Outcomes of Hand-assisted Surgery Significantly Worse Than Laparoscopic Colectomy

Since the adoption of laparoscopic colorectal surgery in 1991, laparoscopic colorectal surgery has evolved to theoretically less invasive methods including NOTES, transanal total mesorectal excision, and single port surgery.

Interestingly, there has been a divergent pathway to the more invasive hand-assisted surgery, which requires a much larger incision than does a laparoscopic colectomy.

Multiple small, single-center series have postulated that the significant increase in incision length needed to perform hand-assisted surgery is potentially justifiable due to the alleged improved tactile feedback theoretically allowing reduced operative time.

Gilmore and coworkers, including Cleveland Clinic Florida colorectal surgery alumnus, John Migaly from Duke University, tested this hypothesis through the National Surgical Quality Improvement Program participant data use file.

They specifically queried the NSQIP database for patients who underwent either laparoscopic or hand-assisted colectomy between 2012 and 2013.

During this time period, 7,865 patients (56.4%) underwent laparoscopic colectomy while 6,084 patients (43.6%) underwent hand-assisted surgery. As compared with patients who underwent laparoscopic colectomy, patients who underwent hand-assisted colectomy had higher rates of postoperative ileus (8.7% vs. 6.3%, P = 0.001), wound complications (8.8% vs. 6.3%, P = 0.006), and 30-day readmission (7.5% vs. 6.0%, P = 0.002) without any differences in operating time (156 vs. 157 minutes).

A subgroup analysis of patients who underwent segmental colectomy was undertaken. Compared with laparoscopy, hand-assisted surgery remained associated with high rates of wound complications (8.6% vs. 6.5%, P = 0.016), postoperative ileus (8.9% vs. 6.3%, P = 0.001), and 30-day readmissions (7.1% vs. 5.9%, P = 0.041) with a failure to show any reduction in operative times (145 minutes in both groups).

According to the authors, this very well-powered, large population-based analysis demonstrated that the use of hand-assisted surgery in routine colectomy “should be limited.”

It will be very interesting to see whether surgeons heed the results of the study or continue to make larger hand-assist incisions ― thereby, accordingly to these results ― increasing the morbidity rates in their patients without actually reducing operative time. I applaud the authors for this very well analyzed large, national data set.