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212
N.G. Berger et al.
Several randomized controlled trials have demonstrated the superiority of HALS
colonic surgery over traditional open techniques. In 2004, Kang etal. compared
perioperative outcomes in 60 patients randomized to HAL or open colectomy. The
study demonstrated shorter hospital stay, incision length, faster gastrointestinal
function recovery, less analgesic use, and lower pain scores, with no differences in
operative time or complications [25]. A similar study in 2007 examined 81 patients
undergoing non-emergent colectomy for nonmetastatic right-sided lesions, demonstrating less blood loss, less pain and analgesia use, faster recovery, and shorter
hospital stay but longer operative times (12.5 min) for HALS colectomy.
Furthermore, long-term follow-up 28months demonstrated no difference in disease
recurrence or 5-year survival rates between HAL and open cohorts [26]. Finally,
Sheng etal., in a report on 116 randomized patients, noted that HALS patients had
a signicantly shorter incision length, less blood loss, less pain, earlier passage of
atus, and shorter length of stay but longer operative time and higher costs compared to open cohorts. These three studies demonstrated improved perioperative
outcomes for HALS over open colectomy, despite some reports of longer operative
times and higher costs (Table19.1) [27].
These outcomes are supported by retrospective National Surgical Quality
Improvement Program (NSQIP) data reporting lower hospital stay and morbidity as
dened as supercial surgical site infection (SSI), deep SSI, organ space SSI, wound
disruption, sepsis, bleeding, and ileus [28]. As with previous comparisons of laparoscopic to open colectomy, HALS minimally invasive techniques provide improved
perioperative outcomes, lower morbidity, and shorter hospital stay in the context of
similar oncologic outcomes. An extensive review of the literature published in 2010
looking at studies comparing HALS versus open resection concluded that HALS
has advantages over open surgery while reducing some of the disadvantages of laparoscopic surgery, and, overall, HALS provides an excellent treatment option for the
management of colorectal disease [29].
In addition to offering advantages over open operation, HALS has also been
demonstrated to have specic benets over conventional laparoscopy. The HALS
Study Group reported a series in which 40 patients were randomized to HALS versus straight laparoscopic operation for either benign or incurable malignant disease,
reporting similar operative time, incision length, conversion rates, return of bowel
function, length of stay, postoperative pain, and rate of functional recovery. The
study concluded that HALS is safe and retains the perioperative benets of minimally invasive laparoscopic colectomy and may allow a surgeon to perform complex operations more easily [30]. Marcello etal. reported a multicenter randomized
trial examining HALS vs. laparoscopic sigmoid and total colectomy. Operative
times were signicantly decreased in the HALS group, though incision length was
longer. There were no differences noted in perioperative parameters or conversion
rates [17]. Examining long-term oncologic outcomes following right colectomy, Ng
etal. demonstrated no difference in 5-year survival rates between HALS and laparoscopic groups, with no signicant differences noted in operating time, length of
stay, and morbidity [31]. Last, Targarona et al. examined clinical outcomes and
inammatory response of HALS vs. laparoscopic surgery, noting lower conversion
19 Is There Still aRole forHand-Assisted Laparoscopic Surgery (HALS)?
Table 19.1 Summarized outcomes of randomized trials comparing HALS colectomy to open
colectomy
Reference
Kang etal.
[25]
Chung etal.
[26]
Sheng etal.
[27]
HALS approach Open approach
Less operative blood loss Operative time
Shorter incision length Overall complications
Improved time to rst oral
intake
Improved return of bowel
function
Decreased length of stay
Less operative blood loss Shorter operative
Improved time to rst oral
intake
Improved return of bowel
function
Decreased length of stay
Improved pain scores
Decreased narcotic use
Less operative blood loss Shorter operative
Shorter incision length Decreased overall
Improved time to rst oral
intake
Improved return of bowel
function
Decreased length of stay
Improved pain scores
time
time
costs
No difference
Time to resume normal
activities
Lymph nodes harvested
Mortality
Anastomotic leak
Wound sepsis
Oncologic survival
Lymph nodes harvested
Overall complications
213
rate (7 vs. 23%) but increased interleuken-6 (IL-6) and C-reactive protein (CRP)
during the postoperative period for HALS (Table19.2) [32].
Clearly HALS is associated with equivalent perioperative outcome parameters
and oncologic outcomes compared to purely laparoscopic approaches. A recent
meta-analysis of the data concluded that compared to straight laparoscopic operations, HALS exhibited reduced operative times, a reduction in the likelihood of
conversion to open operation, and no difference in hospital length of stay. The
authors concluded that HALS approaches can provide a more efcient segmental
colectomy compared to laparoscopic colectomy and the advantages for the HALS
approach were particularly evident when the indication for operation was diverticulitis. They suggested that HALS must be considered a valuable addition to the laparoscopic armamentarium [14]. The reduced operative times and conversion rates
demonstrating the effectiveness of HALS colectomy compared to laparoscopy are
also supported by institutional reviews and nationwide database studies. The NSQIP
targeted colectomy data set comparing HALS, and laparoscopy has demonstrated
shorter operating times with similar hospital stay in HALS compared to laparoscopic cohorts. However, higher odds of SSI in the HALS group compared to
straight laparoscopy was also reported. Other similar single-institution reviews of
214
Table 19.2 Summarized outcomes of randomized trials comparing HALS colectomy to laparoscopic colectomy
Reference
HALS Study Group
[30]
Marcello etal. [17] Shorter operative
Ng etal. [31] Operative time
Targarona etal.
[32]
HALS approach
time
Lower conversion
rate
Laparoscopic
approach
Shorter incision length Intraoperative
Lower postoperative
IL-6
Lower postoperative
CRP
N.G. Berger et al.
No difference
Operative time
Incision length
Operative blood loss
Conversion rates
Postoperative pain
Quality of life index
Hospital length of stay
Complications
Conversion rates
Operative blood loss
Return of bowel
function
Hospital length of stay
Conversion rates
Operative blood loss
Postoperative pain
Hospital length of stay
Postoperative
complications
5-year survival
Operative time
Return of bowel function
Overall complications
Hospital length of stay
HAL vs. laparoscopic colectomy have demonstrated higher postoperative medical
morbidity and similar costs in their HAL cohort, with one of these reviews demonstrating a higher lymph node yield for oncologic resections [18, 33, 34].
Conclusions
The surgical literature and practical considerations endorse HALS colon surgery as
an appropriate, oncologically sound technique with many advantages over open surgery and several over laparoscopy. While HALS was initially considered an intermediate operation meant to encourage laparoscopic skill development, this is no
longer the case. HALS colorectal surgery can be a destination operation that has
advantages over open surgery and achieves the short-term benets of straight laparoscopic operation while saving time in the operating room and minimizing
19 Is There Still aRole forHand-Assisted Laparoscopic Surgery (HALS)?
215
conversion rates. Especially for complicated operations, extended resections, and
operations conducted in overweight or obese patients, a HALS approach is a valuable technique for the minimally invasive surgeon to have at his or her disposal. The
available data supports these contentions. So, to the question “is there still a role for
hand-assisted laparoscopic surgery?” for colorectal disease, the authors would
answer with an emphatic “yes.”
References
1. Clinical Outcomes of Surgical Therapy Study Group, etal. A comparison of laparoscopically
assisted and open colectomy for colon cancer. N Engl JMed. 2004;350(20):2050–9.
2. Colon Cancer Laparoscopic or Open Resection Study Group, etal. Survival after laparoscopic
surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical
trial. Lancet Oncol. 2009;10(1):44–52.
3. Fleshman J, et al. Laparoscopic colectomy for cancer is not inferior to open surgery based
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662–4
4. Guillou PJ, etal. Short-term endpoints of conventional versus laparoscopic-assisted surgery
in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled
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7. Aly EH.Laparoscopic colorectal surgery: summary of the current evidence. Ann R Coll Surg
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11. Senagore AJ, Luchtefeld MA, Mackeigan JM.What is the learning curve for laparoscopic
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826–8
18. Ringley C, etal. Comparison of conventional laparoscopic and hand-assisted oncologic seg-
mental colonic resection. Surg Endosc. 2007;21(12):2137–41.
19. Flegal KM, et al. Prevalence of obesity and trends in the distribution of body mass index
among US adults, 1999-2010. JAMA. 2012;307(5):491–7.
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21. Bemelman WA, etal. Laparoscopic-assisted colectomy with the dexterity pneumo sleeve. Dis
Colon Rectum. 1996;39(10 Suppl):S59–61.
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trolled trial. Ann Surg. 2007;246(5):728–33.
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N.G. Berger et al.
Intracorporeal Anastomosis forRight
Colon Resection: Should This
BethePreferred Method?
BarrySalky
Abbreviations
BMI Body mass index
EC Extracorporeal
IBD Inammatory bowel disease
IC Intracorporeal
LLQ Left lower quadrant
LUQ Left upper quadrant
Definitions
20
Laparoscopic-assisted extracorporeal anastomosis: (EC) The bowel is mobilized
intracorporeally with division of the blood vessels inside the abdomen. An incision
is then made in the abdominal wall with extraction of the mobilized segment. The
two ends of the bowel are anastomosed outside the abdomen, and the completed
anastomosis is put back into the abdomen. The extraction incision is closed.
Laparoscopic intracorporeal anastomosis: (IC) The bowel is mobilized intracorporeally with division of the blood vessels inside the abdomen. The bowel is transected laparoscopically with laparoscopic stapling instruments. The two ends of the
bowel are then anastomosed inside the abdomen. The specimen is then extracted
through an incision in the abdominal wall. The extraction site is closed.
B. Salky (*)
Department of Surgery, Mount Sinai Health System, New York, NY, USA
e-mail: barry.salky@mountsinai.org
© Springer International Publishing AG 2018
C.M. Schlachta, P. Sylla (eds.), Current Common Dilemmas in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-70117-2_20
217
218
B. Salky
Introduction
I began laparoscopic colectomy in late 1992, and I have now performed about 1300
colorectal procedures. At the beginning, all procedures were laparoscopic-assisted
with extracorporeal anastomoses. While early procedures were performed with a
lateral to medial dissection, almost all are now performed medial to lateral. At the
beginning, all blood vessels were divided with clips and ties (or endoloop); now
every blood vessel is divided with either an energy source or vascular-loaded stapling devices. I began to switch to an intracorporeal technique in 2007; the reason
why is an interesting, short story. I was performing a demonstration right colectomy
for cancer at a teaching conference in Europe. I was getting ready to extract the
specimen in my usual way when Professor Jacques Perrisat asked me, “Why don’t
you make the anastomosis intracorporeally?” He then said, “It’s sitting right in front
of you, and you know how to use staplers and you can sew.” He was correct. So, my
rst intracorporeal anastomosis was on closed circuit television to more than 100
surgeons. It went beautifully. As the patient had a body mass index (BMI) of 36, I
was able to make a relatively short Pfannenstiel incision for extraction (my usual
incision was transverse midline). The postoperative pain difference was dramatic,
and I have not done an extracorporeal anastomosis for a right colon since then.
Advantages ofIC Anastomosis
It was difcult to change after having already performed more than 500 right colectomies in an extracorporeal fashion. I couldn’t believe that there was a better way.
Therefore, I began a prospective study of my own cases, comparing consecutive
cases [1]. Tables 20.1 and 20.2 list the patient demographics and intraoperative ndings in these two, consecutive groups of patients. There were no statistical differences in any category except that it took longer in the intracorporeal group, but the
blood loss was more in the extracorporeal group. The clinical differences in the
post-op course are listed in Table20.3, and they were dramatic, all in favor of intracorporeal anastomosis group.
The study clearly demonstrated less morbidity with the IC vs EC anastomosis,
all statistically signicant. As a side benet, the time to atus was shorter, time to
Table 20.1 Demographics
Intracorporeal (n=54) Extracorporeal (n=51)
Age (years) 45 50 0.181
Male to female (n) 19(35) 28(23) 0.042
BMI (kg/m
ASA class (mean) 2.1 2.2 0.242
Prior operation 21 23 0.519
Indication for surgery 0.167
IBD 33 30
Neoplasm 19 16
Other 2 5
2
) 23.8 23.4 0.705
P value
20 Intracorporeal Anastomosis forRight Colon Resection…
Table 20.2 Intraoperative
Operation performed
Ileocolic 33 33 0.583
R hemi 14 15
L hemi 6 3
Subtotal 1 0
Fistula takedown 14 16 0.537
OR time (min) 190 156 0.001
EBL (mL) 85.4 164 0.014
Intraop narcotics (mg)
morphine equivalents
Intraop complications 0 0
Table 20.3 Postoperative
Narcotic use (mg) 16 49 0.001
Time to atus (days) 2.0 2.4 0.017
Time to BM (days) 2.2 2.5 0.167
Length of stay (days) 3.2 3.8 0.019
Periop morbidity (n) 6 15 0.019
Anastomotic leak 0 1
Enterotomy 1 0
GI bleed 0 2
Obstruction 1 4
Intra-abd abscess 0 2
Wound infection 0 2
Cardiac 2 0
Blood transfusion 1 3
Urinary retention 0 1
Hematuria 0 2
Other 0 2
Mortality 0 0
Intracorporeal (n=54) Extracorporeal (n=51)
49 48 0.826
Intracorporeal Extracorporeal
p value
P value
219
bowel movement shorter, and length of stay shorter as well (all statistically signicant).
There was three-quarter less morphine equivalent usage as well. All extraction sites
were Pfannenstiel, which is a cosmetic bonus. When setting up the anastomosis, the
base of the mesentery is clearly seen, so that twisting the anastomosis is really
impossible (I have twisted three EC anastomoses).
Disadvantages ofIC Anastomosis
The only disadvantage I can think of is that the surgeon has to be comfortable with
intracorporeal suturing and knot-tying techniques. I would argue that this should be
a prerequisite for advanced laparoscopic cases anyway. It does require a change in
220
the thought process of the surgeon used to doing an extracorporeal anastomosis. It’s
hard to believe that an IC anastomosis can lead to less morbidity and a nicer cosmetic result unless the surgeon actually sees it.
B. Salky
Technique forLaparoscopic Ileocolic or Right Hemicolectomy
The patient is prepared for surgery according to modern guidelines and positioned
supine, unless a known ileosigmoid stula is present, and rst trocar access is
obtained. (I was trained to mechanically bowel prep patients having colon resection.
I have not seen any deleterious effects of bowel prepping a patient over the 40years
of performing colon surgery, and I am familiar with the literature). In my own study
quoted above, the only infectious complications were in the extracorporeal patients,
and the bowel prep was the same in both groups. Four trocars are placed. The 5mm
epigastric port is used for retraction, the midline 5mm for the 30-degree optic, and
the surgeon uses the suprapubic 5mm and the left lower quadrant (LLQ) 12mm
port to work. A 12mm port is necessary for placement of the stapling instruments.
I prefer bipolar energy and a medial to lateral approach to the dissection, but other
energy sources are okay, and a lateral to medial approach is ne too. Because I have
a 12mm port for the stapling instruments, I use a 10mm bipolar energy instrument.
It is possible to use a 5mm bipolar device, but there is too much “play” within the
trocar for me with a 5mm instrument.
Identify theAnatomy
The rst step is identifying the anatomy, which includes the ileocolic vessels, the
duodenum and the right transverse mesocolon (Fig. 20.1). The assistant uses the
epigastric port to grasp the cecum and elevate it. This will put tension on the IC vessels. In the vast majority of cases (even obese patients), the second portion of the
duodenum will be visible with this maneuver. Depending on the pathology, the anastomosis could be as low as the ascending colon or as high as the right mid- transverse
colon. If the anastomosis is lower, then the 12mm port is in the LLQ.If the anastomosis is going to be into the transverse colon, then the 12mm port is placed in the
left upper quadrant (LUQ). This will make it much easier to place the laparoscopic
GIA into the ileum and colon.
Intracorporeal Resection
Once the proper anatomy has been identied, traction is placed on the cecum with
the epigastric port grasper. (It is easier to use a self-locking grasper here). The peritoneum over the ileocolic vessels. If this is an inammatory bowel disease (IBD)
20 Intracorporeal Anastomosis forRight Colon Resection…
Fig. 20.1 A prominent
ileocolic blood vessel is
seen in the foreground. The
second portion of the
duodenum is seen just
below the scissor tip. This
patient has a right colic
vessel as well
221
patient, the division of the peritoneum is higher on the mesentery. If this is for cancer, the division is lower in order to encompass a complete lymphadenectomy. I like
to use an electrocautery scissor to score the mesentery. It is important to not get into
the mesenteric fat (bleeding) doing this scoring of the mesentery. I use 20 watts of
current on the electrocautery. The main reason for scoring the mesentery is to allow
the energy source that is going to divide the vessels to be placed directly on the vessel, not the peritoneum over the vessel. This will decrease the risk of bleeding from
use of the energy device. The proper surgical plane between the mesentery and the
retroperitoneal fascia is developed here. The ureters and gonadal vessels are below
this fascial plane. It is common to see vermiculation of the ureter through the fascia,
but I don’t make an effort to actually see the ureter. I do insist on seeing an intact
retroperitoneal fascia. If the fascia has been breached (or if this is a secondary ileocolic resection), the ureter is identied. In my mind, this would be a reason for
conversion to open if the ureter (or fascia) could not be identied with certainty.
This is an avascular plane between the mesentery and the retroperitoneal fascia.
If bleeding occurs here, it should alert the surgeon that the proper plane has not been
entered. If in the correct plane, the medial to lateral dissection should be very quick
and bloodless. Depending on the pathology, the actual number of blood vessels to
be divided can be different, but the principles are the same. There is also an avascular
plane just next to the bowel wall. I like to dissect all the tissues off so that I have only
bowel wall to transect with the laparoscopic linear cutting stapler. It is important to
transect at right angle to the bowel wall (Fig.20.2). This will reduce the incidence
of ischemia of the bowel wall. I must say it is encouraging to see a little bleeding
from the staple line to conrm good blood supply. Once the proximal and distal
bowel segments have been divided, the specimen is placed in the pelvis for extraction later on in the surgery. If this is cancer or there was a stula, the bowel is stored
in a nonporous retrieval bag until extracted.