title: Combination of hand-assisted and laparoscopic proctocolectomy (HALP): Technical aspects, learning curve and early postoperative results.
abstract: BACKGROUND
  Various techniques for laparoscopic proctocolectomy have been reported worldwide. We evaluated the technical aspects and early postoperative results of hand-assisted laparoscopic proctocolectomy (HALP) with construction of an ileal pouch-anal anastomosis through a Pfannenstiel incision.
  
  
  METHODS
  Between June 2004 and May 2006, 20 patients (median age 28 years) underwent combined HALP at our institution. Preoperative diagnosis included ulcerative colitis (n = 16), indeterminate colitis (n = 1), familial adenomatous polyposis (n = 2), and carcinoma of the rectum associated with ulcerative colitis (n = 1). All patients were under immunosuppressive therapy. Laparoscopic mobilisation of rectum, sigmoid and descending colon was performed first. Subsequently, hand-assisted laparoscopic mobilization of the transverse and ascending colon as well as creation of an ileal J-pouch were performed through a Pfannenstiel incision. Ileal pouch-anal anastomosis was completed by transrectal stapling device and protected by a loop ileostomy.
  
  
  RESULTS
  The ileal pouch-anal anastomosis could be achieved in 19 cases (95%). There was one conversion (5%) to open surgery with construction of an end-ileostomy. No intraoperative blood transfusions were necessary. The median operating time was 210 minutes (range 180 min to 330 min). It was longer for the first five procedures but then remained constant. Two patients (10%) developed anastomotic leakage, which could be treated conservatively. Mean length of hospital stay was 11 days (range 7-32 days).
  
  
  CONCLUSIONS
  Combined HALP with construction of an ileal J-pouch-anal anastomosis can be performed safely and effectively. The Pfannenstiel incision proved to be advantageous for hand-assisted mobilisation of the transverse colon. Additionally, it was useful for the specimen removal and the J-pouch construction. Our new technique not only proved to be safe, but also resulted in a shortened total operation-time after a learning curve of about five procedures.
authors.affiliation: Department of Surgery, University of Regensburg, Regensburg, Germany. ayman.agha@klinik.uni-regensburg.de
authors.forename: Ayman
authors.initials: A
authors.lastname: Agha
authors.forename: Christian
authors.initials: C
authors.lastname: Moser
authors.forename: Igors
authors.initials: I
authors.lastname: Iesalnieks
authors.forename: Pompiliou
authors.initials: P
authors.lastname: Piso
authors.forename: Hans-J
authors.initials: HJ
authors.lastname: Schlitt
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000601:surgery; D000714:Anastomosis, Surgical / Q000379:methods; D003108:Colonic Diseases / Q000601:surgery*; D039021:Colonic Pouches; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016737:Proctocolectomy, Restorative / Q000193:education / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome