Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director Residency in General Surgery University of Cincinnati

Disclosures Paid Consultant for Ethicon Endo Inc.

Challenges

–BMI –Adhesions –Complicated Diverticulitis –pT stage –Left vs Right sided resections Delaney et al. Surg Endosc 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 AuthorYearTypePatientsComment HALS2000RPT59Same as lap Targarona2002RPT54Fewer conversions Kang2004RPT60Better than open Chang2005CCT151Fewer conversions Milsom2006CCT42Fewer conversions Boushey2005NRT130Same as lap TAC Maartense2005RPT60Same as open IPAA Marcello2008RPT95Same as lap

Cost Orenstein et al. Surg Endosc May;25(5):

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

HALS Long Term Outcomes Sonoda et al. J Am Coll Surg 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 May;206(5):946-50

Conversions – Why? Cima et al. J Am Coll Surg May;206(5):946-50

Conversions Park et al. Surg Endosc Jul;24(7):

Effective Orenstein et al. Surg Endosc May;25(5):

Effective HALSLAPP value Sigmoid/Left Colectomy Operative Times (mins) Incision (cm)86.01 LOS5.75.2NS Total Colectomy Operative Times (mins) Incision(cm) LOS6.98.9NS Marcello P, et al. Dis Colon Rectum 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 Jun;51(6):818-26

Complicated Diverticulitis HALS (n=21)Straight Lap (n=21) Operative Times (mins) Incision Length (cm)59 Conversion4%14%* LOS (days)65* Complications24%19%* Lee et al. Dis Colon Rectum Apr;49(4): *p=NS

Vogel at al. J Am Coll Surg Mar;212(3): Effective

The Unexpected Bleeding Stapler Misfire Difficulty identifying the lesion

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Operative Technique LAP HAL

Vogel at al. J Am Coll Surg 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 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