Hand Assisted Laparoscopic Colorectal Surgery Biology Essay

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Laparoscopic colorectal surgery was first reported by Jacobs and colleagues in 1991 . After 2 decades of experience, hundreds of reports have appeared in the literature describing LAC techniques, complications, outcomes, and cost. Numerous comparative studies of LAC vs open colectomy for both benign and malignant conditions have demonstrated many short-term clinical benefits of LAC, including less postoperative pain, fewer wound and pulmonary complications, decreased need for blood transfusion, faster return of bowel function, and decreased hospital stay [2-3]. It is noteworthy that randomized controlled trials have shown equivalent oncologic outcomes [4].

Despite having all the benefits of laparoscopic surgery, adoption to LAC has been relatively slow in colorectal surgeon as well as general surgeon performing colorectal surgery across the world. It was estimated that LAC accounted for only less than 10% of colectomies [5]. The adaptation of the laparoscopic approach has not been as rapid for colectomy as it was for cholecystectomy for several reasons. First, laparoscopic colon surgery is associated with a steep learning curve because of the need to work in multiple abdominal quadrants on a mobile target, the ligation of substantial vascular structures, and the possible challenge of an intracorporeal anastomosis [6]. The estimated learning curve is between 25 and 60 cases, depending on the level of complexity [7]. For the majority of general surgeons, that number of colectomies would equal or exceed their annual colectomy volume.

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Hand-assisted laparoscopic surgery (HALS) is a technique that developed soon after the introduction of general abdominal laparoscopic surgery which seemingly bridges the gap between open and LAC and that might widen the appeal of benefits of laparoscopic surgery by rendering the procedure easier to perform. A porthole-like device is inserted in the abdominal wall and allows the surgeon's hand to be placed into the abdominal cavity while preserving pneumoperitoneum. The surgeon's hand can work in concert with standard laparoscopic cameras and instrumentation to assist in palpation, dissection, retraction, and easy control of bleeding, while the hand port (6 to 7 cm in length) serves as the extraction site for the specimen. The surgeon's intra-abdominal hand facilitates the operation, thereby increasing the ease.

This study aimed to describe the efficacy of HALS for segmental oncologic colon resection on the growth of a single institution's minimally invasive colorectal surgery. We evaluated the patient demographics, operation indication and type, operative times, intraoperative blood loss, incision length, length of hospital stay and intraoperative and short-term patient benefits of HALS colectomies performed within our institution.

Materials and methods

A prospectively maintained database was used to identify all patients who underwent HALS for colorectal cancer from July 1, 2009 to October 1, 2012 at Vilnius oncology institute. All the patients with histologically confirmed colorectal cancer of descending colon, sigmoid colon or upper rectum, age 18 years or older were included in this study. Patients with diagnosis of carcinoma in situ were excluded. There were no other exclusion criteria (former abdominal surgery etc.). All the patients were informed about the study and gave signed informed consent.

The electronic medical records of the patient hospital database were reviewed for patient demographics, indications for operation, the operation performed, operative times, and short-term (30-day) postoperative outcomes. Specific variables included age, sex, body mass index, operative indication, procedure, medical comorbidities, intra- and postoperative complications, conversion, operative time, estimated blood loss, time to return to gastrointestinal function, and length of hospital stay. Conversion to an open procedure was defined as lengthening of the incision more than what was planned to perform the procedure along with the specimen extraction. Length of hospital stay was defined as the number of nights the patient spent from the day of surgery. Return of GI function was defined as the postoperative day when the patient tolerated soft diet and passed stool. Descriptive data represent Data were presented as mean ± standard deviation unless otherwise specified. This project was approved by the Vilnius oncology institutional review board.

Surgical Techniques

Operations were performed in a standardized manner by two consultant surgeons. Under general anesthesia with patient in a supine horizontal position with legs stretched, body fixed to the operating table and operator standing between the stretched legs, a 6-6.5 cm trans-umbilical incision is performed for the Gelport (Applied Medical, Rancho Santa Margarita, CA, USA). The HALS resection was accomplished with the hand port and three additional ports (Fig. 1). Likewise, the location of the hand port and trocars as well as the port size was determined by each surgeon based on the location of the colonic lesion to be resected.

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Mobilization begins with the descending colon moving upwards to splenic flexure and left side of transverse colon, using hand and harmonic scalpel. After this part, the mobilization continues with the sigmoid colon, then lifting the rectosigmoid at the level of promontorium with superior rectal vessels. Continuous visualization of the left ureter is the critical part of the dissection. Then inferior mesenteric artery is mobilized and ligated using titanium 10 mm clips 1-2 cm from the aorta, and continuing mobilization of the inferior mesenteric vein and ligating it at the level of ligament of Treitz. The specimen is divided using endoscopic linear stapler, at the level of promontorium for left hemicolectomy / sigmoidectomy, and dividing it 5 cm below the lower edge of tumor in partial TME for upper third rectal cancer. Specimen is removed through the Gelport incision, and further anastomosis is performed laparoscopically using a double stapling technique, making water-air leak test and examining the rings from the stapler for integrity. Drain was routinely used only after anterior rectal resections and partial mesorectal excision, and removed on day 2 to 5. Fascia is closed at the level of 12 mm trocar with single interrupted suture, and hand port - with running PDS 0 suture. Skin incisions are closed with interrupted sutures.

RESULTS

Over a 36-month period 103 HALS colectomies were performed. Overall, patients were old-aged, an average age 64 ± 13.4 (32 -89) years. The male: female ratio was 1:1.2. BMI was normal 28.9 ± 5.8 (22 -36) kg/m2. ……….. percent of patients had cardiac, pulmonary, or renal comorbidity. All patients were operated for invasive colorectal cancer (stage I-IV). Diagnoses included sigmoid cancer 49 patients (47.6%), upper rectal cancer 42 patients (40.8%), mid rectal cancer 4 patients (3.9%), descending colon cancer 7 patients (6.8%), and splenic flexure cancer 1 patients (0.9%). ……….. percent of patients had prior abdominal surgery. (Table 1)

Table1. Patient demographics

Demographic variables

N=103

Age (years)*

64 ± 13.4 (32 -89)

Gender, M:F

46/57

BMI (kg/m2)*

28.9 ± 5.8 (22 -36)

Prior abdominal surgery

Medical comorbidities

Cardiac

Pulmonary

Renal

Diabetes

Others

*Mean ± SD (range)

Operative Details

The procedures performed were as follows: 42 patients (40.8%) anterior resection with PME (cancers in the rectum above 11 cm from the dentate line) performed, 40 patients (38.8%) left hemicolectomies, 15 patients (14.5%) sigmoid colectomies, 2 patients (1.9%) subtotal colectomy with ileorectal anastomosis.

The operative time, estimated blood loss, and intraoperative complications are detailed in Table 2. The mean operative time was 105 (range 55-185) minutes. Overall, a significant reduction of operative time for HALS was observed over the years. Intraoperatively, 13 patients (12.6%) received blood products. Intraoperative complication was encountered in two patients (1.9%).They had positive air-leak test and anastomotic defect in a staple line after partial mesorectal excision for upper rectal cancer, demanding additional interrupted single layer sutures. Three of our patients (2.9%) required conversion to open laparotomy: one due to T4 upper rectal cancer penetrating in to the left ovary, one due to cancer localized in splenic flexure (preoperatively diagnosed as descending colon cancer) and one due to massive adhesions The average lymph node harvested in specimen was 16 (3 - 40). Average length of specimen resected was 19.5 cm (8 to 95 cm). Tumor stage was as follows: stage I - 27 (26.2%), stage II - 29 (28.1%), stage III - 39 (37.9%) and stage IV - 9 (8.7%). (Table 2)

Two patients underwent subtotal colectomy and ileorectal anastomosis: one because of familial adenomatous polyposis and sigmoid cancer, second due to multiple polyps in transverse and right colon with descending colon cancer. Two patients underwent HALS sigmoid colectomy 9 and 10 days respectively after same type laparoscopic procedure with sigmoid colotomy and polypectomy for large sigmoid adenomas with high-grade dysplasia, which in surgical specimen histology turned out to be T1 sigmoid cancer; none had residual or lymph-node disease in final pathology.

Table2. Operative details

Operative details

N=103

Operative time (minutes)*

105 (55-185)

Estimated blood loss (mL)*

120 (60-270)

Intraoperative complications

2 (1.9%)

anastomotic defect in a staple line

Conversion

3 (2.7%)

Adhesion

1 (.9%)

Oncologic reason

1 (.9%)

Unexpected finding

1 (.9%)

Tumor stage

Stage I

27 (26.2%)

Stage II

29 (28.1%)

Stage III

39 (37.9%)

Stage IV

9 (8.7%)

* Mean ± SD (range)

Short-term (30-Day) Outcomes

Short-term (30-day) outcomes are reported in Table 3. The median length of hospital stay was 9 days. The postoperative hospital length of stay ranged from a minimum of 3 days to a maximum of 31 days. The median of return of GI function was 2.5 (2.2-4.5) days. Type of operation, complications, managements and outcome are detailed in Table 4.

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Postoperative complications occurred in 11 (10.7%) cases. Only two patients (1.9%) (Patient with anastomotic leakage and patient with bowel perforation above the anastomotic line and paracolic abscess) demanded reoperation. There was only one mortality in this study, a 78 year old patient underwent partial TME for stage III upper rectal cancer, died from septic pneumonia in the intensive care unit on 7th postoperative day.

Follow up

There were ….. incisional hernias seen on a mean follow-up of …… years. None of the patients with colorectal cancer had trocar or hand-port site recurrence.

Table3. Short term (30days) outcomes

Short term outcomes

N=103

Length of stay, Days**

9 (3-31)

Return to GI function, Days**

2.5 (2.2-4.5)

Postoperative complications

11 (10.7 %)

**Median (range)

Table4. Type of operation, complications, managements and outcome

Type of operation

Complications

N=103

Management

Outcome

PME

Suture dehiscence

(anastomotic leak)

1(0.9%)

Relaparotomy, lavage, covering ileostomy

Recovered

Left hemicolectomy

Perforation above the suture line with paracolic abscess

1(0.9%)

Relaparotomy, drainage of the abscess, covering ileostomy

Recovered

PME

Urinary retention

2(1.9%)

Epicystostomy

Recovered

PME

Bleeding from the anastomotic line

1(0.9%)

Conservative

Recovered

Subtotal colectomy with ileorectal anastomosis

Stroke

1(0.9%)

Conservative

Recovered

PME

Myocardial infarction

1(0.9%)

Conservative

Recovered

Left hemicolectomy

Subacute intestinal obstruction

3(2.7%)

Conservative

Recovered

PME (conversion to open)

Septic pneumonia

1(0.9%)

Conservative

Died

Discussion

The indications of HALS are extended successfully for broad range of disease. Although used for all types of colectomies, segmental colectomies represented the most common procedure with a significant percentage being left sided or rectal resections [8]. As our institution is a tertiary oncological center, the most of our HALS cases were operated for malignant diseases. The patients with descending colon, sigmoid and upper rectal cancer are ideal candidates for this technique. This is attributed to fact that left sided colonic cancers are more common than right sided once in our area. Furthermore, most right sided tumors are dealt with by general surgeons in nearby secondary general hospitals, while left sided and especially rectal cancer are usually referred to our institution for management. Although in literature, HALS for right hemicolectomy, we do not use this approach for right hemicolectomy, as we do not see much advantage there, as anastomosis is done extracorporeal after right hemicolectomy.

With the increasing experience, we performed HALS for more complex colon procedures, including subtotal and total colectomies. Also, the operative times decreased significantly with increased experience. The 30-day short-term outcomes are comparable to outcomes in the laparoscopic-assisted colectomy literature [2].

Our findings are similar to those of others, who have reported decreased operative times for HALS compared with LAC, while maintaining many of the short-term outcomes benefits and morbidity as compared with LAC [9-11].

In an attempt to broaden the horizon of laparoscopic abdominal surgery, HALS was introduced in the mid-1990s. Although this technique was met by fierce resistance by the laparoscopic community, it is now gaining the popularity as adjunct and a bridge towards total laparoscopic colorectal surgery [12]. In the comparison of the short-term patient outcomes of HALS colectomy and LAC (i.e. length of stay, return of bowel function, and postoperative complications) are similar, as shown in a meta-analysis of HALS colectomies studies [13].The conversion rate is less suitable variable for a HALS analysis as conversion is required infrequently. The conversion rate in our study (2.7%) is decreased, in comparison to 3-12% reported in various studies [13, 14].

In this study, we found that our short term complication rate are similar to those published in the HALS studies and are comparable to the reported LAC experience [13-15]. However, there were significant differences, including decreased operative times and fewer converted procedures, in the HALS cases. In a multicenter, prospective, randomized trial comparing HALS and LAC for left sided segmental and total colectomies, there were significant reductions in operative times for both segmental and total colectomies [16]. In the present study, we observed a significant reduction in operative times for all types of procedures over the study period.

We inserted the HALS device in the midline because the mobilized colon is a midline structure. It also keeps the lateral abdomen free of incisions should an ostomy ever become an issue, and it allows for easy conversion to an open procedure if necessary. In fact, most of the conversions in this stud only required a small extension of the HALS incision.

The cost of a new technology needs to be considered in the current health care system. The economic consideration of LAC and HALS colectomy has been analysed in various studies [17, 18]. In a comparative study of 100 HALS colectomies to LAC demonstrated that, although the costs of operating room supplies were higher in the HALS cases, there was no difference in the hospitalization costs [17]. In most institutions where operating room costs are allocated in fractions of an hour, a 30- to 60-minute decrease in operating time could represent a significant financial savings for institutions.

There was no trocar site or HAL incision site recurrence in any of our patients. Although trocar site recurrence is a concern [19], a recent prospective study comparing laparoscopic with open colectomy for cancer does not show any difference in survival between the two groups [20], and a randomized multi-center trial demonstrated oncological noninferiority for the laparoscopic approach [4]. Most HAL devices function as a wound protector, which should theoretically protect the HAL wound from tumor implantation.

The long term complication of HALS has been the center of recent debate. It has been postulated that continuous and persistent stretch of the port site may predispose to the development of incisional hernia. Furthermore, placement of hand in the abdomen in HALS increases the risk of postoperative ileus, development of intraabdominal adhesions with future risk of small bowel obstruction [21]. In our series with follow up of ….. months, there was no postoperative ileus and incisional hernia.

Inspite of its major limitation as a descriptive review study of an electronic maintained database, this study, a diverse colorectal practice over more than 3 years, provide discernment into the applicability and outcome of HALS to colorectal resections. HALS technique has provided all the benefit of a minimal invasive surgery for the patients undergoing colorectal resections. We have detailed short term and long-term follow-up for nearly all our surgical patients.

Conclusion

we have found that the operative time for HALC decreased as operative experience was gained. For quality-related outcome, there was no learning curve. Rather, acceptable HALC outcomes were achieved from the outset. Thus, concerns about initial quality-related outcomes should not be a deterrent to surgeons who are considering the adoption of this technique.