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INTRODUCTION: Hand-assisted laparoscopy has been shown to maintain the short-term advantages of standard laparoscopy while providing surgeons with stereotactic feedback. In addition, it has been proposed to reduce the length of the training curve for minimally invasive colorectal surgery. We hypothesize that the widespread adoption of hand-assisted laparoscopy in colorectal cancer resections would allow for a rapid increase in the use of minimally invasive techniques without compromising patient safety or operative efficiency.METHODS: A retrospective analysis of a prospectively maintained colorectal cancer database containing cases prior and subsequent to the adoption of hand-assisted laparoscopy was completed. There was no significant variation in the composition of surgeons in the practice during the study period. The change in distribution of minimally invasive cases over time quantified the rapidity of implementation of minimally invasive techniques. Surrogate markers of the learning curve, including complication rates, conversion rates, and operative times, were similarly evaluated. The Fisher’s exact and Mann-Whitney U tests were used, where appropriate, for analysis.RESULTS: 115 hand-assisted laparoscopic cases were performed during the study period, of which 44% were rectal resections, 44% were right-sided, 11% were left-sided, and 2% were subtotal or total resections. Prior to the initiation of hand-assisted laparoscopy, the volume of laparoscopic-assisted colorectal surgeries was 10%. For the year following implementation of hand-assisted laparoscopy, the rate of minimally invasive cases increased to 39%, followed by 89% and 90% for the subsequent years (p<0.0005, see Table 1). Rates of complications in minimally invasive cases, including rates of wound infection and anastomotic leak, did not change with the increased use of minimally invasive techniques (p=0.076 and 0.618, respectively). Conversion rates decreased dramatically, from 42% to 12% (p<0.0005). Similar patterns were noted when individual surgeons were analyzed independently. In terms of operative efficiency, prior to the use of hand-assisted laparoscopy, the operative time for laparoscopic-assisted resections was significantly higher than for open resections (p=0.001, see Table 2). After implementation of hand-assisted laparoscopy, the operative times for minimally invasive resections and for open resections equalized (p=0.519).CONCLUSION: Implementation of hand-assisted laparoscopy into a colorectal cancer practice leads to an abbreviation of the laparoscopic learning curve with a rapid adoption of minimally invasive techniques, while maintaining patient safety and operative efficiency.
Table 1. Learning curve and safety. Values reported are percentages.

	Prior to HAL implementation	2008	2009	2010	p-value
MIS surgeries (% total cases)	10.2%	38.5%	89.0%	89.7%	<0.0005
Complications
Wound infection rate	19.4%	19.4%	18.5%	7.7%	0.076
Anastomotic leak rate	0%	3.3%	4.6%	0%	0.618
Conversion rate	41.9%	3.3%	7.8%	11.5%	<0.0005

HAL - hand-assisted laparoscopy. MIS - minimally invasive.
Table 2. Learning curve and operative efficiency. Values reported are median (range).

		Prior to HAL implementation	2008	2009	2010
Operative time (minutes)	Open cases	198(38-545)	200 (103-711)	337 (241-662)	259(205-705)
	MIS cases	238(138-450)	201 (113-457)	227 (96-639)	251(107-446)
p-value		0.001	0.996	0.008	0.519

MIS - minimally invasive.