title: Evolution of technique in performance of minimally invasive colectomies.
abstract: BACKGROUND
  Hand-assisted laparoscopic surgery is commonly used in colorectal surgery and provides benefit in complex cases.
  
  
  OBJECTIVE
  This study examined the minimally invasive surgical trends, patient characteristics, and operative variables unique to patients undergoing hand-assisted laparoscopic surgery.
  
  
  METHODS
  This was a retrospective medical chart review.
  
  
  METHODS
  The study was conducted in a tertiary care medical center.
  
  
  METHODS
  Patients included in the study were those who underwent pure laparoscopic colectomies, hand-assisted laparoscopic colectomies, and traditional open surgery for elective treatment of diverticular disease, colorectal cancer, IBD, and benign polyp disease.
  
  
  METHODS
  Primary outcomes included patient characteristics and operative variables unique to patients undergoing hand-assisted laparoscopic surgery and documentation of operative technique trends within an experienced colorectal group.
  
  
  RESULTS
  Diverticular disease characteristics specific to hand-assisted laparoscopic surgery included the presence of dense inflammatory adhesions (p < 0.0001), diverticular fistulas (p < 0.0001), and unresolved phlegmon (p = 0.0003). Characteristics specific for colorectal cancer included intraoperative tumor bulk (p < 0.0001) and the inability to achieve appropriate surgical resection margins (p < 0.001). Similarly, variables identified for benign polyp disease included adhesions (p < 0.0001) and the ability to gain adequate exposure (p < 0.0001). Limited use of hand-assisted laparoscopic surgery was observed in patients with IBD.
  
  
  CONCLUSIONS
  This was a retrospective, observational study from a single center.
  
  
  CONCLUSIONS
  Conversion to hand-assisted laparoscopic surgery provides benefit in surgical scenarios where dense inflammatory adhesions, diverticular fistulas, and intra-abdominal postdiverticulitis phlegmon are present. In addition, benefit is observed in patients with colorectal cancer where laparoscopic dissection of bulky tumor proves to be difficult and where the technical ability to obtain margins using pure laparoscopy is compromised. Although our practice has changed to favor pure laparoscopy, hand-assisted laparoscopic surgery continues to play an important role in complex colorectal cases that otherwise would require open surgery (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A146).
authors.affiliation: 1Department of Surgery, Hartford Hospital, Hartford, Connecticut 2University of Connecticut Integrated General Surgery Residency Program, Farmington, Connecticut 3School of Medicine, University of Connecticut, Farmington, Connecticut 4Department of Surgery, Hospital of Central Connecticut, New Britain, Connecticut.
authors.forename: Caroline C
authors.initials: CC
authors.lastname: Jadlowiec
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Mannion
authors.forename: Mary J
authors.initials: MJ
authors.lastname: Thielman
authors.forename: Christine M
authors.initials: CM
authors.lastname: Bartus
authors.forename: Kristina H
authors.initials: KH
authors.lastname: Johnson
authors.forename: William V
authors.initials: WV
authors.lastname: Sardella
authors.forename: Paul V
authors.initials: PV
authors.lastname: Vignati
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Cohen
mesh_terms: D002983:Clinical Competence; D003082:Colectomy / Q000379:methods*; D003111:Colonic Polyps / Q000601:surgery; D015179:Colorectal Neoplasms / Q000601:surgery; D003107:Colorectal Surgery / Q000379:methods*; D004241:Diverticulum, Colon / Q000601:surgery; D005260:Female; D058733:Hand-Assisted Laparoscopy; D006801:Humans; D043183:Irritable Bowel Syndrome / Q000601:surgery; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome