Novel approach to minimizing trocar sites during challenging hand-assisted laparoscopic surgery utilizing the Gelport: trans-gel instrument insertion and utilization

Hand-assisted laparoscopic colon and rectal cancer surgery: feasibility, short-term, and oncological outcomes

BACKGROUND

Hand-assisted laparoscopic surgery (HALS) is an established alternative to laparoscopic-assisted surgery, but limited data exist regarding its applicability for colorectal cancer (CRC). We report short-term outcomes in a large series of CRC patients who underwent HALS between 2004 and 2009.

METHODS

A prospectively maintained database was used to identify all CRC patients. Patients with colon cancer (CC) and rectal cancer (RC) were considered separately. Three patients with synchronous CC and RC were excluded. Data are frequency (%) or median (interquartile range).

RESULTS

Between 2004 and 2009, 323 CRC patients underwent a HALS procedure. Median age was 65 (53-73) years, 39% were women, and the median BMI was 27 (24-31) kg/m(2). Diagnoses included 194 colon cancers (CC, 56.7% stage I/II), 129 rectal cancers (RC, 62.7% stage I/II). Operative time was less for CC than RC (157 vs 204 min; P < .0001). Conversion to laparotomy occurred in similar proportions of CC and RC cases (14% vs 10%; P = .38); lymph nodes retrieval was also similar (18 vs 18; P = .45). Overall duration of stay was 5 (4-7) days. At 30 days, postoperative complications occurred in similar proportions of CC and RC patients (28% vs 30%; P = .72). There was 1 mortality (0.5%). For the subgroup with 3 year follow-up, (73 CC and 45 RC patients), the overall survival was 80% and 88% (CC and RC, respectively), and disease free survival 79% and 85%, respectively.

CONCLUSION

Colon and rectal cancer can be resected safely using HALS techniques. Conversion rates are low, complication rates expected, durations of hospital stay shorter, and the number of lymph nodes retrieved is high.

A retrospective review of the GelPort system in single-port access pelvic surgery

STUDY OBJECTIVE

Since the advent of single-port access surgery, novel instruments have been developed to facilitate this laparoscopic approach. The GelPort system is an innovative sealing device that permits abdominal access and frequent instrument exchange during surgery while preserving the pneumoperitoneum. The GelPort system has been previously reported in gastric, colorectal, and urologic single-port access procedures but has yet to be described during pelvic surgery.

DESIGN

A retrospective pilot study reviewing 19 single-port access pelvic surgeries that involved the GelPort system was undertaken. Patient and operative statistics, including diagnosis, surgery and anesthesia times, complications and length of hospital stay were evaluated (Canadian Task Force Classification II-2).

RESULTS

Operative time exhibited a direct association with anesthesia time (p=.001). Additionally, patient blood loss (p=.043) and anesthesia time (p=.003) were significant prognostic indicators for length of hospital stay. There were no significant patient complications or subsequent port site hernias.

CONCLUSIONS

The GelPort system appears to contribute favorably to single-port access surgery because the device permits circumferential access and retraction during instrumentation. Furthermore, the specialized design augments a surgeon's versatility and access to complicated anatomic regions without compromising the peritoneum.

Single access site laparoscopic radical nephrectomy: initial clinical experience

PURPOSE

We present the initial clinical experience with single access site (SAS) laparoscopic radical nephrectomy.

MATERIALS AND METHODS

An 86-year-old woman presented with an 8-cm central-enhancing right renal lesion. The patient elected to undergo a laparoscopic radical nephrectomy. A 7-cm paramedian incision was made just lateral to the left rectus muscle and cranial to the umbilicus. A GelPort was inserted into the incision. Three trocars (12 mm, 10 mm, and 5 mm) were placed through the access port, and only standard laparoscopic instruments were used. The kidney was mobilized in the standard fashion. Controlling the renal artery with nonabsorbable polymer clips and the renal vein with a stapling device, the specimen was manipulated into a laparoscopic retrieval bag and removed intact. Hemostasis was confirmed, the GelPort was removed, and the 7-cm incision was closed.

RESULTS

The procedure was completed in 96 minutes without complications. Blood loss was estimated to be 10 mL. Postoperatively, the patient was treated with intermittent intravenous and oral analgesics. She was discharged on postoperative day 2 and tolerated a regular diet.

CONCLUSION

This represents the initial report of an SAS laparoscopic radical nephrectomy, with intact specimen extraction. Using standard laparoscopic instrumentation, the procedure was performed safely and effectively, with minimal blood loss, and short hospitalization. Additional evaluation and development of this type of approach and instrumentation may allow for further expansion of SAS laparoscopic surgery in the future.

HAND-ASSISTED LAPAROSCOPY ON A SHOESTRING

BACKGROUND

Hand-assisted laparoscopic surgery is useful in difficult laparoscopic operations. Expensive and cumbersome devices are necessary to ensure airtightness between the surgeon's hand and the abdominal wall so that pneumoperitoneum can be maintained.

METHOD

A simple method of maintaining pneumo-peritoneum in hand-assisted laparoscopic surgery was carried out by tying a strong nylon suture in a criss-cross fashion on one end of the incision. Airtightness was maintained by tightening the suture around the wrist and wedging the dorsum of the hand against the abdominal wall.

RESULT

The method was used successfully to remove a pyonephrotic left kidney in a 28-year-old man from Papua New Guinea.

CONCLUSION

Hand-assisted laparoscopic operations can be carried out expediently and inexpensively without specialized equipment by simply tying a shoestring suture at one end of the wound.

Hand-assisted laparoscopic surgery using Gelport

INTRODUCTION

Minimally invasive surgery has revolutionized general surgery during the past 10 years. However, for more advanced surgical procedures, the acceptance of the minimally invasive approach has been slower than expected. Advanced laparoscopic surgery is complex and time-consuming. The major drawbacks of laparoscopic surgery are two-dimensional view, lack of depth perception and loss of tactile sensation. This has led to the innovation of hand-assisted laparoscopic surgery (HALS). The objective of the present study was to determine that safety of HALS.

MATERIALS AND METHODS

We preformed 18 HALS procedures in our department between July 2003 and January 2005 on patients who had given their informed consent for the use of Gelport. Out of these, 15 were colectomy, 2 nephrectomy and 1 splenectomy. Out of the 18 patients, 13 were males and 5 were females with the age group ranging from 44 to 72 years.

RESULTS

Hand-assisted laparoscopic surgery could be completed in 17 patients maintaining all the oncological principals of surgery. The mean operating times were 120 min for right haemicolectomy, 135 min for left colectomy, 150 min for splenectomy, and 150 min for nephrectomy. The patient undergoing radical nephrectomy by HALS had to be converted to open surgery. As the tumour was large and adherent to the spleen and posterior peritoneal wall. Postoperative recovery was excellent with an average hospital stay of 5 days. Histopathology report showed wide clearance and till date we have a good follow up of 30-380 days.

CONCLUSION

Hand-assisted laparoscopic surgery allows tactile sensation and depth perception thereby may simplify the complex procedures. This may result in reduction of operating time and conversion rates at the same time maintaining all the oncological principles. Hand-assisted laparoscopic surgery strikes a perfect balance between an extended open laparotomy incision and an excessively tedious laparoscopic exercise. Hand assistance is an initial tool for the trainee laparoscopic surgeon or a last resort for the experienced laparoscopic surgeon.