Hand Assisted Surgery

Bradley R. Davis, MD, FACS, FASCRSAssociate Professor of Surgery

Director Surgical Education/Surgical Skills LabProgram Director Residency in General Surgery

University of Cincinnati

Disclosures

• Paid Consultant for Ethicon Endo Inc.

Challenges

Challenges

– BMI– Adhesions– Complicated Diverticulitis– pT stage– Left vs Right sided resections

Delaney et al. Surg Endosc. 2005 Jan;19(1):47-54

Challenges

• Two skilled surgeons• Experienced camera operator

– Multi quadrant surgery

• Training

Hand Assisted Laparoscopy• Not a Fad….• Not a Cult….• Not a Religion….• Not a Political Party…..

• Just a tool in the toolbox of MIS

HA Lap Colectomy

Pros• Decrease operative times• Decrease conversion

rates• Adoption• Single surgeon• Undertake more complex

cases• Surgeon’s hand is a

GREAT tool

Cons• Fear of the unknown• Learning curve• Device costs• Hand port placement

– What if you have to convert?

Hand Assisted Surgery

• If you are using an incision to extract specimen….why not use it the whole case

• Hand port incision can be used to perform the anastomosis

• Modern hand ports allow hand exchanges to occur rapidly – facilitate training

Outcomes - Colectomy

Author Year Type Patients Comment

HALS 2000 RPT 59 Same as lap

Targarona 2002 RPT 54 Fewer conversions

Kang 2004 RPT 60 Better than open

Chang 2005 CCT 151 Fewer conversions

Milsom 2006 CCT 42 Fewer conversions

Boushey 2005 NRT 130 Same as lap TAC

Maartense 2005 RPT 60 Same as open IPAA

Marcello 2008 RPT 95 Same as lap

Cost

Orenstein et al. Surg Endosc. 2011 May;25(5):1364-8.

Complications

Cima et al. J Am Coll Surg. 2008 May;206(5):946-50

HALS Long Term Outcomes

Sonoda et al. J Am Coll Surg. 2009 Jan;208(1):62-6.

Conversions

• Most modern RCT – failure to show a decrease in conversion rate– Study authors EXPERTS– If you spend enough time trying – usually can

finish the job– Not all patients have read the studies– Most studies exclude our patients (BMI > 30)

Conversions

Cima et al. J Am Coll Surg. 2008 May;206(5):946-50

Conversions – Why?

Cima et al. J Am Coll Surg. 2008 May;206(5):946-50

Conversions

Park et al. Surg Endosc. 2010 Jul;24(7):1679-85

Effective

Orenstein et al. Surg Endosc. 2011 May;25(5):1364-8.

EffectiveHALS LAP P value

Sigmoid/Left Colectomy

Operative Times (mins)

175 208 .021

Incision (cm) 8 6 .01

LOS 5.7 5.2 NS

Total Colectomy

Operative Times (mins)

127 184 .015

Incision(cm) 7.8 6.7 .09

LOS 6.9 8.9 NS

Marcello P, et al. Dis Colon Rectum. 2008 Jun;51(6):818-26

Operative Times

• Hand assisted vs. straight laparoscopic colectomy results in:

– Shorter operative times– Similar clinical outcomes

Marcello P, et al. Dis Colon Rectum. 2008 Jun;51(6):818-26

Complicated Diverticulitis

HALS (n=21) Straight Lap (n=21)

Operative Times (mins)177 255

Incision Length (cm) 5 9

Conversion 4% 14%*

LOS (days) 6 5*

Complications 24% 19%*

Lee et al. Dis Colon Rectum. 2006 Apr;49(4):464-9.

*p=NS

Vogel at al. J Am Coll Surg. 2011 Mar;212(3):367-72

Effective

The Unexpected

• Bleeding

• Stapler Misfire

• Difficulty identifying the lesion

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Operative TechniqueLAP HAL

Vogel at al. J Am Coll Surg. 2011 Mar;212(3):367-72

Hand Assisted Right Colectomy

Laparoscopy for Rectal Cancer

• Low rectal transection • Cannot come across at 90 o

• Increase # firings EndoGIA– INCREASE LEAKS

• If you need an incision…use it throughout the case

Mid to Low Lesion

Brannigan et al. Surg Endosc. 2006 Jun;20(6):952-5

HALS - When

• Early in learning curve• Complex Patients• Complex Disease

– Reoperative– Phlegmon/fistula– Pelvic pathology

• Operative Times – Complex Case

Just a tool in the toolbox of MIS

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Thank You