Hand-assisted or laparoscopic-assisted approach in colorectal surgery: a systematic review and meta-analysis

Lending a hand: The utility of hand-assisted laparoscopic surgery in diverticulitis with fistula

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.

Hand-assisted versus straight laparoscopy for colorectal surgery - a systematic review and meta-analysis

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.

Surgical outcomes of hybrid hand-assisted laparoscopic pelvic exenteration for locally advanced rectal cancer: Initial experience

INTRODUCTION

Hybrid hand-assisted laparoscopic surgery (HALS) combines better visualization of laparoscopic surgery with the advantages of open surgery. The aim of this study was to describe important technical considerations of HALS and to assess the feasibility of hybrid HALS pelvic exenteration (PE) for primary advanced rectal cancer.

METHODS

From May 2012 to August 2018, we retrospectively analyzed 11 patients who underwent PE for primary advanced rectal cancer (< 10 cm from the anal verge). Patients were divided into the open PE group (n = 5) and the hybrid HALS PE group (n = 6).

RESULTS

There was no significant difference in patient characteristics between the two groups, and all included patients were male. Tumor invasion to adjacent organs was mostly anterior invasion. In addition, four patients (66%) in the hybrid HALS PE group and two (40%) in the open PE group received neoadjuvant therapy (P = .3).

CONCLUSION

Compared to open surgery, hybrid HALS has the advantages of less bleeding and less invasion, and can achieve the same results in the short-term. It was a reasonable procedure which was easy and safe dissection of internal iliac vessels and dorsal vein complex. Thus, hybrid HALS may become a useful approach for PE.

Incisional Hernia After Laparoscopic-Assisted Right Hemicolectomy

BACKGROUND

Different approaches used for laparoscopic right colectomy have different advantages and disadvantages. This study aims to determine the incidence and clinical relevance of IH after LARHC as the preferred technique in an experienced setting and to assess which factors are correlated with the development of IH.

METHODS

Between January 2012 and December 2016, all consecutive patients who underwent LARHC were included. Data were obtained in accordance with the Dutch ColoRectal Audit, and IH was scored based on physical examination and imaging at standard follow-up. Logistic regression analysis was used to identify risk factors for IH.

RESULTS

A total of 170 patients underwent LARHC. In the same period, 64 patients had an open RHC. IH after LARHC was seen in 24 patients after a median time of 7 months (14%). Only four of these patients underwent operative IH repair (2%). Interestingly, a trend for more IH was seen between two surgeons. Multivariable analysis identified BMI [OR 1.08 (95% CI 1.00-1.15) P = 0.043], a history of smoking [OR 2.14 (95% CI 1.03-4.41) P = 0.040], and surgical site infection [OR 2.99 (95% CI 1.28-7.00) P = 0.012] as risk factors for IH.

CONCLUSION

IH incidence after LARHC was considerable, but few were clinically relevant IHs. The IH incidence should be included in shared decision making. The low clinically relevant IH rate does in our opinion not outweigh possible advantages of LARHC.

Thirteen-year experience with hand-assisted laparoscopic surgery in colorectal patients

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.

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

BACKGROUND

Left hemicolectomy and complicated sigmoid colectomy require an anastomosis between the transverse colon and rectum. Generous mobilization will typically allow the colon to reach to the rectum. However, despite full mobilization of the splenic flexure and extensive work on the mesentery, there are cases in which reach to the pelvis is still an issue. Retroileal routing of the colon is one technique for overcoming such a reach problem and achieving a tension-free anastomosis. Performing retroileal routing using laparoscopic techniques has been reported rarely, and to date, there are no data on this technique when performed in a hand-assisted laparoscopic fashion. This study aimed to describe the feasibility of doing a retroileal routing using a hand-assisted laparoscopic technique.

METHODS

This was a retrospective chart review of patients who underwent a colon or rectal resection, either open or laparoscopic, with a pelvic anastomosis, by a single colorectal surgeon at an academic institution between 2008 and 2015 with a focus on the immediate and long-term postoperative complications, estimated blood loss, and operating room time for patients having an operation that included retroileal routing for construction of a colorectal anastomosis.

RESULTS

A total of 340 patients fit inclusion criteria and of these, 13 underwent hand-assisted laparoscopic procedures with retroileal routing of the proximal colon to the colorectal anastomosis. Postoperative morbidity included intubation for CO₂ retention in one patient and a RLL effusion in another patient; there were no anastomotic leaks. Long-term morbidities included two ventral hernias at 2 years postoperatively. Mean operating room time was 208 min. There were no 30- or 90-day mortalities.

CONCLUSIONS

Hand-assisted laparoscopic retroileal routing is a feasible and safe technique in accomplishing a tension-free colorectal anastomosis when proximal colon length makes standard routing of the colon to the rectum an issue.

Hand-assisted Laparoscopy: Expensive but Considerable Step Between Laparoscopic and Open Colectomy

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.

Hand-assisted laparoscopic surgery versus laparoscopic right colectomy: a meta-analysis

Objective

The objective of this study is to systematically assess the clinical efficacy of hand-assisted laparoscopic surgery (HALS) and laparoscopic right colectomy (LRC).

Methods

The randomized controlled trials (RCTs) and non-RCTs were collected by searching electronic databases (Pubmed, Embase, and the Cochrane Library). The outcomes included intraoperative outcomes, postoperative outcomes, postoperative morbidity, and oncologic outcomes. Meta-analysis was performed using of RevMan 5.3 software.

Results

A total of five studies involving 438 patients were finally included, with 202 cases in HALS group and 236 cases in LRC group. Results of meta-analysis showed that there was no statistical difference between HALS and LRC in terms of conversion rate, length of hospital stay, reoperation rate, postoperative morbidity, and oncologic outcomes. The operative time was 6.5 min shorter in HALS group; however, it was not a clinically significant difference. Although the incision length was longer in HALS, it did not influence the postoperative recovery.

Conclusions

HALS can be considered an alternative to LRC which combines the advantages of open as well as laparoscopic surgery.

Thoracoscopic and hand assisted laparoscopic esophagectomy with radical lymph node dissection for esophageal squamous cell carcinoma in the left lateral decubitus position: a single center retrospective analysis of 654 patients

Background

The rates of thoracoscopic esophagectomy performed in the prone and left lateral decubitus positions are similar in Japan. We retrospectively reviewed short- and long-term outcomes of thoracoscopic esophagectomy for esophageal cancer performed in the left lateral decubitus position.

Methods

Between 1996 and 2015, 654 patients with esophageal cancer underwent thoracoscopic esophagectomy in the left lateral decubitus position. Patients were divided into early (1996–2008) and late groups (2009–2015, with standardization of the procedure and formalized training), and their clinical outcomes reviewed.

Results

The completion rate of thoracoscopic esophagectomy was 99.5%, and the procedure was converted to thoracotomy in three patients, due to hemorrhage. The mean intrathoracic operative time, intrathoracic blood loss, and number of dissected mediastinal lymph nodes were 205.0 min, 127.3 mL, and 24.7, respectively. Postoperative complications included pneumonia (8.5%), anastomotic leakage (7.5%), and recurrent nerve paralysis (3.5%). Postoperative (30d) mortality was 4/654 (0.61%) due to anastomotic leak and pneumonia. The five year overall survival rate was 70%. A comparison of the 289 early- and 365 late-study period cases revealed significant differences in mean intrathoracic blood loss (174.0 vs. 94.2 mL), number of mediastinal lymph nodes dissected (20.0 vs. 28.4), hospital length of stay (33.4 vs. 20.0 days, p < 0.001), and postoperative anastomotic leakage (14% vs. 1.6%, p < 0.0001).

Conclusions

Standardization of the procedure for thoracoscopic esophagectomy in the left lateral decubitus position, with a standardized clinical pathway for perioperative care led to significant improvements in surgical outcomes.

Hand-Assisted Laparoscopic Surgery: A Versatile Tool for Colorectal Surgeons

PURPOSE

Hand-assisted laparoscopic surgery (HALS) is a minimally invasive surgical technique with the combined benefits of laparoscopic surgery while allowing the use of the surgeon's hand for better tactile control. Obesity has been associated with higher conversion rates with multiport laparoscopic surgery, but not with HALS. This study aimed to examine the versatility of HALS in various clinical contexts.

METHODS

All HALSs performed at 2 major tertiary centers in Sydney were prospectively collected for retrospective analysis. Variables including age, sex, body mass index (BMI), previous surgeries, pathologies including size and T-stage, and the number of conversions to a midline laparotomy were examined.

RESULTS

A total of 121 HALS colorectal resections were analyzed. The median age of the patients was 62 years, with 63.6% being women. Seven patients required conversion to a midline laparotomy. Of the 121 patients, 50.2% were overweight or obese, and 52.9% had undergone previous abdominal/pelvic operations. However, neither obesity nor abdominal adhesions from previous operations were an indication for conversion to an open laparotomy in any of the 7 converted patients. The presence of intra-abdominal adhesions did not impact the operative time. HALS allowed access to the entire colon and rectum and allowed resection of the bladder, uterus, and ureter, when these organs were involved.

CONCLUSION

HALS is a versatile, minimally invasive technique, which is independent of the patient's BMI, for performing a colorectal resection.

Hand-Assisted Laparoscopic Surgery Versus Conventional Laparoscopic Surgery for Colorectal Cancer: A Systematic Review and Meta-Analysis

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.

A novel hand-assisted laparoscopic versus conventional laparoscopic right hemicolectomy for right colon cancer: study protocol for a randomized controlled trial

Background

Although conventional laparoscopic and hand-assisted laparoscopic surgery for colorectal cancer is widely used today, there remain many technical challenges especially for right colon cancer in obese patients. Herein, we develop a novel hand-assisted laparoscopic surgery (HALS) with complete mesocolic excision (CME), D3 lymphadenectomy, and a total “no-touch” isolation technique (HALS-CME) in right hemicolectomy to overcome these issues. According to previous clinic practice, this novel procedure is not only feasible and safe but has several technical merits. However, the feasibility, short-term minimally invasive virtues, long-term oncological superiority, and potential total “no-touch” isolation technique benefits of HALS-CME should be confirmed by a prospective randomized controlled trial.

Methods/design

This is a single-center, open-label, noninferiority, randomized controlled trial. Eligible participants will be randomly assigned to the HALS-CME group or to the laparoscopic surgery with CME, D3 lymphadenectomy, and total “no-touch” isolation technique (LAP-CME) group, or to conventional laparoscopic surgery with CME and D3 lymphadenectomy (cLAP) group at a 1:1:1 ratio using a centralized randomization list. Primary endpoints include safety, efficacy, and being oncologically clear, and 3-year disease-free, progression-free, and overall survival. Second endpoints include operative outcomes (operation time, blood loss, and incision length), pathologic evaluation (grading the plane of surgery, length of proximal and distal resection margins, distance between the tumor and the central arterial high tie, distance between the nearest bowel wall and the same high tie, area of mesentery resected, width of the chain of lymph-adipose tissue, length of the central lymph-adipose chain, number of harvested lymph nodes), and postoperative outcomes (pain intensity, postoperative inflammatory and immune responses, postoperative recovery).

Discussion

This trial will provide valuable clinical evidence for the feasibility, safety, and potential total “no-touch” isolation technique benefits of HALS-CME for right hemicolectomy. The hypothesis is that HALS-CME is feasible for the radical D3 resection of right colon cancer and offers short-term safety and long-term oncological superiority compared with conventional laparoscopic surgery.

Trial registration

ClinicalTrials.gov, NCT02625272. Registered on 8 December 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2084-3) contains supplementary material, which is available to authorized users.

Minimally Invasive Surgery for Complicated Diverticulitis

Recent guidelines recommend an individualized approach to recurrent uncomplicated diverticulitis, reflecting research showing that non-operative treatment is safe. Thus, the majority of operations for diverticulitis in the future may be for complicated indications. A laparoscopic approach may be used for both acute and chronic complicated diverticulitis in appropriate patients, as described in the American and European guidelines. However, a safe approach to minimally invasive surgery requires recognition when conditions deteriorate or are not suited to laparoscopy as well as knowledge of a variety of technical maneuvers that elucidate difficult anatomy and facilitate resection. Primary anastomosis with or without diversion can be performed safely, and ileostomy reversal is significantly less morbid than Hartmann's (colostomy) reversal. Success in laparoscopy can be achieved with the use of adjunct techniques and technologies, including ureteral stents, hand ports, and hybrid approaches. When completed successfully, a laparoscopic approach has been shown to confer decreased ileus, length of stay, post-operative pain, surgical site infection, and ventral hernia compared to an open approach.

Complete mesocolic excision in right hemicolectomy: comparison between hand-assisted laparoscopic and open approaches

Purpose

To demonstrate the feasibility, safety, and technical strategies of hand-assisted laparoscopic complete mesocolic excision (HAL-CME) and to compare oncological outcomes between HAL-CME and the open approach (O-CME) for right colon cancers.

Methods

Patients who were scheduled to undergo a right hemicolectomy were divided into HAL-CME and O-CME groups. Measured outcomes included demographic variables, perioperative parameters, and follow-up data. Demographic variables included age, sex distribution, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status classification, previous abdominal surgery, tumor localization, and potential comorbidities. Perioperative parameters included incision length, operative time, blood loss, conversion rate, postoperative pain score, postoperative first passage of flatus, duration of hospital stay, total cost, number of lymph nodes retrieved, TNM classification, and postoperative complications. Follow-up data included follow-up time, use of chemotherapy, local recurrence rate, distant metastasis rate, and short-term survival rate.

Results

In total, 150 patients (HAL-CME, 78; O-CME, 72) were included. The groups were similar in age, sex distribution, BMI, ASA classification, history of previous abdominal surgeries, tumor localization, and potential comorbidities. Patients in the HAL-CME group had shorter incision lengths, longer operative times, less operative blood loss, lower pain scores, earlier first passage of flatus, shorter hospital stay, higher total costs, similar numbers of lymph nodes retrieved, similar TNM classifications, and a comparable incidence of postoperative complications. The 2 groups were also similar in local recurrence rate, distant metastasis rate, and short-term survival rate.

Conclusion

The results demonstrate that the HAL-CME procedure is a safe, valid, and feasible surgical method for right hemicolon cancers.

Hand-assisted laparoscopic restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis

INTRODUCTION

In this study, we aimed to evaluate the feasibility and safety of undergoing restorative proctocolectomy through ileal pouch-anal anastomosis (RPC-IPAA) with hand-assisted laparoscopic (HALS) in patients with ulcerative colitis (UC).

PATIENTS AND METHODS

We reviewed 40 consecutive patients who underwent RPC-IPAA with HALS or open technique for treatment of UC between 2010 and 2013. Moreover, the intra-/post-operative outcomes were compared.

RESULTS

We found the median operative time was significantly longer in the HALS group while the blood loss was significantly less in patients with HALS than with open surgery. In the HALS group, the median duration of bed rest and the length of hospital stay were significantly shorter. Moreover, the rate of early post-operative complications in the HALS group was significantly less than that in the open surgery group, among which one patient died in the 30th day after surgery for the extensive use of steroids before the operation.

CONCLUSION

These findings clearly show that HALS RPC is safe and less invasiveness. HALS can become a more comfortable and standardised procedure for UC with the adoption of evolving technologies.

Hand-Assisted Laparoscopic Versus Standard Laparoscopic Colectomy: Are Outcomes and Operative Time Different?

BACKGROUND

HAL colectomy is a technique perceived to provide the benefits of laparoscopic surgery while improving tactile feedback and operative time. Published data are largely limited to small, single-institution studies.

METHODS

The 2012-2013 National Surgical Quality Improvement Program Participant Data Use File was queried for patients undergoing elective SL or HAL colectomy. Patients underwent 1:1 propensity matching and had outcomes compared. An additional subgroup analysis was performed for patients undergoing segmental resections only.

RESULTS

13,949 patients were identified, of whom 6084 (43.6 %) underwent HAL colectomy. Patients undergoing HAL versus SL colectomy had higher rates of postoperative ileus (8.7 vs. 6.3 %, p < 0.001), wound complication (8.8 vs. 6.8 %, p = 0.006), and 30-day readmission (7.5 vs. 6.0 %, p = 0.002), without any differences in operative time (156 vs. 157 min, p = 0.713). Amongst segmental colectomies, HAL remained associated with higher rates of wound complications (8.6 vs. 6.5 %, p = 0.016), postoperative ileus (8.9 vs. 6.3 %, p < 0.001), and 30-day readmission (7.1 vs. 5.9 %, p = 0.041) with no difference in operative time between HAL and SL (145 vs. 145 min, p = 0.334).

CONCLUSIONS

Use of HAL colectomy is associated with increased risk of wound complications, postoperative ileus, and readmissions. Importantly, this technique is not associated with any decrease in operative time.

Current application and prospects of hand-assisted laparoscopic surgery in gastrointestinal tumors

Hand-assisted laparoscopic surgery (HALS) refers to operations in which the surgeon inserts his/her non-dominant hand through a specific auxiliary device into the peritoneal cavity to assist the laparoscopic instruments. Because there is one hand to assist in the operation, HALS can reduce the difficulty of operation and shorten operative time. Previously, HALS is considered the transitional bridge from the traditional open surgery to laparoscopic surgery, but now, HLAS, together with total laparoscopic surgery and laparoscopic assisted surgery, is considered three forms of routine laparoscopic surgery. Along with the extensive use of laparoscopic surgery in gastrointestinal tumors, HALS, as a new method of laparoscopic surgery, has been gradually used in gastrointestinal tumors in recent years.

Minimally invasive surgery of rectal cancer: current evidence and options

Minimally invasive surgery (MIS) of colorectal cancer has become more popular in the past two decades. Laparoscopic colectomy has been accepted as an alternative standard approach in colon cancer, with comparable oncologic outcomes and several better short-term outcomes compared to open surgery. Unlike the treatment for colon cancer, however, the minimally invasive approach in rectal cancer has not been established. In this article, we summarize the current status of MIS for rectal cancer and explore the various technical options.

Comparison of straight vs hand-assisted laparoscopic colectomy: an assessment from the NSQIP procedure-targeted cohort

BACKGROUND

The perioperative outcomes of patients who underwent straight laparoscopic (LAP) vs hand-assisted laparoscopic (HALS) surgery were compared using a recently released procedure-targeted database.

METHODS

The 2012 colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program database was used and patients were classified into 2 groups according to the final surgical approach: LAP vs HALS. Demographics, comorbidities, and 30-day outcomes were compared.

RESULTS

A total of 7,843 patients met the inclusion criteria. There were 4,656 (59%) patients in LAP colectomy and 3,187 (41%) in HALS colectomy groups. Groups were comparable in terms of preoperative characteristics and demographics. Mean operative time was slightly longer in LAP group (178 ± 86 vs 171 ± 84 minutes, P < .001). After covariate-adjustment analysis, the overall morbidity, superficial surgical site infection, and ileus rates remained slightly higher in HALS group.

CONCLUSIONS

Both straight laparoscopic and hand-assisted approaches are used in colorectal surgery and may complement each other in challenging cases. Implementing the best approach to decrease postoperative complication rates and increase use of minimally invasive techniques may play a role in improving patient care and overall quality.

Hand-Assisted versus Straight-Laparoscopic versus Open Proctosigmoidectomy for Treatment of Sigmoid and Rectal Cancer: A Case-Matched Study of 100 Patients

To assess the efficacy of laparoscopic proctosigmoidectomy for cancer treatment, 25 patients who underwent hand-assisted laparoscopic resection during the study period (9/2006 - 7/2012) were matched to 25 straight-laparoscopic and 50 open-surgery cases. The patients who underwent hand-assisted resection had higher rates of preoperative cardiac disease and hypertension than did the straight-laparoscopy and open-surgery groups. Straight-laparoscopic surgery seems to provide faster convalescence compared with open surgery and hand-assisted laparoscopic surgery.

Laparoscopic colorectal surgery: Current status and implementation of the latest technological innovations

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.

Clinical application of hand-assisted laparoscopy in transverse colectomy for middle transverse colon cancer

AIM: To assess the safety, feasibility and clinical application value of hand-assisted laparoscopy in transverse colectomy for middle transverse colon cancer.

METHODS: From April 2012 to April 2015, a total of 20 patients with middle transverse colon cancer underwent radical transverse colon resection at Department of Gastrointestinal Surgery of the First Affiliated Hospital of Nanchang University, of whom 11 underwent hand assisted laparoscopic surgery (HALS), and 9 underwent laparoscopic-assisted surgery (LAS). The clinical data of all the patients were retrospectively analyzed and compared between the two groups.

RESULTS: All the 20 patients had successful surgery. There was no conversion to open surgery or no operative death. Operative time was significantly shorter in the HALS group than in the LAS group (153.6 min ± 28.1 min vs 190.6 min ± 35.0 min, P = 0.017). There were no significant differences between the two groups in blood loss (121.8 mL ± 79.4 mL vs 116.1 mL ± 78.1 mL), number of lymph nodes harvested (15.4 ± 5.4 vs 17.6 ± 11.7), rate of postoperative complications (9.1% vs 11.1%), postoperative exhaust time (3.1 d ± 0.7 d vs 2.9 d ± 0.6 d), or postoperative hospital stay (7.4 d ± 0.7 d vs 7.8 d ± 1.1 d) (P > 0.05). The patients were followed for 2-38 months. In the HALS group, one patient developed intestinal obstruction at 1 mo and one patient developed liver metastases at 8 mo. In the LAS group, one patient died of extensive abdominal metastasis.

CONCLUSION: The hand-assisted laparoscopic technique is feasible and safe in the radical resection of middle transverse colon cancer. Due to a small number of patients included and short follow-up time in this study, further studies are required.

Surgical Treatment of Diverticulitis: Hand-Assisted Laparoscopic Resection Is Predominantly Used for Complex Cases and Is Associated With Increased Postoperative Complications and Prolonged Hospitalization

Introduction Laparoscopic (LAP) colectomy is now the "gold" standard for diverticulitis; the role of hand-assisted LAP (HAL) and Open methods today is unclear. This study assessed the elective use of these methods for diverticulitis. Methods A retrospective review of demographic, comorbidity (Carlson Comorbidity Index [CCI]), resection type, and short-term outcomes was carried out. Results There were 125 (44.5%) LAP, 125 (44.5%) HAL, and 31 (11%) Open cases (overall N = 281). The mean age, body mass index, and percentage of high-risk patients (CCI score >2) of the HAL group were greater (P < .05) than the LAP group (vs Open, P = ns). The Open group's mean age and percent with CCI >2 was greater when compared with the LAP group (P < .05). More Open (P < .05) and HAL patients had complex disease (Open, 63%; HAL, 40%, LAP, 22%) and were diverted (Open, 35%; HAL, 10%; LAP, 3%). Time to bowel movement was not different; however, there was a stepwise increase in median length of stay (LOS; days) from the LAP (5 days) to HAL (6 days) to Open group (7 days) (P < .05 for all). The LAP complication rate (22.4%) was lower (P < .05) than the HAL (42.4%) or Open groups' (45.2%) rates. The LAP surgical site infection rate (5.6%) was lower (P < .05) than the HAL (12.8%) or Open groups (19.6%). Conclusion The HAL and Open groups had more high risk, complex disease, diverted, and older patients than the LAP group; likewise, the overall complication rate and LOS was higher in the HAL and Open groups. Use of HAL methods likely contributed to the high minimally invasive surgery utilization rate (89%).

Hand-assisted laparoscopic surgery compared with open resection for mid and low rectal cancer: a case-matched study with long-term follow-up

BACKGROUND

This study was designed to compare the long-term surgical outcomes of patients with mid and low rectal cancer after open or hand-assisted laparoscopic surgery (HALS).

METHODS

A case-matched controlled prospective analysis of 116 patients who underwent hand-assisted laparoscopic surgery (HALS) for stage I to III mid and low rectal cancer from 2005 to 2010 was performed. Contemporary patients who underwent open rectal surgery were matched to the HALS group at the ratio of 1:1. The perioperative clinical outcomes, postoperative pathology, and survival outcomes were compared between the groups.

RESULTS

The patient characteristics between the two groups were comparable. Ninety patients in the open group and 85 in the HALS group received sphincter-preserving surgery. HALS resulted in less blood loss and wound infection, faster return to oral diet, shorter postoperative hospital stay, and longer operating time. The two groups had similar complication rates. Lymph node retrieval and involvement of circumferential and distal margins were similar for both procedures. Cumulative incidences of locoregional recurrence, disease-free, or overall survival rates were statistically similar.

CONCLUSIONS

This study suggests that HALS for mid and low rectal cancer is acceptable in terms of short-term clinical outcomes and long-term survival results.

Comparative Study on Therapeutic Efficacy Between Hand-Assisted Laparoscopic Surgery and Conventional Laparotomy for Acute Obstructive Right-Sided Colon Cancer

INTRODUCTION

This retrospective study aims to compare open colectomy and hand-assisted laparoscopic surgery (HALS) in the management of acute obstructive right-sided colon cancer and to analyze and evaluate the feasibility and safety of HALS.

PATIENTS AND METHODS

Ten consecutive patients who underwent hand-assisted laparoscopic right hemicolectomy due to acute obstructive right-sided colon cancer were retrospectively well matched with 25 patients scheduled for a conventional laparotomy during the same time. Demographic, intraoperative, and postoperative data were assessed.

RESULTS

The HALS group had the advantage in the length of incision (5.8±0.7 cm) over the conventional group (16±2.3 cm) (P<.05), and the mean blood loss during the operations was significantly less in the HALS group (30±15.2 mL) than in the laparotomy group (90±29.4 mL) (P<.05). Moreover, the time of postoperative ambulation was earlier (2.5±0.8 days versus 3.2±0.9 days) (P<.05). Seven cases underwent intestinal decompression for severe intestinal dilatation and had a satisfactory result. The hand-assisted device can fairly meet the demands of a minimally invasive operation and can protect the abdominal incision and avoid infection. There was no intergroup difference in complication rate, although the conventional group had a higher rate.

CONCLUSIONS

In this study, compared with conventional laparotomy for acute obstructive right-sided colon neoplasm, HALS is associated with less blood loss, shorter incision, and earlier ambulation. Emergency laparoscopic-assisted right hemicolectomy can be safely performed in patients with obstructing right-sided colonic carcinoma. If practiced more, it might be advocated as a bridge between the conventional open approach and traditional laparoscopic surgery.

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

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

Comparison of hand-assisted laparoscopic surgery using tissue fusion devices and open resection for treatment of rectosigmoid carcinoma

Modern tissue fusion devices used in hand-assisted laparoscopic surgery (HALS), a method of combining endoscopic surgery with tactile sensation, can minimize surgical trauma and hospitalization times beyond both conventional laparoscopy and open surgery. The outcomes of HALS using tissue fusion devices and conventional open surgery for curative resection of rectosigmoid carcinoma were compared. A total of 78 (45 males, 33 females; mean age, 57.2±11.7 y) rectosigmoid carcinoma patients underwent HALS surgery (HALS group) and 78 age-matched, sex-matched, and tumor status-matched rectosigmoid carcinoma patients (control group) underwent open resection between June 2008 and June 2010. In the HALS and control groups, abdominal incision length, intraoperative blood loss, procedure time, postoperative abdominal drainage, time to first flatus (bowel function return), length of hospital stay, morbidity, mortality, and pathology were assessed. Procedure times were similar in both groups (142.37±42.09 vs. 137.56±36.24 min). However, length of abdominal incision (5.14±0.47 vs. 13.17±2.41 cm), intraoperative blood loss (125.96±75.58 vs. 142.56±65.37 mL), need for postoperative analgesia, bowel function return (68.01±22.64 vs. 79.77±19.94 h), and postoperative hospital stay (6.47±1.73 vs. 7.73±1.71 d) were all significantly improved in the HALS group. At a median follow-up of 26 months, no significant differences in anastomotic recurrence were observed between groups (1 case/each group). Thus, the HALS approach for curative resection of rectosigmoid carcinoma was found to be similarly safe and effective compared with open resection. Furthermore, HALS may improve postoperative recovery and reduce hospitalization times.

Comparison of hand-assisted laparoscopy with open total colectomy for slow transit constipation: a retrospective study

OBJECTIVE

To compare the efficacy and safety of hand-assisted laparoscopic colectomy (HALC) and open colectomy (OC) for patients with slow transit constipation (STC).

METHODS

Data of patients with STC who underwent total colectomy from January 2008 to December 2012 were retrospectively reviewed after clinical evaluation and an exclusion of secondary causes. These patients were further divided into the HALC and OC groups. Patients' outcomes, including intraoperative and postoperative data on their recovery and complications were compared between the two groups.

RESULTS

A total of 68 patients with STC were finally enrolled in the study, including 32 in the HALC group and 36 in the OC group. The baseline characteristics did not significantly differ between the two groups. Compared with the OC group, patients in the HALC group had a shorter length of incision, a longer operative time and less blood loss volume. There was no conversion to OC for patients undergoing HALC and no intraoperative complications in both groups. Furthermore, after operation, patients in HALC group experienced less pain (3.4 ± 0.7 vs 4.8 ± 1.0), earlier first passage of flatus (58.3 ± 6.3 h vs 73.4 ± 13.0 h), shorter length of postoperative hospital stay (8.8 ± 1.2 days vs 11.3 ± 1.7 days) but higher medical cost (RMB 33 979 ± 3 135 vs RMB 29 828 ± 3 216). The overall postoperative complications and the satisfaction in defecation were comparable in the two groups.

CONCLUSION

HALC is a safe, minimally invasive and effective surgical alternative for treating STC, which is comparable to OC.

Laparoscopy in diverticular disease: Controversies

A minimally invasive approach to the management of diverticular disease has gained acceptance over the last number of years. Certainly, in the elective setting, laparoscopic sigmoid resection compares favourably with open surgery. The use of laparoscopy in the context of emergency surgery for complicated diverticular disease remains controversial however recent studies have demonstrated a defined role for laparoscopy in the acute setting.

Clinical outcomes of 103 hand-assisted laparoscopic surgeries for left-sided colon and rectal cancer: single institutional review

Purpose

The laparoscopic colectomy is avoided principally because of its technical difficulty, steep learning curve, and increased operative time. Hand-assisted laparoscopic surgery (HALS) is an alternative technique that addresses these problems while preserving the short-term benefits of a laparoscopic colectomy. Our study was aimed to describe the characteristics of patients admitted due to left-sided colon and rectal cancer for HALS.

Methods

A prospectively maintained database was used to identify patients who underwent HALS at the Institute of Oncology, Vilnius University, from July 1, 2009, to October 1, 2012.

Results

One hundred-three HALS colorectal resections were performed. The patients' mean age was 64 ± 13.4 years. There were 46 male and 57 female patients. The body mass index was 27.3 ± 5.8 kg/m². Forty-three patients (41.8%) had experienced prior abdominal surgery. The mean HALS time was 105 minutes (range, 55-85 minutes). The conversion rate was 2.7% (3/103). The median of return of gastrointestinal function was 2.5 days (range, 2.2-4.5 days). The median length of hospital stay was 9 days. The postoperative complication and mortality rates were 10.7% and 0.97%, respectively. Four incisional hernias (3.9%) were seen at a mean follow-up of 7.0 ± 3.4 months. None of the patients had a trocar or a hand-port site recurrence.

Conclusion

A HALS colorectal resection is a safe and effective technique, and it provides all the benefits of minimally invasive surgery.

Hand-assisted laparoscopic surgery versus open surgery for colorectal disease: a systematic review and meta-analysis

BACKGROUND

Laparoscopic colorectal surgery remains one of the most challenging techniques to learn.

METHODS

The authors collected studies that have compared hand-assisted laparoscopic surgery (HALS) and open surgery for the treatment of colorectal disease over the past 17 years. Data of interest for HALS and open surgery were subjected to meta-analysis.

RESULTS

Twelve studies that included 1,362 patients were studied. In total, 2.66% of HALS procedures were converted to laparotomy. Compared with the open surgery group, blood loss, rate of wound infection, and ileus in the HALS group decreased, and incision length, recovery of gastrointestinal function, and hospitalization period were shorter. There were no significant differences in operating time, hospitalization costs, mortality, and complications, including urinary tract infection, pneumonia, and anastomotic leak, between the groups.

CONCLUSIONS

HALS has the advantages of minimal invasion, lower blood loss, shorter incision length, and faster recovery, and it can shorten the length of hospitalization without an increase in costs. The drawbacks are that a small number of patients who undergo HALS may need to be converted to laparotomy, and the oncologic safety and long-term prognosis are not clear.

Laparoscopic colorectal surgery for diverticular disease is not suitable for the early part of the learning curve. A retrospective cohort study

AIM

We evaluate the challenges of laparoscopic colorectal surgery for diverticular disease.

METHODS

Retrospective study of elective laparoscopic colorectal procedures (LCP) performed 2002-2011. The study compares LCP for Diverticular disease (S group) with both LCP for other pathology (C1 group) and open procedures for diverticular disease (C2 group). Statistical analysis was performed using Fisher's exact test, Student "t" test and Mann Whitney U-test.

RESULTS

The study included 194 LCP out of which 22 were in S group. Conversion rate in S group was 27.3% vs 9.9% in C1 group, p = 0.017. The mean operating time was significantly higher in S group (250 min) compared with 196 min in C1 group, p = 0.0004. The median length of hospital stay was 6 days in S group and 4 days in C group, p = 0.12. Both morbidities and mortality rates were not statistically different between the two groups. In the second part of the study we compare LCP with OCP performed for diverticular disease.

CONCLUSION

LCP for Diverticular disease are technically challenging and should be attempted later in the learning curve.

The evolving role of laparoscopy in colonic diverticular disease: a systematic review

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.

Is hybrid robotic laparoscopic assistance the ideal approach for restorative rectal cancer dissection?

AIM

While the use of robotic assistance in the management of rectal cancer has gradually increased in popularity over the years, the optimal technique is still under debate. The authors' preferred technique is a robotic low anterior resection that requires a hybrid approach with laparoscopic hand-assisted mobilization of the left colon and robotic assistance for rectal dissection. The aim of this study was to determine the efficacy of this approach as it relates to intra-operative and short-term outcomes.

METHOD

Between August 2005 and July 2011, consecutive patients undergoing rectal dissection for cancer via the hybrid robotic technique were included in our study. Demographics, margin positivity, intra-operative and short-term outcomes were evaluated.

RESULTS

The preferred approach was performed in 77 patients with rectal adenocarcinoma. Of these, 68 underwent low anterior resection and nine had a coloanal pull-through procedure (mean age 60.1 years; mean body mass index 28.0 kg/m(2) ; mean operative time 327 min; conversion rate 3.9%). Three patients (3.9%) had positive resection margins (one circumferential, two distal). Five patients had an anastomotic leak (6.4%). No robot-specific complications were observed.

CONCLUSION

The hybrid approach involving hand-assisted left colon mobilization and robotic rectal dissection is a safe and feasible technique for minimally invasive low anterior resection. This approach can be considered an viable option for surgeons new to robotic rectal dissection.

Single-incision laparoscopic colectomy versus conventional multiport laparoscopic colectomy: a meta-analysis of comparative studies

OBJECTIVE

This study aimed to compare single-incision laparoscopic colectomy (SILC) to conventional multiport laparoscopic colectomy (MLC).

BACKGROUND

Single-incision laparoscopic surgery (SILS) is a minimally invasive technique being recently applied to colorectal surgery. A number of studies comparing SILC to conventional MLC have recently been published.

METHODS

A literature search of PubMed and MEDLINE databases for studies comparing SILC to conventional MLC was conducted. The primary outcome measures for meta-analysis were postoperative complications, length of stay, and operative time. Secondary outcome measures were incision length, estimated blood loss, and number of lymph nodes harvested.

RESULTS

Fifteen studies comparing 467 patients undergoing SILC to 539 patients undergoing conventional MLC were reviewed and the data pooled for analysis. Patients undergoing SILC had a shorter length of stay (pooled weighted mean difference (WMD) = -0.68; 95 % CI = -1.20 to -0.16; p = 0.0099), shorter incision length (pooled WMD = -1.37; 95 % CI = -2.74 to 0.000199; p = 0.05), less estimated blood loss (pooled WMD = -20.25; 95 % CI = -39.25 to -1.24; p = 0.037), and more lymph nodes harvested (pooled WMD = 1.75; 95 % CI = 0.12 to 3.38; p = 0.035), while there was no significant difference in the number of postoperative complications (pooled odds ratio = 0.83; 95 % CI = 0.57 to 1.20; p = 0.33) or operative time (pooled WMD = 5.06; 95 % CI = -2.91 to 13.03; p = 0.21).

CONCLUSION

SILC appears to have comparable results to conventional MLC in the hands of experienced surgeons. Prospective randomized trials are necessary to define the relative benefits of one procedure over the other.

Clinical application of hand-assisted laparoscopic right hemicolectomy: An analysis of 56 cases

AIM: To explore the clinical value of hand-assisted laparoscopic (HALS) right hemicolectomy.

METHODS: The clinical data for 56 patients who underwent HALS right hemicolectomy were retrospectively analyzed.

RESULTS: One case required conversion to open surgery due to abnormal blood vessels and bleeding, and all the others successfully recovered after HALS surgery. No operative deaths occurred. Operative time ranged from 90 to 150 min, with a mean value of 136 min. Operative blood loss ranged from 20 to 230 mL, with an average of 87 mL. Postoperative hospital stay was 4-10 d. Postoperative pain was mild. The patients progressed to a liquid diet 2 d postoperatively and underwent removal of stitches and extubation on postoperative day 7. Two patients developed postoperative mechanical intestinal obstruction but recovered after receiving treatment.

CONCLUSION: HALS right hemicolectomy is a safe treatment with fewer traumas, less bleeding, and faster recovery, in line with the concept of fast track surgery.

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

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.

Hand-assisted laparoscopic versus open right hemicolectomy: short-term outcomes in a single institution from China

AIM

To compare the perioperative parameters and short-term outcomes of hand-assisted laparoscopic colectomy (HALC) and open colectomy (OC) for the treatment of patients with cancer of the right hemicolon.

METHODS

Patients who were scheduled to perform right hemicolectomy between August 2009 and December 2010 were randomized into either HALC or OC group. Patients were excluded if they had synchronous cancers, hepatic metastases, acute intestinal obstruction, or intestinal perforations. All the operations in the 2 groups were performed by a single surgical team. Measured outcomes included the demographic variables and perioperative parameters. The former included age, sex, body mass index, American Society of Anesthesiologists class, prior abdominal surgery, distribution of tumors, and histopathologic stage; whereas the latter included length of incision, operative time, estimated blood loss, conversion rate, number of lymph nodes retrieved, postoperative pain score, time to return of bowel function, postoperative complications, duration of hospital stay, and total cost.

RESULTS

One hundred sixteen patients with cancer of the right hemicolon (HALC=59, OC=57) were recruited. The 2 groups of patients were similar in age, sex distribution, body mass index, American Society of Anesthesiologists class, and previous abdominal surgery. No significant difference was observed between the 2 groups in terms of distribution of tumors and the final histopathologic staging. HALC had a significantly shorter incision length and longer operative time than OC. Patients in the HALC group had significantly less operative blood loss, less pain and earlier passage of flatus after operation than those in the OC group. The number of lymph nodes recovered in the specimen and the overall postoperative complications was comparable in the 2 groups. The postoperative duration of hospital stay was significantly shorter in the HALC group, whereas the median overall costs in the HALC group were significantly higher than that in the OC group.

CONCLUSIONS

The results from the present study demonstrate that the HALC is a valid surgical approach for cancer of the right hemicolon that retains the benefits of minimally invasive surgery. We believe that this technique is a safe, useful, and feasible method for patients with right-sided colonic cancer. If practiced more, it might be advocated as a "bridge" between traditional laparoscopic surgery and conventional open procedures.

Single-incision laparoscopic colectomy versus conventional multiport laparoscopic colectomy: a meta-analysis of comparative studies

OBJECTIVE

This study aimed to compare single-incision laparoscopic colectomy (SILC) to conventional multiport laparoscopic colectomy (MLC).

BACKGROUND

Single-incision laparoscopic surgery (SILS) is a minimally invasive technique being recently applied to colorectal surgery. A number of studies comparing SILC to conventional MLC have recently been published.

METHODS

A literature search of PubMed and MEDLINE databases for studies comparing SILC to conventional MLC was conducted. The primary outcome measures for meta-analysis were postoperative complications, length of stay, and operative time. Secondary outcome measures were incision length, estimated blood loss, and number of lymph nodes harvested.

RESULTS

Fifteen studies comparing 467 patients undergoing SILC to 539 patients undergoing conventional MLC were reviewed and the data pooled for analysis. Patients undergoing SILC had a shorter length of stay (pooled weighted mean difference (WMD) = -0.68; 95 % CI = -1.20 to -0.16; p = 0.0099), shorter incision length (pooled WMD = -1.37; 95 % CI = -2.74 to 0.000199; p = 0.05), less estimated blood loss (pooled WMD = -20.25; 95 % CI = -39.25 to -1.24; p = 0.037), and more lymph nodes harvested (pooled WMD = 1.75; 95 % CI = 0.12 to 3.38; p = 0.035), while there was no significant difference in the number of postoperative complications (pooled odds ratio = 0.83; 95 % CI = 0.57 to 1.20; p = 0.33) or operative time (pooled WMD = 5.06; 95 % CI = -2.91 to 13.03; p = 0.21).

CONCLUSION

SILC appears to have comparable results to conventional MLC in the hands of experienced surgeons. Prospective randomized trials are necessary to define the relative benefits of one procedure over the other.

Feasibility and safety of single-incision laparoscopic colectomy: a systematic review

OBJECTIVE

The aim of this review was to evaluate the feasibility, safety, and potential benefits of single-incision laparoscopic colectomy (SILC).

METHODS

We conducted a comprehensive review for the years 1983 to March 2011 to retrieve all relevant articles.

RESULTS

A total of 23 studies with 378 patients undergoing SILC were reviewed. All studies except 2 used a commercially available single-port device. Range of body mass index was 20.9 to 30.0 kg/m². Ranges of operative times and estimated blood losses were 83 to 225 minutes and 0 to 115 mL, respectively. Of 378 cases, a total of 6 cases (1.6%) were converted to open, 6 (1.6%) to hand-assisted laparoscopic (HALC), and 14 (4.0%) to conventional (multiport) laparoscopic colectomy (MLC) (overall conversion rate, 6.9%). An additional laparoscopic port was used in 4.9% (12/247) cases. Range of harvested lymph nodes number for malignant cases was 13.5 to 27 and surgical margins were negative in all cases. Overall mortality and morbidity rates were 0.5% (2/378) and 12.9% (45/349), respectively. The length of hospital stay (LOS) varied across reports (1.9-9.8 days). Among 4 case-matched studies, 2 showed shorter LOS after SILC than after HALC (2.7 vs 3.3 days) or after MLC/HALC (3.4 vs 4.6/4.9 days). Furthermore, one of these studies reported that maximum pain score on postoperative days 1 and 2 was significantly lower in SILS than in MLC and HALC.

CONCLUSIONS

In early series of highly selected patients, SILC appears to be feasible and safe when performed by surgeons who are highly skilled in laparoscopy. Despite technical difficulties, there may be potential benefits associated with SILC over MLC/HALC but it is yet to be proven objectively.