title: Laparoscopic colorectal surgery for obese patients: decreased conversions with the hand-assisted technique.
abstract: BACKGROUND
  Laparoscopic surgery benefits obese patients but technical difficulties associated with suboptimal exposure and access in these subjects may prompt conversion to open surgery. Hand-assisted laparoscopic surgery (HALS) confers advantages over standard laparoscopy (LAP) by facilitating tactile feedback, assisted dissection, and retraction. These benefits could be particularly valuable in obese patients, allowing completion of difficult laparoscopic procedures in this subgroup. Our aim was to compare intra-operative and post-operative outcomes of HALS and LAP approaches in obese patients undergoing colorectal resection at our institution.
  
  
  METHODS
  A retrospective study of a prospectively maintained laparoscopic colorectal surgery database was performed. HALS and LAP cases performed in obese patients (body mass index (BMI) >30) were identified and compared for the following outcomes: operative time, intra-operative complications, rate of conversion to open, blood loss, length of stay, post-operative morbidity, and mortality. Outcomes for the converted patients were included on an intention-to-treat basis for all primary analyses. A secondary analysis of nonconverted and converted cases was also performed.
  
  
  RESULTS
  Over a 5-year period, 496 obese patients underwent laparoscopic colorectal resection; 86 HALS and 410 LAP cases. The two groups were comparable in terms of age, gender, BMI, and indications for surgery. Conversion to open surgery was less often necessary in HALS compared to LAP cases (3.5 % vs. 12.7 %, p = 0.014). The LAP group had a significantly smaller incision length for specimen extraction (HALS (7.0 ± 1.3 cm) vs. LAP (5.7 ± 2.1 cm), p < 0.001). Length of stay, operative time, morbidity, and mortality rates were comparable between the two groups.
  
  
  CONCLUSIONS
  In obese patients who require colectomy, the HALS approach increases the likelihood of a successful minimally invasive operation. At the cost of a clinically negligible increase in incision length, HALS may save a high-risk group conversion to formal laparotomy and the adverse outcomes related to this.
authors.affiliation: Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
authors.forename: Helen M
authors.initials: HM
authors.lastname: Heneghan
authors.forename: Sean T
authors.initials: ST
authors.lastname: Martin
authors.forename: Ravi P
authors.initials: RP
authors.lastname: Kiran
authors.forename: Wisam
authors.initials: W
authors.lastname: Khoury
authors.forename: Luca
authors.initials: L
authors.lastname: Stocchi
authors.forename: Feza H
authors.initials: FH
authors.lastname: Remzi
authors.forename: Jon D
authors.initials: JD
authors.lastname: Vogel
mesh_terms: D000328:Adult; D000368:Aged; D016063:Blood Loss, Surgical; D003082:Colectomy / Q000379:methods*; D005260:Female; D058733:Hand-Assisted Laparoscopy; D006801:Humans; D007431:Intraoperative Complications / Q000209:etiology*; D010535:Laparoscopy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000150:complications*; D061646:Operative Time; D012007:Rectum / Q000601:surgery; D012189:Retrospective Studies; D018709:Statistics, Nonparametric