Upload
alaina-hall
View
220
Download
0
Embed Size (px)
Citation preview
Hand Assisted Surgery
Bradley R. Davis, MD, FACS, FASCRSAssociate Professor of Surgery
Director Surgical Education/Surgical Skills LabProgram Director Residency in General Surgery
University of Cincinnati
Disclosures
• Paid Consultant for Ethicon Endo Inc.
Challenges
Challenges
– BMI– Adhesions– Complicated Diverticulitis– pT stage– Left vs Right sided resections
Delaney et al. Surg Endosc. 2005 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
Author Year Type Patients Comment
HALS 2000 RPT 59 Same as lap
Targarona 2002 RPT 54 Fewer conversions
Kang 2004 RPT 60 Better than open
Chang 2005 CCT 151 Fewer conversions
Milsom 2006 CCT 42 Fewer conversions
Boushey 2005 NRT 130 Same as lap TAC
Maartense 2005 RPT 60 Same as open IPAA
Marcello 2008 RPT 95 Same as lap
Cost
Orenstein et al. Surg Endosc. 2011 May;25(5):1364-8.
Complications
Cima et al. J Am Coll Surg. 2008 May;206(5):946-50
HALS Long Term Outcomes
Sonoda et al. J Am Coll Surg. 2009 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. 2008 May;206(5):946-50
Conversions – Why?
Cima et al. J Am Coll Surg. 2008 May;206(5):946-50
Conversions
Park et al. Surg Endosc. 2010 Jul;24(7):1679-85
Effective
Orenstein et al. Surg Endosc. 2011 May;25(5):1364-8.
EffectiveHALS LAP P value
Sigmoid/Left Colectomy
Operative Times (mins)
175 208 .021
Incision (cm) 8 6 .01
LOS 5.7 5.2 NS
Total Colectomy
Operative Times (mins)
127 184 .015
Incision(cm) 7.8 6.7 .09
LOS 6.9 8.9 NS
Marcello P, et al. Dis Colon Rectum. 2008 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. 2008 Jun;51(6):818-26
Complicated Diverticulitis
HALS (n=21) Straight Lap (n=21)
Operative Times (mins)177 255
Incision Length (cm) 5 9
Conversion 4% 14%*
LOS (days) 6 5*
Complications 24% 19%*
Lee et al. Dis Colon Rectum. 2006 Apr;49(4):464-9.
*p=NS
Vogel at al. J Am Coll Surg. 2011 Mar;212(3):367-72
Effective
The Unexpected
• Bleeding
• Stapler Misfire
• Difficulty identifying the lesion
24
Operative TechniqueLAP HAL
Vogel at al. J Am Coll Surg. 2011 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. 2006 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
31
Thank You