Prospective randomized trial comparing conventional laparoscopic colectomy with hand-assisted laparoscopic colectomy: applicability, immediate clinical outcome, inflammatory response, and cost. Hand-assisted laparoscopic vs. laparoscopic colorectal surgery: a multicenter, prospective, randomized trial. A prospective randomized comparison of two instruments for dissection and vessel sealing in laparoscopic colorectal surgery. Energy sources for laparoscopic colectomy: a prospective randomized comparison of conventional electrosurgery, bipolar computer-controlled electrosurgery and ultrasonic dissection. Operative outcome and costs analysis. The usefulness of restorative laparoscopic-assisted total colectomy for ulcerative colitis. Prospective evaluation of laparoscopy-assisted colectomy versus laparotomy with resection for management of complex polyps of the sigmoid colon.
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.
                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.
                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.
                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. This study was designed to compare short-term outcomes after hand-assisted laparoscopic vs. straight laparoscopic colorectal surgery.
                Eleven surgeons at five centers participated in a prospective, randomized trial of patients undergoing elective laparoscopic sigmoid/left colectomy and total colectomy. The study was powered to detect a 30-minute reduction in operative time between hand-assisted laparoscopic and straight laparoscopic groups.
                There were 47 hand-assisted patients (33 sigmoid/left colectomy, 14 total colectomy) and 48 straight laparoscopic patients (33 sigmoid/left colectomy, 15 total colectomy). There were no differences in the patient age, sex, body mass index, previous surgery, diagnosis, and procedures performed between the hand-assisted and straight laparoscopic groups. Resident participation in the procedures was similar for all groups. The mean operative time (in minutes) was significantly less in the hand-assisted laparoscopic group for both the sigmoid colectomy (175 +/- 58 vs. 208 +/- 55; P = 0.021) and total colectomy groups (time to colectomy completion, 127 +/- 31 vs. 184 +/- 72; P = 0.015). There were no apparent differences in the time to return of bowel function, tolerance of diet, length of stay, postoperative pain scores, or narcotic usage between the hand-assisted laparoscopic and straight laparoscopic groups. There was one (2 percent) conversion in the hand-assisted laparoscopic group and six (12.5 percent) in the straight laparoscopic group (P = 0.11). Complications were similar in both groups (hand-assisted, 21 percent vs. straight laparoscopic, 19 percent; P = 0.68).
                In this prospective, randomized study, hand-assisted laparoscopic colorectal surgery resulted in significantly shorter operative times while maintaining similar clinical outcomes as straight laparoscopic techniques for patients undergoing left-sided colectomy and total abdominal colectomy. A newly available, laparoscopic 5-mm bipolar vessel sealing device promises substantial advantages over the 10-mm instrument. This study compared the safety as well as the technical and surgical aspects of these different tools.
                For this study, 30 consecutive patients undergoing laparoscopic left-sided colectomy were prospectively randomized for the 5-mm LigaSure or The 10-mm LigaSure. The patients' demographics were analyzed together with their intraoperative and postoperative parameters, and the instruments were assessed by the surgeons with a standardized questionnaire.
                The two groups were comparable and demonstrated similar mean operation times, blood losses, and hospital stays. The 5-mm LigaSure was applied in more operation steps and resulted in fewer bleeding episodes and less lens cleaning. Monopolar scissors were used less frequently in the 5-mm group, thus minimizing cauteric lesions and their complications (0 in the 5-mm group vs 2 in the 10-mm group). Overall satisfaction with the 5-mm LigaSure was significantly higher (8.4 +/- 0.18 vs 6.9 +/- 0.41 out of 10; p = 0.002), with significant advantages in terms of dissection capacity, visibility, and handling.
                The 5-mm LigaSure is as secure and fast as the larger 10-mm device and compares favorably in terms of finer dissection as well as trocar flexibility and handling. Therefore, it can be used safely in laparoscopic colorectal surgery. The development of operative laparoscopic surgery is linked to advances in ancillary surgical instrumentation. Ultrasonic energy devices avoid the use of electricity and provide effective control of small- to medium-sized vessels. Bipolar computer-controlled electrosurgical technology eliminates the disadvantages of electrical energy, and a mechanical blade adds a cutting action. This instrument can provide effective hemostasis of large vessels up to 7 mm. Such devices significantly increase the cost of laparoscopic procedures, however, and the amount of evidence-based information on this topic is surprisingly scarce. This study compared the effectiveness of three different energy sources on the laparoscopic performance of a left colectomy. The trial included 38 nonselected patients with a disease of the colon requiring an elective segmental left-sided colon resection. Patients were preoperatively randomized into three groups. Group I had electrosurgery; vascular dissection was performed entirely with an electrosurgery generator, and vessels were controlled with clips. Group II underwent computer-controlled bipolar electrosurgery; vascular and mesocolon section was completed by using the 10-mm Ligasure device alone. In group III, 5-mm ultrasonic shears (Harmonic Scalpel) were used for bowel dissection, vascular pedicle dissection, and mesocolon transection. The mesenteric vessel pedicle was controlled with an endostapler. Demographics (age, sex, body mass index, comorbidity, previous surgery and diagnoses requiring surgery) were recorded, as were surgical details (operative time, conversion, blood loss), additional disposable instruments (number of trocars, EndoGIA charges, and clip appliers), and clinical outcome. Intraoperative economic costs were also evaluated. End points of the trial were operative time and intraoperative blood loss, and an intention-to-treat principle was followed. The three groups were well matched for demographic and pathologic features. Surgical time was significantly longer in patients operated on with conventional electrosurgery vs the Harmonic Scalpel or computed-based bipolar energy devices. This finding correlated with a significant reduction in intraoperative blood loss. Conversion to other endoscopic techniques was more frequent in Group I; however, conversion to open surgery was similar in all three groups. No intraoperative accident related to the use of the specific device was observed in any group. Immediate outcome was similar in the three groups, without differences in morbidity, mortality, or hospital stay. Analysis of operative costs showed no significant differences between the three groups. High-energy power sources specifically adapted for endoscopic surgery reduce operative time and blood loss and may be considered cost-effective when left colectomy is used as a model. The aim of this study was to evaluate the effectiveness of laparoscopic-assisted total colectomy with ileal J-pouch anal anastomosis in comparison with that of conventional open total colectomy in patients with ulcerative colitis. From 1990 until 1999, 11 patients underwent open total colectomy, while 21 patients had laparoscopic-assisted total colectomy. Patients characteristics, perioperative course, and recovery were compared. Differences between the groups were tested using Student's t-test for independent groups and chi-square tests when appropriate. Nasogastric tube could be removed after POD 1.1 vs. 4.8 (p < 0.05), the mean time to passage of stool was 1.7 (range, 1 to 3) vs. 5.4 (range, 3 to 7) days (p < 0.05), and in the laparoscopic group watery stool was soon made solid after POD 24.3 vs. 87.3 (p < 0.01). There were no significant differences in the mean operating time and mean estimated operating blood loss between two groups. Postoperative morbidity did not differ significantly between the patients treated conventionally (45.5%) and laparoscopically (33.3%). The findings of this study indicate that laparoscopic-assisted total colectomy improved cosmetic results and to be a safe and effective treatment for the elective surgery of ulcerative colitis. Laparoscopy-assisted colectomy is technically feasible, but objective evidence of its benefits remains scarce. This study was done to evaluate the outcomes and operative stress of laparoscopy-assisted colectomy versus the traditional open method in the management of sigmoid complex polyps that cannot be safely or adequately removed by colonofibroscopy. Between January 1997 and December 1999, a total of 42 patients were equally randomized to the laparoscopy group and the laparotomy group by the blocked randomization method. Three patients randomized to the laparoscopy group did not complete the trial; therefore 18 patients treated by laparoscopy-assisted sigmoidectomy and the other 21 treated by the open method were prospectively evaluated. These two groups of patients were well matched in age, gender, symptoms, tumor location, localization method, tumor size, morphology, histopathology, and the accuracy of the clinical diagnosis. Two standardized surgical strategies, the lateral-to-medial and medial-to-lateral dissection sequences, were performed in 14 and 4 patients of the laparoscopy group, respectively, according to whether their tumors were located above or below 20 cm above the anal verge. After evaluating the surgical outcomes, we found that the laparoscopy group was significantly better than the laparotomy group in regard to parameters that included severity of postoperative pain, wound size, postoperative complication rate, and the duration of postoperative ileus, hospitalization, and disability. There was no significant difference in the operating times for these two groups. However, the costs of the laparoscopy group were significantly higher. To evaluate the surgical stress, we measured the serum C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), total lymphocyte count, and CD4+/CD8+ ratio 24 hours before and after surgery. We found that the postoperative serum CRP level and the ESR were significantly less elevated and the total lymphocyte counts and CD4+/CD8+ ratio were significantly less depressed in the laparoscopy group than in the laparotomy group. We thus concluded that laparoscopy-assisted sigmoidectomy can be safely performed with shorter convalescence and less operative stress but at a higher cost. We strongly recommended the use of this technique in the management of sigmoid complex polyps if the patient's economic status permits.
The limitations of this review is the small number of trials and heterogeneity of the studies included. With the current evidence it is not possible to demonstrate which is the best instrument in laparoscopic colectomy. Hopefully more data would follow and subsequent updates of this review could become more informative.