Prospective randomized trial comparing conventional laparoscopic colectomy with hand-assisted laparoscopic colectomy: applicability, immediate clinical outcome, inflammatory response, and cost.
BACKGROUND
Hand-assisted laparoscopic surgery (HALS) represents a useful alternative to conventional laparoscopic surgery (LS). Its potential advantages--(a quicker, safer procedure and less need to convert to open surgery) are due to the recovery of tactile feedback. However, HALS requires the performance of a mini-laparotomy when surgery commences, and the wound is stretched and compressed throughout the procedure. In addition, it is associated with a more intense manipulation of the intraabdominal viscera. All of these factors increase the surgical trauma, it is not known whether HALS maintains the minimally invasive characteristics of conventional LS. Therefore, we set out to study the applicability, immediate clinical outcome, inflammatory response, and cost of HALS compared with conventional LS using colectomy as a model.


METHODS
We performed a prospective randomized trial comparing laparoscopic-assisted colectomy with HAL colectomy. The aims of the study were to assess (a) perioperative features, including time, advantages, and conversion; (b) the patient's immediate clinical response, including recovery of bowel sounds, refeeding time, postoperative pain, local and general morbidity, and hospital stay; (c) the effect on the inflammatory response, using interleukin-6 (ILG) and C-reactive protein (CRP) measurements; (d) oncological issues, including intraoperative cytology and features of the specimen; and (d) the relative costs of the two procedures.


RESULTS
A total of 54 patients were enrolled in the study, 27 laparoscopic and 27 HALS. The operative times were similar, but HALS was associated with a far lower conversion rate--7% vs 23%. Immediate clinical outcomes, oncological features, and costs were similar for the two procedures, but HALS was associated with a significantly greater increase in IL6 and CRP than the conventional laparoscopic procedure.


CONCLUSIONS
This comparative study shows that HALS simplifies difficult intraoperative situations, reducing the need for conversion. Although it is a more aggressive procedure, HALS preserves the features of a minimally invasive approach, maintains all of the oncological features of conventional laparoscopic surgery, and does not increase the cost. HALS should therefore be considered as a useful adjunct when difficult situations arise during conventional laparoscopic colectomy.
Targarona
E M
EM
Department of General and Digestive Surgery, Hospital de Sant Pau, Autonomous University of Barcelona, C/ Padre Claret 167, 08025 Barcelona, Spain. etargarona@hsp.santpau.es
Gracia
E
E
Garriga
J
J
Martínez-Bru
C
C
Cortés
M
M
Boluda
R
R
Lerma
L
L
Trías
M
M
D000368:Aged; D000369:Aged, 80 and over; D015992:Body Mass Index; D003082:Colectomy / Q000009:adverse effects / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007249:Inflammation / Q000209:etiology; D007432:Intraoperative Period; D010535:Laparoscopy / Q000009:adverse effects / Q000191:economics / Q000379:methods* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D016896:Treatment Outcome