1. 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

2. Disclosures Paid Consultant for Ethicon Endo Inc.

3. Challenges

4. –BMI –Adhesions –Complicated Diverticulitis –pT stage –Left vs Right sided resections Delaney et al. Surg Endosc. 2005 Jan;19(1):47-54

5. Challenges Two skilled surgeons Experienced camera operator –Multi quadrant surgery Training

7. Hand Assisted Laparoscopy Not a Fad…. Not a Cult…. Not a Religion…. Not a Political Party….. Just a tool in the toolbox of MIS

8. 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?

9. 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

10. 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

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

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

13. HALS Long Term Outcomes Sonoda et al. J Am Coll Surg. 2009 Jan;208(1):62-6.

14. 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)

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

16. Conversions – Why? Cima et al. J Am Coll Surg. 2008 May;206(5):946-50

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

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

19. Effective HALSLAPP value Sigmoid/Left Colectomy Operative Times (mins) 175208.021 Incision (cm)86.01 LOS5.75.2NS Total Colectomy Operative Times (mins) 127184.015 Incision(cm)7.86.7.09 LOS6.98.9NS Marcello P, et al. Dis Colon Rectum. 2008 Jun;51(6):818-26

20. 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

21. Complicated Diverticulitis HALS (n=21)Straight Lap (n=21) Operative Times (mins) 177255 Incision Length (cm)59 Conversion4%14%* LOS (days)65* Complications24%19%* Lee et al. Dis Colon Rectum. 2006 Apr;49(4):464-9. *p=NS

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

23. The Unexpected Bleeding Stapler Misfire Difficulty identifying the lesion

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25. Operative Technique LAP HAL

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

28. Hand Assisted Right Colectomy

29. 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

30. 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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32. Thank You