hand-assisted laparoscopic versus open right hemicolectomy short-term outcomes

Hand-assisted Laparoscopic Versus Open Right Hemicolectomy:Short-term Outcomes in a SingleInstitution From ChinaQin-Song Sheng,MD,Jian-Jiang Lin,MSc,Wen-Bin Chen,MD,Fan-Long Liu,MD, Xiang-Ming Xu,MD,Cai-Zhao Lin,MD,Jin-Hai Wang,MSc,and Yan-Dong Li,MScAim:To compare the perioperative parameters and short-term outcomes of hand-assisted laparoscopic colectomy(HALC)and open colectomy(OC)for the treatment of patients with cancer of the right hemicolon.Methods:Patients who were scheduled to perform right hemi-colectomy between August2009and December2010were randomized into either HALC or OC group.Patients were ex-cluded if they had synchronous cancers,hepatic metastases,acute intestinal obstruction,or intestinal perforations.All the operations in the2groups were performed by a single surgical team.Measured outcomes included the demographic variables and perioperative parameters.The former included age,sex,body mass index, American Society of Anesthesiologists class,prior abdominal surgery,distribution of tumors,and histopathologic stage;whereas the latter included length of incision,operative time,estimated blood loss,conversion rate,number of lymph nodes retrieved, postoperative pain score,time to return of bowel function, postoperative complications,duration of hospital stay,and total cost.Results:One hundred sixteen patients with cancer of the right hemicolon(HALC=59,OC=57)were recruited.The2groups of patients were similar in age,sex distribution,body mass index, American Society of Anesthesiologists class,and previous ab-dominal surgery.No significant difference was observed between the2groups in terms of distribution of tumors and thefinal his-topathologic staging.HALC had a significantly shorter incision length and longer operative time than OC.Patients in the HALC group had significantly less operative blood loss,less pain and earlier passage offlatus after operation than those in the OC group. The number of lymph nodes recovered in the specimen and the overall postoperative complications was comparable in the2 groups.The postoperative duration of hospital stay was sig-nificantly shorter in the HALC group,whereas the median overall costs in the HALC group were significantly higher than that in the OC group.Conclusions:The results from the present study demonstrate that the HALC is a valid surgical approach for cancer of the right hemicolon that retains the benefits of minimally invasive surgery. We believe that this technique is a safe,useful,and feasible method for patients with right-sided colonic cancer.If practiced more,it might be advocated as a“bridge”between traditional laparoscopic surgery and conventional open procedures.Key Words:hand-assisted laparoscopic surgery,hand-assisted laparoscopic colectomy,open colectomy,colon cancer,laparo-scopic colorectal surgery(Surg Laparosc Endosc Percutan Tech2012;22:267–271) S ince its initial introduction in1991,1–3laparoscopic colorectal surgery has already confirmed its particular benefits including minimal trauma,less operative blood loss,decreased postoperative pain,earlier ambulation, faster recovery of bowel function,shorter length of stay in hospital as well as reductions in stress and immuno-suppression.4–6But,on the other hand,some deficiencies have been raised regarding the lack of tactile feedback,the prolonged operative time,the steep learning curve,the cost effectiveness of laparoscopic techniques,and the potential for port site recurrence of tumor.7–9Hand-assisted laparo-scopic surgery(HALS),a relatively new hybrid minimally invasive surgical(MIS)technique that emerged in the mid 1990s,can be introduced as a useful alternative to totally laparoscopic procedures.10In HALS,it allows the surgeon to insert the nondominant hand into the abdominal cavity through a special hand port and assist the laparoscopic instruments directly while maintaining the pneumoperitoneum. Using laparoscopic visualization and instrumentation,the sur-geon’s hand can assist with retraction,dissection,and hemo-stasis.In addition,the hand-access device incision serves as the specimen extraction site.Because of its combined advantages of both laparoscopic(minimally invasive)and conventional open surgery,increasingly more studies have demonstrated its feasi-bility in the completion of various laparoscopic procedures such as gastrectomy,nephrectomy,splenectomy,colectomy, and liver resection.11–13With regard to colectomy,preliminary outcomes of hand-assisted laparoscopic colectomy(HALC)are encouraging,which confirm that HALC is a safe,minimally invasive,and feasible technique.5,6,10,14Although there are a number of studies in surgical literature evaluating this techni-que,especially in the context of colon cancer,little has been reported on the comparison of HALC and conventional open colectomy(OC)in right hemicolectomy.8With the above background,we conducted a pro-spective randomized trial in a single institution to compare the perioperative parameters and outcomes of HALC and OC for the treatment of patients with cancer of the right hemicolon.To our knowledge,no such prospective randomized trial from Chinese mainland has been pub-lished to date.Received for publication July7,2011;accepted February21,2012.From the Department of Colorectal and Anal Surgery,The FirstAffiliated Hospital of College of Medicine,Zhejiang University,Zhejiang,China.The authors declare no conflicts of interest.Reprints:Jian-Jiang Lin,MSc,Department of Colorectal and AnalSurgery,The First Affiliated Hospital of College of Medicine,Zhejiang University,Zhejiang310003,China(e-mail:linjjzju@).Copyright r2012by Lippincott Williams&WilkinsO RIGINAL A RTICLESurg Laparosc Endosc Percutan Tech Volume22,Number3,|267PATIENTS AND METHODSPatient Selection,Preoperative Preparationand the Criteria for DischargePatients who were scheduled to perform right hemi-colectomy with ileocolic anastomosis between August2009 and December2010were enrolled into the study.The en-rolled patients were randomized into2treatment groups, either HALC or OC,according to a predetermined scheme using random numbers.To ensure a homogenous group of patients and to facilitate comparison of the2different techniques,only patients with tumor located in the cecal or ascending colon or hepaticflexure of colon were studied. Patients were excluded if they had synchronous cancers, hepatic metastases,acute intestinal obstruction,or in-testinal perforations.Preoperative chest x-ray and transabdominal ultraso-nography were routinely performed to exclude pulmonary and hepatic metastasis.Abdominal enhanced computed tomography was also used in patients routinely,both to measure the size of the lesion and to assess extramural in-vasion,distant metastasis,and its resectability.Colono-scopy and biopsy are of vital importance for the diagnosis of patients.Patients were put on a liquid diet the day before operation and underwent preoperative mechanical bowel preparation the night before surgery.The study protocol was approved by the hospital ethical committee and all patients and their families gave written informed consent for participation in the study.The criteria for patients’discharge included no fever, no abdominal pain,recovery of bowel function,intaking liquid diet or semiliquid diet,and good wound healing.Surgical ProceduresHALC GroupIn HALC,the patient was placed in the supine posi-tion.A6.0-cm midline incision of3-finger breadth around umbilicus wasfirst made for placement of the hand port (Lap-Disc;Ethicon Endo-Surgery)(Fig.1).A12-mm tro-car for301telescope was next created in the right mid-clavicular line at the level of umbilicus and,after establishment of pneumoperitoneum,another10-mm trocar for harmonic scalpel was inserted3to4cm below the xiphoid process under direct vision.The chief surgeon stood to the left of the patient, using his left(nondominant)hand for retraction and dis-section.The assistant surgeon stood to the right of the patient for providing a good view with the telescope(Fig.2).Routine exploration was made including liver,stomach,and peritoneal surfaces.A medial to lateral dissection was performed with harmonic scalpel as in open surgery.Cecal,ascending colon, and proximal transverse colon(including hepaticflexure)were mobilized before division of ileocolic,right and middle colic vessels at the mesenteric base.Then the ileocolic and right colic vessels and right branch of middle colic vessel were dis-sected.After this,pneumoperitoneum was abolished and the mobilized right hemicolon was brought out through the hand port.Extracorporeal ileotransverse side-to-side anastomosis was then operated with linear cutter stapler(Ethicon Endo-Surgery)55mm or75mm and the mesenteric defect was closed.Finally,a suction drain was inserted into the pelvis,and the abdominal wall wounds were closed layer by layer.OC GroupIn OC,the patient was also placed in the supine po-sition and the operation was carried out in a standard manner.A midline incision of about15to20cm was made and then a medial to lateral dissection was performed.The right-sided colon was mobilized before mesenteric division and the same vessels were dissected sequently.Ileotrans-verse side-to-side anastomosis was operated as well with linear cutter stapler(Ethicon Endo-Surgery)55mm or 75mm and the mesenteric defect was closed. Measured OutcomesThe2groups were compared with respect to demo-graphic variables and perioperative parameters.The former included age,sex,body mass index(BMI),American So-ciety of Anesthesiologists class,prior abdominal surgery, distribution of tumors and histopathologic stage;whereas the latter included length of incision,operative time,esti-mated blood loss,conversion rate,number of lymph nodes retrieved,postoperative pain score,time to return of bowel function,postoperative complications,duration of hospital stay,and totalcost.FIGURE1.A6.0-cm midline incision of3-finger breadth around umbilicus was first made for placement of the handport.FIGURE2.A12-mm trocar for301telescope was next created in the right midclavicular line at the level of umbilicus,and after establishment of pneumoperitoneum another10-mm trocar for harmonic scalpel was inserted3to4cm below the xiphoid process under direct vision.The chief surgeon stood to the left of the patient using his left(nondominant)hand for retraction and dissection.The assistant surgeon stood to the right of the patient for providing a good view with the telescope.Sheng et al Surg Laparosc Endosc Percutan Tech Volume22,Number3,June2012 268| r2012Lippincott Williams&WilkinsStatistical AnalysisData were shown as mean±SD.Statistical analysis was performed with independent-samples t tests(meas-urement data)or w2test(enumeration data)where appro-priate.SPSS statistical software13.0was used to conduct analysis.For all analyses,a P value of<0.05was consid-ered statistically significant.RESULTSOne hundred sixteen patients with cancer of the right hemicolon(HALC=59,OC=57)were included in the study.All the operations in the2groups were performed successfully by a single surgical team.There was no con-version to OC for patients undergoing the HALC proce-dure in the present study.Demographic variables of these patients and the tu-mors were listed in Table1.The2groups of patients were similar in age,sex distribution,body mass index,American Society of Anesthesiologists class,and previous abdominal surgery.No significant difference was observed between the 2groups in terms of distribution of tumors and thefinalhistopathologic staging.The perioperative parameters of the2groups were presented in Table2.Incision length in the HALC group was significantly shorter than that in the open approach. HALC had a significantly longer operative time than OC. Patients in the HALC group had significantly less operative blood loss than those in the OC group.The number of lymph nodes recovered in the specimen was comparable in the2groups.Patients after HALC experienced significantly less pain and earlier passage offlatus after operation than those after OC.The overall postoperative complications were comparable in the2groups.The postoperative dura-tion of hospital stay was significantly shorter in the HALC group than that in the OC group;whereas the median overall costs in the HALC group were significantly higher than that in the OC group.All patients were followed up in the surgical clinic.The median follow-up periods for the HALC and OC groups were(13.3±4.6)months.In this duration of follow-up, there was no local recurrence and port site metastasis of tumor in either group.DISCUSSIONSurgeons who perform colectomy are now faced with a variety of operative techniques that they can choose from. In addition to open surgery,conventional and hand-assisted laparoscopy,single-port laparoscopy,robotic,and laparoscopy with natural orifice specimen extraction must also be considered.15HALS is a newly developed and hy-brid endoscopic technique incorporating elements of both laparoscopic technique and traditional open technique.The most suitable operations for HALS are those that require extraction of a specimen and therefore necessitate an in-cision anyway.16In colorectal procedures an incision is often required for extraction of the specimen,so it is a naturalfit for HALS.The most important advantage of HALS is that the surgeon regains tactile feedback.Sur-geons can palpate the tumor and the lymph nodes can also be used for blunt dissection,retraction,control of bleeding, and organ removal.14Many studies demonstrate that the HALS technique is a valid surgical approach for colorectal resection and offers similar short-term and long-term MIS benefits such as laparoscopic-assisted procedures,while being less techni-cally demanding,with shorter learning curve for less experienced surgeons and lower conversion rate to OC.6,10,15,17,18Moreover,a recent systematic review sug-gests that HALS has the advantages of laparoscopic sur-gery over open surgery while reducing some of the disadvantages of laparoscopic surgery.5Patients in the HALS group had clear benefits from the combination of smaller incisions,less intraoperative blood loss,less pain, and a more rapid recovery of gastrointestinal function. These combined factors are very likely to have led to the shorter duration of hospital stay in the HALC group compared with the OC group.5,7,8The location of the incision depends on the target organ and on whether the surgeon is left-handed or TABLE1.Demographic Variables of the Patients and the Tumors in2GroupsVariablesHALC(n=59)OC(n=57)P Age(y)62.4±12.864.6±14.20.380 Sex(M:F)32:2735:220.435 BMI21.7±2.322.2±2.80.243 ASA class(I:II:III)24:29:623:29:50.962 Previous abdominal surgery430.732 Distribution of tumors(hepaticflexure:ascendingcolon:cecum)26:13:2128:15:140.463Staging of tumors(AJCC)I7110.269 II25240.977 III27220.435 IV00—BMI indicates body mass index;HALC,hand-assisted laparoscopic colectomy;OC,open colectomy.TABLE2.The Perioperative Parameters of the Patients in2 GroupsVariablesHALC(n=59)OC(n=57)P Incision length(cm) 6.1±0.219.2±3.30.000 Operative time(min)138±30113±330.000 Operative blood loss(mL)110±60136±630.023 Conversion rate0——Number of lymph nodes14.4±5.414.0±5.60.690 Postoperative pain score 3.1±1.1 5.9±1.00.000 First passage offlatus(h)46.1±8.376.6±7.40.000 Duration of hospital stay(d)8.3±1.412.1±4.00.000Overall cost(RMB)36,200±699332,544±97740.022 Postoperativecomplications470.357 Anastomotic leakage00—Wound infection140.203 Ileus210.579 Chest infection120.538 Intra-abdominal sepsis00—HALC indicates hand-assisted laparoscopic colectomy;OC,open colectomy.Surg Laparosc Endosc Percutan Tech Volume22,Number3,June2012HALC Versus OC in Right Hemicolectomy r2012Lippincott Williams&Wilkins |269right-handed.In other studies,the incision was made in the left or right iliac fossa or in the suprapubic region.7How-ever,in the present study,an incision of3-finger breadth for the HALS device,the minimum size that permitted in-sertion of the surgeon’s hand into the peritoneal cavity,was made in the midline around umbilicus because:(1)the mobilized colon is a midline structure and there is good access to the right and left sides from the midline19;(2)it allows for easy conversion to an open procedure with a simple extension if necessary;(3)it also allows a general exploration during surgery and provides an excellent cos-metic result after surgery.As far as the operative time is concerned,our study showed that the HALC group still took significantly longer time than the OC group.This outcome was in agreement with the literature reviews.5However,the increase of 25minutes in our study is unlikely to have significant im-pact on patients clinically or on the consumption of theater time in clinical practice.The operative time of HALC group was still acceptable.Moreover,with the improvement of operation skill and cooperation,the operative time will decrease.Conversion was defined as a lengthening of the surgi-cal incision beyond what was normally required to com-plete the operation by the HALS or laparoscopic-assisted technique.Because of the characteristic of the HALS, where the procedure can be“converted”to an open mode through the hand port without making a larger incision, low conversion rates were observed in the prior studies.The reported conversion rate of HALC varies from0%to 10%,5whereas in published laparoscopic colorectal series, the rate of conversion to open surgery varies from17%to 42%.7In the present study there was no conversion to open surgery for patients undergoing the HALC procedure.Based on the reviewed literatures,there was no sig-nificant difference in short-term postoperative complica-tions such as anastomotic leak and ileus and wound infection between HALC group and OC group.7,8,10,14In the present study,the2groups had comparable post-operative complication rate.We found that the rate of wound infection in OC group was a little higher than that in HALC group,although there was no statistical significance. The reasons were probably associated with the shorter in-cision in HALC and the protection of hand-port device. During HALC,the hand-port device was used as a wound protector and all the specimen extractions and bowel anastomoses were performed through this device.Despite the above advantages provided by the HALS technique,there still were several limitations.(1)With re-gard to the overall cost of the HALC procedure,several studies concluded that the total costs of HALC and lapa-roscopic colectomy were similar and that costs of HALC should not be a deterrent to its use.10,20In our study,be-cause of the cost of hand port,trocars,and other devices, the average overall cost of HALC group was higher than that of OC group.However,Maartense et al21reported that although the cost for the surgical procedure was higher in the HALC group than that in OC group,overall costs were comparable.(2)The study of Kang et al7suggested that the effort needed to maintain the pneumoperitoneum by the hand port can cause wrist and forearm constriction,re-sulting in numbness and fatigue of the surgeon’s hand. In the present study,the chief surgeon experienced hand fatigue during some procedures which could be related to the size of the skin and fascial incision,the operative time,and the location and size of the tumor.(3)It is also speculated that the increased handling and mobilization of the bowel will result in the development of postoperative ileus and intra-abdominal adhesions.Moreover,there is uncertainty about the long-term results such as develop-ment of adhesive small bowel obstruction.10In conclusion,we present a prospective randomized single-institution trial that compared the short-term out-comes of HALC and OC for the treatment of patients with cancer of the right hemicolon.The results from the present study demonstrate that the HALS technique is a valid surgical approach for cancer of the right hemicolon that retains the benefits of MIS.The HALC procedure is asso-ciated with smaller incision,less operative blood loss,less postoperative pain,earlier passage offlatus after operation, and shorter duration of hospital stay than traditional OC. 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