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Hand Assisted Surgery

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. Disclosures. Paid Consultant for Ethicon Endo Inc. Challenges. Challenges. BMI

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Hand Assisted Surgery

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  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. Challenges • BMI • Adhesions • Complicated Diverticulitis • pTstage • 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

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

  7. HA Lap Colectomy Pros Cons Fear of the unknown Learning curve Device costs Hand port placement What if you have to convert? • Decrease operative times • Decrease conversion rates • Adoption • Single surgeon • Undertake more complex cases • Surgeon’s hand is a GREAT tool

  8. 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

  9. Outcomes - Colectomy

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

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

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

  13. 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)

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

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

  16. Conversions Park et al. SurgEndosc. 2010 Jul;24(7):1679-85

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

  18. Effective Marcello P, et al. Dis Colon Rectum. 2008 Jun;51(6):818-26

  19. 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

  20. Complicated Diverticulitis *p=NS Lee et al. Dis Colon Rectum. 2006 Apr;49(4):464-9.

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

  22. The Unexpected • Bleeding • Stapler Misfire • Difficulty identifying the lesion

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  24. Operative Technique LAP HAL

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

  26. Hand Assisted Right Colectomy

  27. Laparoscopy for Rectal Cancer Mid to Low Lesion • Low rectal transection • Cannot come across at 90 o • Increase # firings EndoGIA • INCREASE LEAKS • If you need an incision… use it throughout the case Brannigan et al. Surg Endosc. 2006 Jun;20(6):952-5

  28. 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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  30. Thank You

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