The advantages of hand-assisted laparoscopy

Comparison of hand-assisted laparoscopy versus open and laparoscopic techniques in urology procedures: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Hand-assisted laparoscopic surgery (HALS) is an integral part of the urologist's armamentarium. We aimed to perform a comprehensive meta-analysis comparing HALS renal surgery with open and laparoscopic techniques.

METHODS

A systematic review and meta-analysis of HALS renal procedures (donor nephrectomy, nephrectomy, or nephroureterectomy) from 1996 to 2007 was performed.

RESULTS

Sixty-two studies of 30 donor nephrectomy, 21 radical nephrectomy, and 14 nephroureterectomy procedures in 5446 patients were included in the analysis. In donor nephrectomy, estimated blood loss (EBL) was statistically significant for HALS vs the open and laparoscopic cohorts, -69.0 mL (95% confidence interval [CI], -129.7, -8.2) and -40.1 mL (95% CI, -68.2, -12.0), respectively. Length of stay (LOS) was shorter compared with the open group, -1.7 days (95% CI, -2.3, -1.1). For nephroureterectomy, EBL (-29.9 mL (95% CI, -242.3, 182.5)), and LOS (-1.5 d [95% CI, -2.8, -0.3]) again favored HALS vs open procedures. Operating room (OR) time and warm ischemia time (WIT) were statistically significant in favor of HALS donor nephrectomy vs the laparoscopic cohort; -36.8 minutes (95% CI, -61.3, -12.3) and -1.3 minutes (95% CI, -1.8, -0.7), respectively. For radical nephrectomy, both EBL -232.9 mL (95% CI, -383.6, -82.2) and LOS -2.4 days (95% CI, -3.5, -1.3) were statistically significant, favoring HALS vs the open group.

CONCLUSION

We report the largest meta-analysis of HALS renal surgery to date. When compared with open surgery, HALS allows for a significant decrease in EBL and LOS. Compared with laparoscopic donor nephrectomy, HALS resulted in a significant decrease in blood loss, OR time, and WIT.

Incorporation of Hand-Assisted Laparoscopic Nephrectomy into an Academic Training Program: An Assessment of the Utility of a 3-Month Minifellowship

INTRODUCTION

The aim of this study was to assess the amount of training necessary for a midcareer urologic surgeon to incorporate hand-assisted laparoscopic (HAL) renal surgery into an academic practice.

MATERIALS AND METHODS

A urologist (JAB) without laparoscopic surgical experience in his fifth year of practice completed a 3-month minifellowship at a high-volume center primarily to learn HAL nephrectomy (HALN), during which he performed 15 HALNs (and 2 HAL nephroureterectomies) and assisted during 5 HALNs. Surgical outcomes and resident surgical participation on nephrectomy cases at the home medical center during the 6 months prior to (phase 1) and after (phase 2) the fellowship were evaluated.

RESULTS

During phase 1, 12 open nephrectomies were performed in a mean operative time of 265 (10-387) minutes. During phase 2, 16 HALNs were initiated and 2 (13%) combined cases were converted to open at the discretion of general surgeon. The mean operative time was 288 (226-355) minutes. Ten (10) and 5 patients from each cohort had concomitant procedures performed. The mean tumor size was 8.7 (2-15) and 7.1 (2.5-15) cm. Three (3) patients from each cohort were anemic preoperatively (hemoglobin < or =10 mg/dL). Ten (10) (83%) and 4 (25%) patients from each cohort received transfusions. There were 3 and 2 intraoperative and postoperative cohort complications, respectively. Residents were the operative surgeon on all cohort 1 and two thirds of cohort 2 cases. Chief residents completed the entirety of their third and fourth HALNs, respectively.

CONCLUSIONS

A 3-month fellowship is an effective tool for a midcareer urologist to rapidly gain significant HALN experience. Twenty-two (22) cases (17 as surgeon) allowed for the immediate incorporation of this procedure into a complex academic practice without any interruption of residency training.

[Hand-assisted laparoscopic nephrectomy]

INTRODUCTION AND OBJECTIVES

To present the number of cases of hand-assisted laparoscopic nephrectomy. This study evaluates our results and difficulties of starting a progresive programme of laparoscopy.

MATERIAL AND METHOD

Between november 2003 and november 2005, 35 hand-assisted laparoscopic nephrectomies were carried out, of a total of 45 laparoscopic nephrectomies. 22 radical nephrectomies, 3 simple nephrectomies and 10 nephroureterectomies. The average age of patients was 66 years (47-89). On average, they were overweight (IMC 28,3), with approximately 38% being obese. ASA 2.3 (1-4). The tumors measured 4.8cm on average, and 80% of these were T1. In 28.6% of the cases, they had previously undergone abdominal surgery.

RESULTS

One was undertaken in 2003, 17 in 2004, and 17 in 2005. The surgery time was 140 minutes, 130 minutes (80-210) in radical nephrectomies, 135 minutes (120-150) in simple nephrectomies and 163 minutes (80-240) in the nephroureterectomy. Patients began an oral diet 1.7 days later, and were able to get up 1.7 days later. In the case of obese patients, they began an oral diet 2.3 days later and were able to get up (2.4 days) later than those non obese cases. (1.5 and 1.4 days respectively). The average stay has been 5.8 days (3-15). The average stay of the cases without complications was 4.2 days and those that encountered complications 9.7 days. In no cases was there a need for a blood transfusion. In 11.4% we had major complications with an average stay of 11.7 days. In 5.7% of cases there were reconversions, and 5.7% of cases were reoperated. 17.1% had minor complications, with an average stay of 8.8 days

CONCLUSIONS

The advantage of hand-assisted nephrectomy is that it allows one to begin a laparoscopy, with a reduced learning time, and with satisfactory results, allowing the incorporation of laparoscopy surgery in hospitals with a reduced annual volume.

Learning curve in human laparoscopic surgery

Laparoscopic urology has gained considerable popularity since the first laparoscopic nephrectomy was performed. However, the rapid application of the technique in urologic practice has led to increased reports of complications, even in the hands of surgeons who are well experienced in open surgical techniques, often early in a surgeon's laparoscopic experience. The lack of translation of open surgical skills into laparoscopic results has led us to reappraise the learning curves relevant to open and laparoscopic surgery, to understand the differences, and enable us to make changes in the curriculum and the training to acquire laparoscopic skills.

Comparison of second-generation hand-assisted laparoscopic devices for surgeon pain and arm circulation

OBJECTIVES

To compare two second-generation hand-assist devices (HADs) for surgeon pain and manual blood flow over time in an in vitro model.

METHODS

Nineteen participants placed their nondominant hand through both the LapDisc and GelPort into a pneumoperitoneum chamber with an insufflation pressure of 15 mm Hg for a 2-hour test period. Pain, on a 10-point visual analog scale, and manual blood flow to the index finger using a laser Doppler skin probe were measured at 10 points during the 2 hours. Participants completed a questionnaire regarding hand comfort and the physical effects of the HAD.

RESULTS

At 30, 45, and 60 minutes after hand insertion, the pain scores were significantly greater for the GelPort than for the LapDisc (P = 0.04, P = 0.01, and P = 0.03, respectively). The GelPort caused an immediate reduction in manual blood flow, and the LapDisc caused a small initial increase in manual blood flow (P = 0.03) and, thereafter, a decrease in blood flow. Three participants voluntarily removed their hand at 30, 45, and 60 minutes owing to the pain from GelPort use. No participant withdrew from the LapDisc because of pain.

CONCLUSIONS

Both HADs resulted in surgeon discomfort in our in vitro model. The GelPort resulted in more subjective pain compared with the LapDisc. Both HADs caused a reduction in manual blood flow. However, compared with the LapDisc, the GelPort caused significantly more reduction in manual blood flow. Surgeon comfort is only one parameter to consider when choosing a HAD.