Comparison of conventional laparoscopic and hand-assisted oncologic segmental colonic resection
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- Ringley, C., Lee, Y.K., Iqbal, A. et al. Surg Endosc (2007) 21: 2137. doi:10.1007/s00464-007-9401-y
Laparoscopically assisted colon resection has evolved to be a viable option for the treatment of colorectal cancer. This study evaluates the efficacy of hand-assisted laparascopic surgery (HALS) as compared with totally laparoscopic surgery (LAP) for segmental oncologic colon resection with regard to lymph node harvest, operative times, intraoperative blood loss, pedicle length, incision length, and length of hospital stay in an attempt to help delineate the role of each in the treatment of colorectal cancer.
Patient charts were retrospectively reviewed to acquire data for this evaluation. Between June 2001 and July 2005, 40 patients underwent elective oncologic segmental colon resection (22 HALS and 18 LAP). The main outcome measures included lymph node harvest, operative times, intraoperative blood loss, pedicle length, incision length, and length of hospital stay.
The two groups were comparable in terms of demographics. The tumor margins were clear in all the patients. The HALS resection resulted in a significantly higher lymph node yield than the LAP resection (HALS: 16 nodes; range, 5–35 nodes vs LAP: 8 nodes; range, 5–22 nodes; p < 0.05) and significantly shorter operative times (HALS: 120 min; range, 78–181 min vs LAP: 156 min; range, 74–300 min; p < 0.05). Both groups were comparable with regard to length of hospital stay, pedicle length, and intraoperative blood loss. However, the LAP group yielded a significantly smaller incision for specimen extraction (LAP: 7 cm; range, 6–8 cm vs HALS: 5.5 cm; range, 5–7 cm; p < 0.05).
The findings suggest that hand-assisted laparoscopic oncologic segmental colonic resection is associated with shorter operative times, more lymph nodes harvested, and equivalent hospital stays, pedicle lengths, and intraoperative blood losses as compared with the totally laparoscopic approach. The totally laparoscopic technique was completed with a smaller incision. However, this less than 1 cm reduction in incision length has doubtful clinical significance.
KeywordsBowelClinical papers/trials/researchColorectal cancerSurgical technicalTechnical
Minimally invasive approaches to diseases requiring surgery have grown in popularity since the inception of minimally invasive surgery for cholecystectomy in the early 1990s . Likewise, in the same period, it was conceived that these techniques also could benefit those undergoing colectomy . Since that time, multiple investigations have suggested that laparoscopic colectomy is associated with reduced postoperative pain, shorter hospitalization, and faster return to bowel function and normal daily activities than the open approach [2, 14].
The acceptance 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 creation of an intestinal anastamosis [16, 19]. In addition, there were several oncologic concerns when this approach was considered for colon cancer [1, 3, 9, 15].
A recent prospective, multi-institutional, randomized study was conducted to evaluate oncologic outcomes of laparoscopic verses open colectomy for cancer . The resultant data showed that the laparoscopic approach is an acceptable alternative to open surgery for colon cancer based on recurrence rates after 3 years of follow-up evaluation. This enables a wider application of minimally invasive techniques for colorectal surgery.
However, the high degree of technique skill and extensive experience required remains a hurdle for many surgeons to overcome before offering their patients laparoscopic colectomy. Hand-assisted laparoscopic surgery allows the surgeon to place a hand within the abdominal cavity, thus easing the transition from open colectomy to the minimally invasive approach and blunting the aforementioned learning curve. Previous investigations have demonstrated that the benefits associated with totally laparoscopic colon resection are not lost with the application of the hand-assisted technique for benign colonic disease [8, 11].
Identifying lymph node metastases is both prognostically and therapeutically important in the treatment of colon cancer. Some debate exists with regard to the number of nodes sufficient for accurate staging of this disease [7, 10]. Currently, it is recommended that at least 12 mesenteric lymph nodes be harvested and pathologically evaluated [4, 12]. Some existing data suggest that a minimum number should not be adopted because the likelihood of identifying a positive node increases as more nodes are examined .
This study aimed to evaluate the efficacy of hand-assisted laparoscopic surgery (HALS) as compared with the totally laparoscopic surgery (LAP) for segmental oncologic colon resection in terms of lymph nodes harvested, operative times, intraoperative blood loss, incision length, and length of hospital stay. We aimed to ensure that a sufficient number of lymph nodes are obtained for staging and that the HALS technique retain the benefits of minimally invasive colectomy as it pertains to colon cancer.
Materials and methods
A retrospective analysis of the medical record was performed for all the patients undergoing a laparoscopic segmental colonic resection for colon cancer between June 2001 and July 2005 at a single institution. All the cases were managed over the same period. The inclusion criteria specified patients 18 years old or older requiring segmental colon resection with oncologic intent including tumor margins and lymph node harvest. Low anterior, abdominal peroneal and transverse colonic resections were not included in this evaluation. Three cases in which laparoscopic procedures converted to open colectomies (two right and one left, two LAP and one HALS colectomy; in all cases the indication for conversion to open surgery was firm adhesion to the lateral wall) also were excluded from the analysis. In addition, none of the patients in this evaluation had stage IV disease. The surgeries were performed by four surgeons involved in this study, none of whom were experienced in the LAP or HALS procedure previously.
All the subjects underwent preoperative mechanical bowel preparation followed by segmental oncologic colonic resection and anastamosis using either a traditional laparoscopic approach involving a counterincision isolated with a wound protector for specimen extraction or HALS with early hand insertion and specimen extraction via the hand port. The choice to use either HALS or LAP colectomy was made by each surgeon on a case by case basis. Each surgeon chose the technique on the basis of individual preference, and each surgeon practiced both techniques.
When comparing the groups, we could not tell any significant difference between the two techniques that would have made the surgeon choose the one over the other. Although this was not borne out by either time of surgery or patient characteristics, I suspect the surgeons chose HALS when they anticipated more difficult operations and LAP when they anticipated easier operations.
The Gelport (Applied Medical, Rancho Santa Margarita, CA, USA) was the hand port used for the HALS procedures during the data collection period. For the LAP technique, typically four ports were used, with one of the port sites enlarged for specimen extraction. The HALS resection was accomplished with the hand port and three additional ports. 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. There were four cases with previous abdominal surgery. The hepatic flexure was mobilized in all right colectomies. The splenic flexure was mobilized in 5 of the 11 left colectomies in the HALS group and 2 of the 7 left colectomies in the LAP group. The intestinal anastamosis was completed extracorporally after ligation of the vascular pedicle intracorporally in all cases.
The subjects were allowed to have a clear liquid diet immediately after surgery. Once the patients were tolerating a liquid diet, passing flatus, and experiencing adequate pain control with oral analgesics, they were discharged from the hospital to be seen back for follow-up assessment in 10 to 14 days. Prolonged postoperative ileus was defined as a lack of flatus for more than 4 days postoperatively.
At our institution, lymph nodes are identified in the specimen via a standard manual dissection method without the use of clearing solutions or ancillary techniques. Pathology residents perform this dissection on unfixed or minimally fixed specimens. The length of the pedicle was obtained from the surgical pathology report, as indicated by the middle number (yellow-gold pericolonic adipose tissue example, 15.0 × 7.0 × 2. 0 cm).
The two groups were compared with respect to the number of lymph nodes harvested, operative times, intraoperative blood loss, pedicle length, incision length, length of hospital stay, and segment of colon resected. In addition, patient demographic data including age, gender, body mass index (BMI), and previous surgery were recorded and compared between the two groups.
Statistical analysis was performed using the SPSS statistical program. The nonparametric two-independent-samples test was used to ascertain any statistical difference between the two groups, as represented by a p value less than 0.05.
Patient demographics and proceduresa
HALS (n = 22)
LAP (n = 18)
Median age: years (range)
Median BMI (range)
Previous Surgery (n)
In the HALS group, 3 of the 22 patients had undergone previous surgery, as compared with 1 of the 18 patients in the LAP group (Table 1). The operative time for these patients exceeded the median.
HALS (n = 22) n (range)
LAP (n = 18) n (range)
Lymph node harvest
Operative time (min)
Estimated blood loss (ml)
Incision length (cm)
Length of pedicle (cm)
The HALS resection was associated with a significantly higher lymph node harvest than the LAP resection (Table 2). Of the 22 patients undergoing hand-assisted colectomy, 17 had 12 or more lymph nodes pathologically evaluated, with 68% yielding 15 or more nodes. Only eight LAP resections (44%) produced 12 or more lymph nodes, including three (17%) with 15 or more nodes.
The findings showed no significant difference in the pedicle length between the two groups. The pedicle length taken by Hals was slightly longer than the one taken by LAP but this was not statistically significant (Table 2).
Over the past decade, the use of minimally invasive techniques has increased in general surgery. Procedures such as laparoscopic cholecystectomy, antireflux surgery, and ventral incision herniorrhaphy have been refined and shown to be comparable with open surgery, with the result that the minimally invasive approach currently is favored. However, the application of these techniques to colorectal surgery has been embraced much less rapidly.
This lag is a result of several complicating factors. First, laparoscopic colorectal resections can be technically demanding and difficult to learn and teach [16, 19]. Second, there have been several oncologic concerns about laparoscopic colorectal surgery for cancer, namely, the adequacy of resection based on whether a satisfactory number of lymph nodes are obtained for accurate staging, port-site recurrences, and whether acceptable distal and proximal margins are achieved [1, 3, 9, 15].
These issues have been addressed in the form of multiple investigations showing that laparoscopic procedures for benign colorectal disease are safe, effective, and typically associated with reduced postoperative pain, shorter hospital stays, and faster return of bowel function leading to a more rapid total recovery for the patient [2, 14].
However, the technical difficulty implicit with laparoscopic colectomy has limited its availability to patients whose surgeon has significant experience in advanced minimally invasive techniques . The HALS technique has been suggested to ease the transition from open surgery to laparoscopic surgery by blunting the learning curve .
With the HALS technique, the surgeon has the ability to insert a hand into the abdominal cavity, thus restoring tactile sensation and facilitating both blunt dissection and organ retraction. The aforementioned characteristics may reduce conversion rates, quoted by some as 20% to 30%, and may allow for difficult resections to be performed with the retention of the minimally invasive benefits [3, 8, 18]. It also is important to note that because most laparoscopic colorectal procedures require an incision for specimen extraction, the incision required for hand insertion adds little to the morbidity of the operation.
A recent multi-institutional randomized prospective investigation comparing laparoscopically assisted and open colectomies for colon cancer has been published . It was noted in this evaluation that the rates for recurrent cancer were similar between the laparoscopically assisted and open colectomy groups, indicating that the laparoscopic approach to colectomy for cancer does not have adverse oncologic consequences.
These recent data, in addition to data from other smaller studies, indicate that the laparoscopic approach is an acceptable alternative to open surgery for colon cancer, enabling the application of minimally invasive techniques toward curative resections of colorectal cancer, and that a substantial number of colorectal cases are managed in the United States per year [6, 12].
In this evaluation, we compared HALS to LAP segmental colonic resections with oncologic intent. Our data suggest that the HALS resection was accomplished with significantly shorter operative times than the LAP resection, which is congruent with other studies . We contend that the operative times in this study are not a result of a discrepancy in the type of procedure performed between the two groups because 11 right hemicolectomies were performed in the HALS group and 11 in the laparoscopic group, with a higher percentage of splenic flexure mobilizations performed in the hand-assisted group.
In addition, there was no statistically significant difference between the ages of the two groups and, more importantly, no difference in the BMI between the two groups. This alleviated the bias of obesity, found by others to increase the technical difficulty of laparoscopic colectomy . However, the operative time for the patients with previous abdominal surgery exceeded the median in all cases.
With respect to the length of hospital stay, we found no significant difference between the HALS and LAP groups. Two patients in the HALS group experienced prolonged hospitalization, the longest being 11 days secondary to postoperative ileus. Likewise, two patients in the LAP group had prolonged hospital stays, the longest being 14 days, again, secondary to postoperative ileus.
These findings suggest that the addition of a hand port did not negate the benefits of laparoscopic colectomy, which is in accordance with other published data [8, 11]. Although not measured directly in this investigation, several published series have shown that hand-assisted surgery is not associated with an increase in postoperative narcotic use, subjective pain, or time until a return to normal activity [8, 11, 18].
From an oncologic standpoint, the colonic resections in both groups were completed with acceptable proximal and distal margins of at least 5 cm. There were no statistically significant differences in the lengths of the pedicle dissections in the two groups. However, resection in the HALS group was associated with significantly more lymph nodes harvested, with a higher percentage of resections yielding 12 or more nodes for examination than in the LAP group.
The American Joint Committee on Cancer and the College of American Pathologist recommend evaluating at least 12 nodes for accurate identification of stage III disease [4, 7, 12]. However, there are some existing data to suggest that survival increases as more nodes are analyzed [7, 10]. The explanation for this may be that those patients with more nodes in the specimen may have had a more complete resection or that evaluating more nodes increases the likelihood of identifying a nodal metastasis.
The explanation for this discrepancy in lymph node harvest between the two groups is difficult to ascertain because the initial studies comparing open colectomy with laparoscopic colectomy for colon cancer did not show any significant difference in lymph node harvest [3, 5, 6]. A careful dissection of the mesentery by the pathologist to obtain all the nodes present may be a factor as well as the technique used. The LAP resections had a smaller percentage of positive nodes, and these were typically of lower stage disease, indicating that the mesenteric nodes may have been smaller and more difficult for the pathologist to identify.
Regardless of the possible explanation, the lymph node yield of the included resections was similar to that of other published series including that for open surgery [3, 5, 6]. Follow-up evaluation of survival and recurrences would be important for further evaluation of these two techniques used for colorectal cancer.
Evaluation of the incision length data did show a significantly smaller incision in the LAP group than in the HALS group. However, the incision length difference of less than 1 cm likely is of little clinical significance. It also is evident from other studies that the benefits of laparoscopic colectomy are not lost with the requirement of the 1-cm longer incision for a HALS colorectal resection [8, 11].
In conclusion, hand-assisted laparoscopic colonic resection for colon cancer may result in the retention of minimally invasive surgery benefits without infringement on the oncologic adequacy of a colonic cancer resection, and may rather enhance the number of lymph nodes resected. In addition, a shorter operative time, no difference in the length of hospital stay, and equivalent intraoperative blood loss indicate that this is a viable option for the treatment of both right- and left-side colonic cancers. This technique may provide an effective bridge between purely laparoscopic and traditionally open surgery for patients undergoing colorectal resections for cancer.