Hand-Assisted Laparoscopic Surgery

ORIGINAL ARTICLE Hand-Assisted Laparoscopic Surgery

Eduardo M. Targarona, MD, PhD; Ester Gracia, MD; Manuel Rodriguez, MD; Gemma Cerda´n, MD; Carmen Balague´, MD, PhD; Jordi Garriga, MD; Manuel Trias, MD, PhD

Hypothesis: Hand-assisted laparoscopic surgery (HALS) tive trials on HALS for splenectomy and colectomy have has been proposed as a useful alternative to conven- been published. tional open or laparoscopic surgery. However, most in- formation is fragmented and comes from specific or se- Conclusions: Hand-assisted laparoscopic surgery seems lective indications. To assess the current situation of HALS, to be a promising technique that has been applied with a general overview of the fields of application, results, success in a wide range of digestive tract–related surgi- and quality of the evidence of these results is necessary. cal procedures. The main role is to help in difficult cases before conversion is necessary or for training unskilled Data Sources: Current English-language literature surgeons, and not as an alternative to pure laparoscopic review. surgery. However, not enough evidence-based data are available to know exactly the final outcome of this tech- Study Selection: Case reports, series, and opinion ar- nique in general surgery. Prospective randomized trials ticles on HALS. with established open or laparoscopic procedures are lacking, and these trials are needed to support the final role Data Extraction and Synthesis: Evaluation of the type of HALS. of study and results. Most of the articles are short case series. Only a few comparative or randomized compara- Arch Surg. 2003;138:133-141

HE USE of videolaparoscopy globalized learning curve that has in- has been one of the most im- cluded the development of what is known portant steps forward in gen- as “advanced LS,” surgeons have reached eral and digestive tract sur- a stage in which the terms “conversion” gery in recent years. Over the and “selection” are part of the laparo- lastT decade most intra-abdominal surgical scopic glossary. However, often selection procedures have been shown to be techni- or conversion is not because of the tech- cally feasible using a laparoscopic ap- nical or anatomical impossibility of per- proach. However, practitioners of laparo- forming the procedures (for instance, in scopic surgery (LS) inevitably lose the sense cases of dense adhesions or local ad- of depth and their perception of tactile feel- vanced disease), but because of the diffi- ing may also be altered by the use of longer culty of performing certain steps in the lap- instruments, which may significantly im- aroscopic procedure, such as the exposure pair their hand-eye coordination. Sur- of the dissection area or the manipula- geons must, therefore, develop a range of tion of a bulky specimen. new operative skills in addition to those re- As advanced procedures have devel- quired in open surgery and be aware that oped, some authors have proposed the the performance of complex surgical ma- concept of hand-assisted laparoscopic sur- neuvers will be more difficult.1 gery (HALS),2-8 a technique that was, for the most part, rejected by the surgical com- See Invited Critique munity because it violated the fundamen- at end of article talist principle of minimal invasion and because the insertion of the hand without the During the early 1990s, many sur- help of a mechanical seal to maintain the geons rather hastily predicted that LS pneumoperitoneum was impracticable ow- From the Surgery Service, would replace the conventional open ap- ing to the loss of gas and the direct con- Hospital de la Santa Creu i proach. However, 14 years after the first tact of the surgeon’s arm with the abdomi- Sant Pau, Barcelona, Spain. laparoscopic cholecystectomy, and after a nal wound.

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C D

Figure 1. A, Hand Port (Smith & Nephew, London, England); B, LapDisc (Hakko-Medical, Tokyo, Japan); and C and D, Omniport (Advanced Surgical Concept, Dublin, Ireland) are 3 devices used to perform hand-assisted laparoscopic surgery. Reprinted with permission from Targarona et al.16

In recent months, however, opinions regarding HALS HALS DEVICES have changed, in particular because of the emergence of devices designed specifically to maintain the pneumo- The simplest way to perform HALS is to insert the hand peritoneum while the hand is inserted intra-abdom- through a minilaparotomy performed for that purpose. inally.9-15 Another factor that has encouraged the use of However, it is difficult to keep the seal tight and to avoid HALS is the clear underdevelopment of advanced LS in loss of gas; in addition, the movements of the arm and certain areas such as colorectal surgery owing to the pro- the hand are limited. cedure’s technical difficulty; some authors10-15 have pro- Three different devices are available for HALS posed HALS as an alternative. Hand-assisted laparo- (Figure 1).16 One type is a glove fixed to a circular plat- scopic surgery may also be justified in cases in which the form that adheres to the surface of the skin, around the laparoscopic procedure requires an accessory incision incision (Dexterity Inc, Roswell, Ga; or Intromit; Medtech to retrieve the specimen, as in cases of colectomy or Ltd, Dublin, Ireland). This device has the drawback of splenectomy for massive splenomegaly. The questions requiring adherence to the skin, which must be well pre- to be answered are whether HALS maintains the mini- pared; adhesive substances are needed, and the device mally invasive features of conventional LS, and whether itself is easily lifted from the skin by the wound fluid. it contributes to the technical development of LS. There are also devices with 2 elements (Hand Port; Smith & Nephew, London, England) (Figure 1A). The inflat- CONCEPT able circular base adapts to the inner contour of the abdominal wall wound and is attached to a sleeve that is Hand-assisted laparoscopic surgery is an alternative lap- fixed to the surgeon’s arm, which allows the insertion and aroscopic approach in which a minilaparotomy is planned withdrawal of the hand. This device is comfortable and and performed to enable the surgeon to introduce his or easy to install, but the fact that the sleeve cannot be her hand while the pneumoperitoneum is maintained and changed prevents the use of the other arm or the hand the dissection maneuvers are performed under videoen- of the assistant. Third, there are single-piece devices that doscopic control. The insertion of the hand restores the adapt to the inner contour of the wall incision and per- tactile feeling and the sensation of depth, and facilitates mit the interchange of hand insertion, either mechani- the exposure, traction, and retraction maneuvers dur- cally (LapDisc; Hakko-Medical, Tokyo, Japan) (Figure ing the procedure. 1B) or by inflation (Omniport; Advanced Surgical Con-

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10-mm Scope

12-mm Instrumental

10-mm Scope

Figure 2. Placement of the minilaparotomy during hand-assisted laparoscopic surgery. Right-sided (A) and left-sided (B) colectomy.

cepts, Dublin) (Figure 1C and D). Some special surgical tant’s. If it is the surgeon’s, the nondominant hand is used; instruments have been designed for HALS. These instru- if it is the assistant’s, the dominant hand is used. If it is ments may help some delicate steps of surgical proce- the surgeon’s hand that is introduced, it should not im- dures such as those used in splenic or kidney vessel dis- pair the visual field of the scope, so as to permit ad- section.17 equate triangulation over the target organ manipulated A procedure derived from HALS is finger-assisted LS by the hand. In addition, the hand should not be placed (fingerscopy). By introducing a finger through a trocar over the structure to be dissected because this may im- wound the surgeon can free adherences or palpate and iden- pair the manipulation of the organ. When the proce- tify structures in situations such as appendectomy.18-20 dure includes an accessory incision to extract the specimen (eg, in splenectomy for splenomegaly) or to perform ADVANTAGES the anastomosis (eg, in colectomy), the hand may be introduced through the anatomical site at which the inci- The obvious advantage of HALS is that it recovers the sion is performed. If it is the assistant who introduces tactile feeling and improves hand-eye coordination de- the hand, the accessory incision may be made far away spite the fact that the operation is performed under vid- from the introduction points of the operative trocars (a eoscopy. The recovery of tactile feeling shortens certain Pfannenstiel incision).22,23 In some situations the incision dissection maneuvers, avoids unnecessary movements, should be made in a multifunctional site (for instance, in favors the smooth traction and exposure of structures, the periumbilical midline, for a subtotal colectomy). and facilitates the control of unexpected or difficult situations such as hemorrhage or the handling of a volumi- INDICATIONS nous or adherent specimen. All of these advantages en- hance the efficiency of the endoscopic procedure. Hand-assisted laparoscopic surgery has been applied in many clinical situations, and its safety and efficacy have DISADVANTAGES been amply demonstrated (Table 1). Two multicenter series that included multiple diagnosis and complex pro- The main drawback of HALS is that it requires an addi- cedures have underlined its efficacy and the low inci- tional incision, thus increasing trauma. For this reason, dence of conversion; surgeons interviewed in those stud- the best indications are those that involve the perfor- ies stated that HALS definitely facilitated the procedure mance of a minilaparotomy to extract the specimen. The (58% of the surgeons considered that HALS reduced op- HALS technique requires a new operative strategy to capi- eration time and 88% that the intra-abdominal hand was talize on the presence of the hand being inside the ab- helpful).25,26 Furthermore, immediate postoperative evo- domen, and the scope and the trocars must be correctly lution was similar to conventional LS procedures. This placed (Figure 2 and Figure 3).21-24 Furthermore, the suggests that HALS maintains the advantages of LS. How- hand takes up space inside the abdomen and may ham- ever, few comparative studies with conventional LS or per certain maneuvers, particularly if the patient is thin open surgery have been performed,27-29 and more are or if the surgeon’s hand is large. Hand-assisted laparo- needed before we are able to confirm the advantages or scopic surgery may also induce hand fatigue in long or drawbacks of this new procedure. complicated procedures. Hand-assisted laparoscopic surgery should be considered a priori as an aggressive surgery because (1) it ELECTION OF INCISION SITE FOR PLACEMENT requires a minilaparotomy incision at the beginning of OF THE HALS DEVICE the procedure, (2) this incision is stretched by the HALS device, and (3) the area of manipulation and traction is The choice of incision site is likely to depend on whether greater than in other procedures that use 5- to 10-mm the intra-abdominal hand is the surgeon’s or the assis- instruments. In a prospective, randomized trial compar-

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Figure 3. Placement of the minilaparotomy during hand-assisted laparoscopic surgical splenectomy. Reprinted with permission from Targarona et al.16

gastrectomy was followed by a better immediate out- Table 1. Laparoscopic Procedures Performed come, and the oncological results were similar to those With Hand-Assisted Laparoscopic Techniques found after conventional open gastrectomy.

Transhiatal esophagectomy Preparation gastric tube Surgery for Morbid Obesity Nissen fundoplication Paraesophageal hernia Partial or total gastrectomy Gastric bypass Gastroplasty Adhesiolysis Since 1993, many laparoscopic techniques for treat- Colorectal cancer Colonic polyps ment of morbid obesity have been described including Diverticulitis Crohn disease vertical banded gastroplasty, gastric bypass, and adjust- Rectal prolapse Hepatectomy able gastric banding.40 All these techniques have also been Cryoablation liver metastasis Pancreatoduodenectomy performed with the help of HALS.40-46 Authors report a Distal pancreatectomy (70% or 80%) Splenectomy significant reduction of operative time, but comparative Splenectomy for massive Staging hematological splenomegaly diseases randomized trials with conventional LS techniques are Adrenalectomy Exeresis retroperitoneal tumor lacking, and the potential source of morbidity of the ac- Nephrectomy Living-donor nephrectomy cessory incision is unknown. Several experiments have Vertebral fusion Aortobifemoral bypass shown the feasibility of vertical banded gastroplasty with a mean time of 100 minutes and a postoperative stay of 3.9 days.46,47 Hand-assisted laparoscopic surgery– assisted gastric bypass entails an operative time of 205 ing HALS with laparoscopic colectomy,28 increases in C- minutes and a hospital stay of 5 days.43,46 However, a com- reactive protein and interleukin 6—used as tissue in- parative trial of HALS gastric bypass with open gastric jury markers after HALS—indicated that HALS is more bypass did not showed differences in operative time, mor- invasive than conventional laparoscopic colectomy. These bidity, or late incisional hernia.48 There are no compara- aspects should be considered in any discussion of the ad- tive studies with conventional LS, and the use of pure vantages of HALS surgery. laparoscopic techniques is associated with a satisfactory result. Esophagogastric Surgery Colorectal Disease Hand-assisted laparoscopic surgery has been applied to perform gastrolysis and gastric tube insertion during The application of HALS in this area of surgery makes esophagectomy. It has also been used for transhiatal more sense because a mini-incision is required at the end esophagectomy without thoracotomy and giant hiatal her- of the procedure to perform the anastomosis, and be- nia repair,30-36 and for total or partial gastrectomy.37-39 The cause this kind of surgery involves procedures in sev- accessory incision may be used to perform the anasto- eral parts of the abdominal cavity and the manipulation mosis and to restore digestive continuity. In a series of of a large specimen. These features have delayed the 60 patients Tanimura et al39 showed that HALS partial development of LS in this area.21,49-51 Hand-assisted lap-

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Table 2. Results of 2 Prospective Randomized Trials Comparing Laparoscopic Colectomy With HALS Colectomy*

Targarona et al28 HALS Study Group27

Laparoscopic HALS Laparoscopic HALS Colectomy Group Colectomy Group Colectomy Group Colectomy Group (n = 27) (n = 27) {n = 18) (n = 22) Age, y 67 70 ...... Sex, M/F 18/9 20/7 ...... No. of patients with benign malignant disease 5/22 5/22 18/0 22/0 No. of patients with right-sided and 11/16 12/15 ...... left-sided colectomy Conversion 6/27 (4 to HALS) 2/27 3/22 8/22 Operative time, min 135 120 141 152 Postoperative bowel movement, h 48 48 72 72 Postoperative refeeding, h 48 72 Morbidity, No. of patients 6741 Minor 4 5 3 . . . Major 2211 Reoperation . . . 1/27 ...... Length of hospital stay, No. (range) of days 6 (5-22) 6 (5-27) 6 6 Length of specimen, mean (range), cm 19 (11-35) 20 (11-40) ...... Lymph nodes, No. (range) 11 (2-35) 12 (5-29) ......

Abbreviation: HALS, hand-assisted laparoscopic surgery. *Ellipses indicate not applicable.

aroscopic surgery has been used for segmental resection Hepatic Surgery of the colon, anterior resection of the rectum, total colectomy, reversal of Hartmann procedure, rectopexy, Few authors have attempted HALS hepatic surgery, but and abdominoperineal resection49-63; its advantages initial results are encouraging in the hands of skilled hepa- include the easier manipulation of the organ (explora- tobiliary surgeons (Table 3). Procedures include seg- tion, dissection, and colonic mobilization), and better mentectomies, left-sided hepatectomies, cryotherapy control of hemorrhagic accidents, thus reducing the of liver metastasis, and liver resection under vascular conversion rate. As far as malignant disease is con- control.69-75 cerned, the greatest advantages that HALS offers are the detection of metastatic lesions and the local staging of Pancreatic Surgery tumors. In a study comparing the number of maneuvers and movements in HALS with those in laparoscopic Tumor staging for pancreatic cancer, proximal, and dis- colectomy, HALS was found to reduce the number of tal pancreatectomy as well as pseudocyst digestive di- unnecessary maneuvers.21 Two prospective, randomized version or endocrine islet tumor enucleation have been trials comparing HALS and conventional laparoscopic reported, but the lack of experience prevents one from colectomy reported only a moderate reduction (about 15 drawing definitive conclusions.(Table 3).73-76 Cuschieri66 minutes) in the duration of the procedure, even though and Gagner and Gentileschi72 have described good re- conversion from conventional LS to HALS made it pos- sults in pancreatic surgery; distal pancreatic resection is sible to finish the procedure in 4 patients, who would one of the best indications for HALS. otherwise have been converted to open surgery (Table 2).27,28 Both trials confirmed that HALS colec- Splenectomy tomy maintains the advantages of the pure laparoscopic approach, that is, bowel movements, refeeding, and hos- Splenectomy is the most widely accepted indication for pital stay. One of these studies ruled out the intraperito- the laparoscopic approach,77,78 including cases of sple- neal mobilization of malignant cells, and the pathologic nomegaly, despite the fact that splenectomy with intra- features of the specimen (the size and number of lymph abdominal manipulation was first described by Kuminsky nodes) were similar in the 2 studies (Table 2).28 An et al79 in 1995 and others.80,81 Anecdotal reports have interesting indication for HALS is in cases of diverticular shown advantages in certain difficult cases such as disease because of the intensity of the adhesive reaction Hodgkin disease associated with node sampling,79 hy- of the diseased sigmoid colon.59,64 datid cysts of the spleen,82 or splenic metastasis.83 Two The HALS technique can also be used in rectal can- series have analyzed the potential advantages of HALS cer. Pietrabissa et al65 used the procedure in a series of for LS, but most of the patients operated on had normal- 16 patients who had tumors between 2 and 8 cm from sized spleens, and the results in terms of morbidity or the anal verge, below the peritoneal reflection. Opera- length of hospital stay were close to those of standard tive time was 238 minutes; there were no conversions, LS.84,85 Gossot et al84 compared HALS with LS per- and the mean postoperative stay was 5.6 days. formed with the patient in lateral decubitus and a pos-

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Length of No. of Operative Time Hospital Source Patients Diagnosis (Range), min Conversion Morbidity, % Mortality Stay, d Procedures Liver Surgery Cuschieri,66,67 2000 8 Metastasis 120 None 0 0 4 Left-sided heparectomy and (2 patients), hepatoma cryoblation (3 patients), and segmentectomy (3 patients) Fong et al,68 2000 11 Liver tumor 248 6 of 11 (tumor 40% (bile leak 0 2 Segmentectomy margins and colitis) [3 patients] and adhesions) Kurokawa et al,69 1 Liver tumor 322 None 0 0 . . .* Left-sided lobectomy 2002 Antonetti et al,70 15 Metastasis 197 4 of 15 (extensive 9 (bleeding 0 4.5 Resection (3 patients), 2002 lesions) and ileus) cryoablation (5 patients), and both (3 patients) Pancreatectomy Cuschieri,66 2000 6 Tumor, chronic 120 1 0 0 3-10 Left-sided pancreatitis, pancreatectomy and cyst Klinger et al,73 1998 1 Cystadenoma 150 0 0 0 5 Left-sided pancreatectomy Shinchi et al,74 2001 2 Cystadenoma 400 0 0 0 NS Left-sided pancreatectomy

Abbreviations: HALS, hand-assisted laparoscopic surgery; NS, not stated. *Ellipsis indicates not applicable.

Table 4. World Experience for HALS Splenectomy

Length of No. of Operative Time Hospital Stay Spleen Weight Source Patients Spleen Size (Range), min Conversion, % Morbidity, % Mortality, % (Range) d (Range), kg Gossot et al,84 1999 8 No splenomegaly 90 (80-130) None 12.5 0 3.8 (3.7) 280 (180-650) Meijer et al,85 1999 22 No splenomegaly 89 (45-120) 5 NS 0 3.9 . . .* Southern Surgeons’ Club 7 No splenomegaly 171 (145-247) 14 17 0 3.8 NS Study Group,25 1999 Litwin et al,26 2000 8 Splenomegaly 177 (33)† 37 12 4.7 (2-9) NS Hellman et al,87 2000 7 Splenomegaly 133 (110-155) 14 28 0 4 (2-15) 4200 (3500-5800) Targarona et al,78 2002 19 Splenomegaly 135 (85-270) 5 10 0 7 (5-13) 1600 (700-4500) Kercher et al,81 2002 12 Splenomegaly 171 (90-369) 0 8 0 2.3 (1-16) . . .*

Abbreviations: HALS, hand-assisted laparoscopic surgery; NS, not stated. *Ellipses indicate not applicable. †Data given as mean (SD).

terior approach to the vessels, finding results similar to unclear anatomy, or an unusual circumstances (ie, preg- those of conventional LS and lesser blood loss. In addi- nancy) (Table 4).86 tion, in a multicenter series of HALS in normal-sized However, the manipulation of an enlarged spleen spleens, Meijer et al85 found no evident improvement over using only laparoscopic instruments is difficult, pro- the results of standard LS and noted the disadvantage of longs the procedure, and conversion to open surgery is the accessory incision. A personal preliminary opinion required in as many as 25% of these cases. In this situ- seems to be that HALS is not indicated in cases with nor- ation HALS has proved to be particularly useful (Table mal-sized spleens. Laparoscopic surgery for normal- 3).25,81 Litwin et al26 demonstrated the feasibility and util- sized spleens is a difficult but well-systematized and re- ity of HALS in a multicenter, noncomparative series of 8 producible LS procedure, and the surgeon’s efforts should cases of splenomegaly without conversion and with a short probably be addressed to mastering the pure laparo- hospital stay. Hellman et al87 also obtained good results scopic procedure. Hand-assisted laparoscopic surgery can (1 of 7 needed conversion, with a mean operative time be considered a technical aid in cases in which conver- of 133 minutes) in a series of 7 patients with massive sple- sion is required owing to intraoperative complication, an nomegaly approached by HALS (spleen weight ranging

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©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 tained. Hand-assisted laparoscopic surgery living- donor nephrectomy has also widened the pool of living donors. Several prospective, randomized trials have confirmed the advantages of HALS living-donor nephrectomy over conventional laparoscopy with a reduction of the operative time, smaller incision, and similar long- term function of the organ.90-94 Hand-assisted laparoscopic surgery has also been applied in urology, in in- terventions ranging from simple or partial nephrectomy to ureteronephrectomy for cancer.89

Vascular Surgery

Hand-assisted laparoscopic surgery has been applied in a range of vascular pathologic conditions. Promising results have been reported for aortobifemoral bypasses and Figure 4. Section of the splenic hilum in a splenectomy for splenomegaly in the treatment of aneurysms of the abdominal aorta.95-97 performed by hand-assisted laparoscopic surgery. Reprinted with permission from Targarona et al.16 Gynecology

between 3.5 and 5.8 kg). In our experience, HALS re- The advantages of HALS have also been described in se- duced the duration of the procedure by 30% and the need lected cases of gynecologic surgery (ie, megamioma, complex hysterectomies, or malignant pelvic lesions [ovary for conversion to 8%, and had a clear impact on out- 98-101 come.29,81 Today, it is our preferred technique for sple- or endometrium]), despite the fact that there are no nectomy in cases of splenomegaly. An extremely inter- comparative studies. esting result of our experience with HALS is that general morbidity is lower and the hospital stay shorter than with CONCLUSIONS conventional LS. This means that operative injury dur- Hand-assisted laparoscopic surgery may be an interesting HALS may well be lower than during LS and that the ing alternative to conventional LS or open surgery. It sim- potential advantages of the laparoscopic approach are plifies the performance of difficult procedures for expe- maintained despite the more intense intra-abdominal ma- rienced surgeons and can initiate less experienced nipulation. Most indications for LS in cases of spleno- surgeons in advanced LS. Comparative trials with well- megaly are hematological malignancies, with a deterio- established laparoscopic techniques are required to de- rated general state. In an earlier multivariate analysis of fine the absolute advantages of HALS. However, it may factors related to complications after LS, we showed that well be a useful resource before conversion to open sur- malignancy and splenomegaly correlated significantly with gery now that it has been demonstrated that it main- the occurrence of complications.78 The reduction in op- tains the advantages of LS. erative injury is likely to be associated with a quicker, safer recovery, and with fewer pulmonary and infec- tious complications. Accepted for publication October 5, 2002. From the technical viewpoint, the main advantage This study was supported by grant 01/ 173 from the of HALS is the smoother retraction and exposition of the Fondo Investigaciones Sanitarias, Barcelona. lower pole. The procedure also allows precise localiza- Corresponding author: Eduardo M. Targarona, MD, tion of the splenic artery, which can be tied, and the mo- PhD, Surgery Service, Hospital de la Santa Creu i Sant Pau, bilization of the posterior face of the spleen. The hands C/ Padre Claret 167, 08025 Barcelona, Spain (e-mail: bluntly dissect the pancreatic tail and facilitate the exact [email protected]). and careful placement of the (Endostapler) (Figure 4). Finally, the spleen can be easily extracted intact or mor- REFERENCES cellated through the 7-cm incision. Ren et al88 have re- 1. Cuschieri A. Whither minimal access surgery: tribulations and expectations. Am ported the satisfactory performance of LS for a ruptured J Surg. 1995;169:9-19. spleen using a HALS technique. 2. Boland JP, Kuminsky RE, Tiley EH. Laparoscopic minilaparotomy with manipulation: the middle path. Minimal Invasive Surg. 1993;2:63-67. 3. Cuschieri A, Shapiro S. Extracorporeal pneumoperitoneum access bubble for Nephrectomy endoscopic surgery. Am J Surg. 1995;170:391-394. 4. Kusminsky RE, Boland JP, Tiley EH. Hand-assisted laparoscopic surgery [let- Hand-assisted laparoscopic surgery may also be particu- ter]. Dis Colon Rectum. 1996;39:111. 89 5. Neufang T, Post S, Markus P, Becker H. Manually assisted laparoscopic surgery— larly useful for nephrectomy. The most widely ac- realistic evolution of the minimally invasive therapy concept? initial experi- cepted urological indication for HALS is living-donor ne- ences with the “Endohand.” Chirurg. 1996;67:952-958. 90-94 6. O’Reilly MJ, Saye WB, Mullins SG, Pinto SE, Falkner PT. Technique of hand- phrectomy. Compared with open surgery, HALS living- assisted laparoscopic surgery. J Laparoendosc Surg. 1996;6:239-244. donor nephrectomy is minimally invasive, warm ischemic 7. Gorey TF, Bonadio F. Laparoscopic assisted surgery. Semin Laparosc Surg. 1997; time is shorter than when using a pure laparoscopic ap- 4:102-109. 8. Memon MA, Fitzgibbons RJ. Hand-assisted laparoscopic surgery (HALS): a use- proach, and donor recovery is more comfortable, as the ful technique for complex laparoscopic abdominal procedures. J Laparoen- immediate and long-term viability of the kidney are main- dosc Adv Surg Tech A. 1998;8:143-150.

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Invited Critique

ne of the most useful contributions to the literature, which helps the surgeon at the grassroots level, is a review of an O emerging or controversial topic. The authors of this article did not disappoint. Their thorough review of the literature on HALS was excellent. The article helps to put into perspective the proposed clinical applicability of what I call “bridg- ing technology devices.” Probably the most credible reason to embrace these appliances is that they may help to prevent the conversion of a laparoscopic to an open procedure. However, a 7-cm incision, suggested in the manuscript as being necessary to use the device, is suspect at best. Many surgeons would need a larger incision. With this in mind, some would argue that an open procedure using standard equipment could be performed without added expense. The proposal that this device could serve as an intermediate step toward the total laparoscopic approach is much more difficult to justify. Without putting forth an organized and sustained educational effort to acquire superior targeting and 2-hand choreography skills, 2-dimensional depth perception compensation, and intracorporeal suturing, this device will “rest in peace” in an ever-increasing “technology grave yard,” populated with other appliances that have fallen short of the mark.1 Other factors that need to be considered when evaluating the potential contribution of this appliance include cost and the possibility of skewing data on procedural effectiveness and quality of life. For example, it has been established in several publications that the cost of minimally invasive colon surgery is more expensive.2 Unfortunately, conversion is associated with a higher operative cost.3 The hand-assisted appliance adds additional financial burden to a procedure struggling to project fiscal responsibility. In addition, the skewing of outcomes in procedural effectiveness and quality of life may become a byprod- uct of widespread use of this class of products. This concern may become a reality if the HALS procedures are lumped in with minimally invasive colon procedures that do not use a less traumatic and morbid umbilical incision as the “primary extraction point” for specimen retrieval and extracorporeal anastomosis portal. Reports in the literature that fall into this “trap” may present data that show the overall morbidity signature for the technique as being more similar to the open procedure, therefore drawing erroneously into question the benefit of many minimally invasive surgical approaches.2 The one cited study in the manuscript showing equality of outcomes (minimally invasive surgery vs HALS) does not eradicate my concern. I am also frustrated by sluggishly advancing minimally invasive surgical procedural adoption rates. Safe expansion of adoption rates must, however, be achieved by “standing on the shoulders of giants,” those surgical pioneers that have come before us to establish sound, reproducible principles based on skill, tactics, and technique rather than technology.

James C. Rosser, Jr, MD New York, NY

1. Melvin WS. Laparoscopic skills enhancement. Am J Surg. 1996;172:377-379. 2. Larach, Ferrara. Cost analysis. In: Jager RM, Wexner SD, eds. Laparoscopic Colorectal Surgery. New York, NY: Churchill-Livingston; 1996:321-323. 3. Falk PM, Beart RW Jr, Wexner SD, et al. Laparoscopic colectomy: a critical appraisal. Dis Colon Rectum. 1993;36:28-34. 4. Weeks JC, Nelson H, Gelber S, Sargent D, Schroeder G. Short-term quality-of-life outcomes following laparoscopic-assisted colectomy vs open colectomy for colon cancer: a randomized trial. JAMA. 2002;287:321-328.

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