matched hand-assisted and laparoscopic-assisted patients, there were no differences in body mass index (29 and 28, respectively), operating time (168 and 163 minutes, respectively), length of stay (4 days), readmission (6% and 11%, respectively), or reoperation rates (5% and 9%, respectively). Overall morbidity was 16% and 32% for hand-assisted and laparoscopic-assisted colectomy, respectively (p = 0.009). Major morbidity, including abscess, hemorrhage, and anastomotic leak, were similar. Operating room costs were increased for hand-assisted colectomy (3,476 versus 3,167 US dollars); total costs were similar (8,521 versus 8,373 US dollars). CONCLUSIONS Short-term outcomes and total costs of hand-assisted and laparoscopic-assisted colectomy are similar.
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Affiliation(s)
- Ersin Ozturk
- Department of Colorectal Surgery, The Cleveland Clinic, Cleveland, OH 44195, USA
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Bouchard A, Martel G, Sabri E, Poulin EC, Mamazza J, Boushey RP. Impact of incision length on the short-term outcomes of laparoscopic colorectal surgery. Surg Endosc 2009; 23:2314-20. [PMID: 19247712 DOI: 10.1007/s00464-009-0328-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Revised: 11/11/2008] [Accepted: 12/16/2008] [Indexed: 12/29/2022]
Abstract
BACKGROUND The recent introduction of hand-assist devices in laparoscopic colorectal surgery has renewed interest in the influence of incision length. This study aimed to define the impact of extraction incision length on the postoperative outcomes of laparoscopic left-sided colon and rectal resections. METHODS Consecutive patients undergoing laparoscopic left-sided colorectal resection from 1991 to 2007 were retrieved from a prospectively collected database. The association between incision length and patient characteristics, diagnosis, and perioperative outcomes were analyzed using logistic regression, Spearman correlation, Wilcoxon test, and chi-square test. RESULTS A total of 494 laparoscopic colorectal resections (left, sigmoid, anterior, and low anterior resections) were retrieved. Patients with conversions to open surgery (n = 59) and missing data (n = 53) were excluded. As a result, 382 cases were included in the study. A slight majority of the patients had malignant disease (n = 202, 53%). The median incision length was 5 cm (interquartile range, 4-6 cm). Increasing weight was positively correlated with incision length (p = 0.0001). Male patients had modestly larger mean incisions than female patients (5.5 vs. 5.0 cm; p = 0.0075). Age, previous surgery, diagnosis, days to resumption of normal diet, and days to discharge from hospital showed no significant relationship with incision length. No association was observed between the incision length and intraoperative or postoperative complications. CONCLUSIONS Patients undergoing laparoscopic colorectal surgery appear to achieve the same perioperative outcomes irrespective of their extraction incision lengths. To maintain the short-term benefits of laparoscopy, surgeons should consider pursuing a minimally invasive technique, even when a larger extraction incision will ultimately be required.
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Affiliation(s)
- Alexandre Bouchard
- Minimally Invasive Surgery Research Group, Division of General Surgery, The Ottawa Hospital, University of Ottawa, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
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Read TE, Salgado J, Ferraro D, Fortunato R, Caushaj PF. “Peek port”: a novel approach for avoiding conversion in laparoscopic colectomy. Surg Endosc 2008; 23:477-81. [DOI: 10.1007/s00464-008-0047-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2008] [Revised: 05/19/2008] [Accepted: 06/09/2008] [Indexed: 12/20/2022]
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Hand-assisted laparoscopic vs. laparoscopic colorectal surgery: a multicenter, prospective, randomized trial. Dis Colon Rectum 2008; 51:818-26; discussion 826-8. [PMID: 18418653 DOI: 10.1007/s10350-008-9269-5] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2007] [Revised: 06/20/2007] [Accepted: 07/18/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to compare short-term outcomes after hand-assisted laparoscopic vs. straight laparoscopic colorectal surgery. METHODS Eleven surgeons at five centers participated in a prospective, randomized trial of patients undergoing elective laparoscopic sigmoid/left colectomy and total colectomy. The study was powered to detect a 30-minute reduction in operative time between hand-assisted laparoscopic and straight laparoscopic groups. RESULTS There were 47 hand-assisted patients (33 sigmoid/left colectomy, 14 total colectomy) and 48 straight laparoscopic patients (33 sigmoid/left colectomy, 15 total colectomy). There were no differences in the patient age, sex, body mass index, previous surgery, diagnosis, and procedures performed between the hand-assisted and straight laparoscopic groups. Resident participation in the procedures was similar for all groups. The mean operative time (in minutes) was significantly less in the hand-assisted laparoscopic group for both the sigmoid colectomy (175 +/- 58 vs. 208 +/- 55; P = 0.021) and total colectomy groups (time to colectomy completion, 127 +/- 31 vs. 184 +/- 72; P = 0.015). There were no apparent differences in the time to return of bowel function, tolerance of diet, length of stay, postoperative pain scores, or narcotic usage between the hand-assisted laparoscopic and straight laparoscopic groups. There was one (2 percent) conversion in the hand-assisted laparoscopic group and six (12.5 percent) in the straight laparoscopic group (P = 0.11). Complications were similar in both groups (hand-assisted, 21 percent vs. straight laparoscopic, 19 percent; P = 0.68). CONCLUSIONS In this prospective, randomized study, hand-assisted laparoscopic colorectal surgery resulted in significantly shorter operative times while maintaining similar clinical outcomes as straight laparoscopic techniques for patients undergoing left-sided colectomy and total abdominal colectomy.
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Champagne BJ, Lee EC, Valerian B, Armstrong D, Ambroze W, Orangio G. A novel end point to assess a resident's ability to perform hand-assisted versus straight laparoscopy for left colectomy: is there really a difference? J Am Coll Surg 2008; 207:554-9. [PMID: 18926459 DOI: 10.1016/j.jamcollsurg.2008.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Revised: 03/04/2008] [Accepted: 03/05/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND It has been suggested that hand-assisted colectomy (HAC) may help residents progress along the learning curve, but there is currently no evidence to support this claim. Previous studies address procedures performed by staff surgeons or residents at various skill levels and report operative times and conversion rates as their primary end points. We measured the percentage of cases completed by a resident as the operating surgeon as the primary end point to determine the most effective approach for teaching laparoscopic colectomy. STUDY DESIGN All patients who underwent left-sided HAC or straight laparoscopic colectomy (SLC) by a single resident starting as the primary surgeon were included. If the assisting attending physician assumed the role of the operating surgeon during the case, it was recorded as an incomplete case for the resident. Operative times and conversions were included as secondary end points. RESULTS A single resident started 147 laparoscopic colectomies as the primary surgeon during residency and colorectal fellowship, including 81 left-sided procedures. There were 44 patients in the HAC group and 37 SLC patients. Cases done by straight laparoscopy were more likely to be completed by the resident than those done by HAC (SLC, 88%; HAC, 72%; p=0.06). There were also differences in mean operative time favoring SLC (HAC, 142 minutes [range 100 to 170 minutes] versus SLC, 133 minutes [range 95 to 195 minutes]; p=0.04). Complications were similar in the 2 groups (HAC, 19% versus SLC, 21%), as were conversions (HAC, 5.6% versus SLC, 4.5%). CONCLUSIONS Both hand-assisted and straight laparoscopic techniques for left colectomy can be applied to successfully train surgical residents with the assistance of a staff surgeon outside of their learning curve. Residents and colorectal fellows may have more success completing straight laparoscopic colectomy than adjusting to the novel hand-assisted approach during training.
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Total laparoscopic restorative proctocolectomy: are there advantages compared with the open and hand-assisted approaches? Dis Colon Rectum 2008; 51:541-8. [PMID: 18301949 PMCID: PMC2365983 DOI: 10.1007/s10350-007-9168-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 04/25/2007] [Accepted: 05/26/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE A randomized, controlled trial comparing hand-assisted laparoscopic restorative proctocolectomy with open surgery did not show an advantage for the laparoscopic approach. The trial was criticized because hand-assisted laparoscopic restorative proctocolectomy was not considered a true laparoscopic proctocolectomy. The objective of the present study was to assess whether total laparoscopic restorative proctocolectomy has advantages over hand-assisted laparoscopic restorative proctocolectomy with respect to early recovery. METHODS Thirty-five patients underwent total laparoscopic restorative proctocolectomy and were compared to 60 patients from a previously conducted randomized, controlled trial comparing hand-assisted laparoscopic restorative proctocolectomy and open restorative proctocolectomy. End points included operating time, conversion rate, reoperation rate, hospital stay, morbidity, quality of life, and costs. The Medical Outcomes Study Short Form 36 and the Gastrointestinal Quality of Life Index were used to evaluate general and bowel-related quality of life. RESULTS Groups were comparable for patient characteristics, such as sex, body mass index, preoperative disease duration, and age. There were neither conversions nor intraoperative complications. Median operating time was longer in the total laparoscopic compared with the hand-assisted laparoscopic group (298 vs. 214 minutes; P < 0.001). Morbidity and reoperation rates in the total laparoscopic, hand-assisted laparoscopic, and open groups were comparable (29 vs. 20 vs. 23 percent and 17 vs.10 vs. 13 percent, respectively). Median hospital-stay was 9 days in the total laparoscopic group compared with 10 days in the hand-assisted laparoscopic group and 11 days in the open group (P = not significant). There were no differences in quality of life and total costs. CONCLUSIONS There were no significant short-term benefits for total laparoscopic compared with hand-assisted laparoscopic restorative proctocolectomy with respect to early morbidity, operating time, quality of life, costs, and hospital stay.
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Hassan I, You YN, Cima RR, Larson DW, Dozois EJ, Barnes SA, Pemberton JH. Hand-assisted versus laparoscopic-assisted colorectal surgery: Practice patterns and clinical outcomes in a minimally-invasive colorectal practice. Surg Endosc 2008; 22:739-43. [PMID: 17704883 DOI: 10.1007/s00464-007-9477-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Laparoscopic assisted (LA) colectomy has significant patient benefits but is technically challenging. Hand-assisted laparoscopic surgery (HALS) allows tactile feedback because the surgeon's hand assists in retraction and dissection. This may decrease the technical difficulty and shorten the learning curve associated with performing laparoscopic colectomy. We investigated the patient selection and short-term clinical outcomes of HALS and LA since the introduction of HALS to our minimally invasive colorectal practice. METHODS Prospectively collected data on 258 patients undergoing HALS (n = 109) or LA colectomy (n = 149) during a calendar year (2004) were analyzed. Patient and disease characteristics, operative parameters, and perioperative outcomes were compared. RESULTS HALS patients were similar to LA patients in age (51 vs. 54 yrs), gender (56 vs. 52% male), body mass index (26 vs. 26 kg/m2), comorbidities (84 vs. 85% with one or more), and diagnosis (83 vs. 80% benign), but differed in incidence of previous surgery (49 vs. 30%; P = 0.008). A significantly greater proportion of HALS patients underwent complex procedures and extensive resections. Conversion rates (15 vs. 11%, P = 0.44), intraoperative complications (4 vs. 1%, P = 0.17), 30-day morbidity (18 vs. 11%, P = 0.12) and surgical reinterventions (2 vs. 1%, P = 0.58) did not differ. Recovery measured by days to flatus was not different [mean (standard deviation) 3(2) vs. 3(2) days, P = 0.26], however HALS patients had longer operative times [276(96) vs. 211(107) minutes P < 0.0001] and 1 day longer stay in hospital [6(3) vs. 5 (3) days, P = 0.0009)]. CONCLUSIONS Patients undergoing HALS underwent more-complex procedures than LA patients but retained the short-term benefits associated with LA colectomy. HALS facilitates expansion of a minimally invasive colectomy practice to include more challenging procedures while maintaining short-term patient benefits.
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Affiliation(s)
- Imran Hassan
- Division of General Surgery, SIU School of Medicine, Springfield, II 62794, USA
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Aalbers AGJ, Biere SSAY, van Berge Henegouwen MI, Bemelman WA. Hand-assisted or laparoscopic-assisted approach in colorectal surgery: a systematic review and meta-analysis. Surg Endosc 2008; 22:1769-80. [PMID: 18437486 PMCID: PMC2471396 DOI: 10.1007/s00464-008-9857-4] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Revised: 01/21/2008] [Accepted: 02/07/2008] [Indexed: 12/14/2022]
Abstract
BACKGROUND Evidence of benefits of laparoscopic and laparoscopic-assisted colectomies (LAC) over open procedures in gastrointestinal surgery has continued to accumulate. With its wide implementation, technical difficulties and limitations of LAC have become clear. Hand-assisted laparoscopic surgery (HALS) was introduced in an attempt to facilitate the transition from open techniques to minimally invasive procedures. Continuing debate exists about which approach is to be preferred, HALS or LAC. Several studies have compared these two techniques in colorectal surgery, but no single study provided evidence which procedure is superior. Therefore, a systematic review was carried out comparing HALS with LAC colorectal resection. METHODS Eligible studies were identified from electronic databases (Medline, Embase Cochrane) and cross-reference search. The database search, quality assessment, and data extraction were independently performed by two reviewers. Minimal outcome criteria for inclusion were operating time, conversion rate, hospital stay, and morbidity. RESULTS Out of 468 studies a total of 13 studies were selected for comprehensive review. Two randomized controlled trials (RCT) and 11 non-RCTs, comprising 1017 patients, met the inclusion criteria. Because of possible clinical heterogeneity two groups of procedures were created: segmental colectomies and total (procto)colectomies. In the segmental colectomy group significant differences in favor of the HALS group were seen in operating time (WMD 19 min) and conversion rate (OR of 0.3 conversions). In the total (procto)colectomy group a significant difference in favor of the HALS group was seen in operating time (WMD 61 min). CONCLUSIONS This systematic review indicates that HALS provides a more efficient segmental colectomy regarding operating time and conversion rate, particularly accounting for diverticulitis. A significant operating time advantage exists for HALS total (procto)colectomy. HALS must therefore be considered a valuable addition to the laparoscopic armamentarium to avoid conversion and speed up complicated colectomies.
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Affiliation(s)
- A G J Aalbers
- Department of Surgery, Academic Medical Center, Location G4-129, Postbox 22660, 1100 DD, Amsterdam, The Netherlands
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Abstract
OBJECTIVE Laparoscopic colectomy has been proved to be both technically and oncologically feasible. However, the approach has been criticized for its procedural complexity and long operative time as a result of the loss of tactile feedback and absence of depth perception. The advent of hand-access devices offered a potential solution to these problems. This randomized controlled trial aims to compare hand-assisted laparoscopic colectomy (HALC) with open colectomy (OC) in the management of right-sided colonic cancer. METHODS Adult patients with nonmetastatic carcinoma of cancer or ascending colon were recruited. Patients were excluded if they presented with surgical emergencies, had synchronous tumors on work-up, or when the tumor was larger than 6.5 cm in any dimension or preoperative imaging. Recruited patients were randomized to undergo either HALC or OC by the same surgical team. Outcome measures included operative time, blood loss, postoperative pain score and analgesic requirement, length of hospital stay, postoperative complications, as well as disease recurrence and patient survival. RESULTS Eighty-one patients (HALC = 41, OC = 40) were successfully recruited. The 2 groups were matched for age, gender distribution, body mass index, and comorbidities. No significant difference was observed between the 2 groups in the distribution of tumors and the final histopathological staging. HALC took significantly longer than OC (110 min vs. 97.5 minutes, P = 0.003) but resulted in significantly less blood loss (35 mL vs. 50 mL, P = 0.005). Patients after HALC experienced significantly less pain, required significantly less parenteral and enteral analgesia, recovered faster, and was associated with a shorter length of stay (7 days vs. 9 days, P = 0.004). With median follow-up of 28 to 30 months, no difference was observed in terms of disease recurrence, and the 5-year survival rates remained similar (83% vs. 74%, P = 0.90). CONCLUSION HALC retained the same short-term benefits of the pure laparoscopic approach. The technique is associated with a slightly increased but acceptable operative time. Aside as a useful adjunct in complex laparoscopic procedures, the hand-assisted laparoscopic technique is also a useful, if not more effective, alternative for patients with right-sided colonic cancer.
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Laparoscopic surgery. COLORECTAL CANCER 2007. [DOI: 10.1017/cbo9780511902468.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Boushey RP, Marcello PW, Martel G, Rusin LC, Roberts PL, Schoetz DJ. Laparoscopic total colectomy: an evolutionary experience. Dis Colon Rectum 2007; 50:1512-9. [PMID: 17762963 DOI: 10.1007/s10350-007-0304-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Laparoscopic total abdominal colectomy and total proctocolectomy are technically challenging operations. Advances in minimally invasive techniques, including sleeveless hand-assist devices, may influence performance of these procedures. This study was designed to evaluate the results of laparoscopic total colectomy and to compare the hand-assisted approach with straight laparoscopy. METHODS Sequential patients undergoing hand-assisted and straight laparoscopic total abdominal colectomy and total proctocolectomy from 1997 to 2004 were identified from a single institution prospective database involving four colorectal surgeons, of which three had limited laparoscopic experience. Patient characteristics, perioperative parameters, and outcomes were assessed. RESULTS A total of 130 patients were analyzed. Sixty-nine patients underwent total abdominal colectomy (hand-assisted 17 vs. straight laparoscopic 52), and 61 underwent total proctocolectomy (hand-assisted 28 vs. straight laparoscopic 33). For both total abdominal colectomy and total proctocolectomy, the hand-assisted and straight laparoscopic groups were well matched. Although no differences were observed in operative blood loss and intraoperative complications, hand assistance resulted in fewer overall conversions to open (1/45 (2.2 percent) vs. 6/85 (7.1 percent); P < 0.01), with no conversions in the total abdominal colectomy group (0 vs. 9.6 percent; P = 0.05). There was a trend toward reduced operative time with hand assistance, and nonlaparoscopic staff surgeons performed a greater proportion of the hand-assisted cases (22.2 vs. 10.6 percent; P < 0.05). CONCLUSIONS Laparoscopic total colectomy is technically feasible and safe. With a significant reduction in conversions and a greater proportion of cases performed by nonlaparoscopic surgeons, there was an evolutionary shift to a hand-assisted technique. A hand-assisted approach may be a useful alternative to a straight laparoscopic approach for this technically challenging operation.
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Affiliation(s)
- Robin P Boushey
- Department of Colon and Rectal Surgery, Lahey Clinic, 41 Mall Road, Burlington, Massachusetts 01805, USA
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Polle SW, Bemelman WA. Surgery insight: minimally invasive surgery for IBD. ACTA ACUST UNITED AC 2007; 4:324-35. [PMID: 17541446 DOI: 10.1038/ncpgasthep0839] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2006] [Accepted: 03/28/2007] [Indexed: 12/21/2022]
Abstract
The most frequently described laparoscopic operations for the management of patients with IBD are restorative proctocolectomy for ulcerative colitis and ileocolic resection for Crohn's disease. For patients with Crohn's disease, there is level 1b evidence that, in experienced hands, laparoscopic ileocolic resection enhances recovery and leads to a shorter hospital stay compared with conventional ileocolic resection. The demonstrated advantages of laparoscopic ileocolic resection with regard to cost and cosmesis, and the acceptable long-term results achieved (which are at least comparable to those achieved by conventional ileocolic resection) favor the use of laparoscopic ileocolic resection over conventional ileocolic resection in patients with ileocolic Crohn's disease. For patients with ulcerative colitis, the expected advantages of laparoscopic restorative proctocolectomy over conventional restorative proctocolectomy have yet to be clearly shown. Although there is a trend towards a reduced hospital stay (of only 1.6 days) when laparoscopic restorative proctocolectomy is performed, operating times are disproportionably prolonged. The most important argument for offering patients with IBD the chance to undergo a laparoscopic procedure, rather than conventional open surgery, is (particularly for women) the long-term superior cosmesis and body image it confers.
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Affiliation(s)
- Sebastiaan W Polle
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Chew SSB, Adams WJ. Laparoscopic hand-assisted extended right hemicolectomy for cancer management. Surg Endosc 2007; 21:1654-6. [PMID: 17593463 DOI: 10.1007/s00464-006-9128-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2006] [Revised: 07/31/2006] [Accepted: 09/25/2006] [Indexed: 02/06/2023]
Abstract
UNLABELLED Laparoscopic extended right hemicolectomy for cancer management is an uncommon operation because it is difficult to divide the middle colic vessels laparoscopically in an oncologic resection. Furthermore, some surgeons believe a left hemicolectomy is an adequate alternative. This study aimed to evaluate the feasibility of performing a laparoscopic hand-assisted extended right hemicolectomy for cancer located between the distal transverse colon and the proximal descending colon. The technique was described and demonstrated with a video presentation. The clinical outcome was recorded for four consecutive patients. ELECTRONIC SUPPLEMENTARY MATERIAL The online version of this article (doi: 10.1007/s00464-006-9128-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S S B Chew
- Department of Surgery, Nepean Hospital, P.O. Box 63, Penrith, NSW 2751, Australia.
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