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Introduction: Most minimally invasive surgery (MIS) surgeons utilize Laparoscopic Assisted (LA) or Hand-Assisted (HA) colorectal resection methods; the majority do not use both methods. This review of the experience of a group of MIS surgeons who embrace both methods selectively for sigmoid resection (SR) was begun in an attempt to identify factor(s) that influence the choice of surgical method. It was believed that the selective use of LA and HA methods would allow more cases to be done using MIS methods.
Methods: A retrospective review of SR data from 2 institutions over a 10 year period was carried out. Demographic data as well as comorbidities, indications, operative data, and short term results were reviewed.
Results: A total of 536 SR patients (pts) were identified, the methods used were: LA, 286 pts (53.4%); HA, 172 (32.1%); and Open (OP), 78 (14.5%). SR indications were cancer in 206 pts (38.4%) and benign problems (diverticulitis, polyps, IBD, etc) in 330 pts (61.6%). The HA group’s mean BMI (29.04±6.18) was significantly greater than the mean BMI of the LA (25.85±5.35) and OP (25.88±5.53) groups (p<0.0001 for both comparisons). In regards to benign SR’s, the HA group had significantly more high risk patients (HRP) than the LA group but significantly fewer HRP’s than the OP group (Charlson Comorbidity Index). In the cancer pts there was a trend toward more HRP’s in the HA vs. the LA group (p=0.074). Notably more OP pts required transfusions (34.6%) than LA (8.3%) or HA (7%) pts (p<0.0001 for both). The mean incision lengths (IL) were: LA, 6.59±4.18 cm; HA, 9.82±3.57 cm; and OP, 19.35±5.94 cm (p<0.05 for all). The mean time to first flatus (FL) and mean time to first bowel movement (BM) were significantly shorter for the LA (FL, 2.60 days; BM, 3.09 days) and HA groups (FL, 2.70 days; BM, 3.30 days) when compared to the OP group’s results (FL, 3.76 days; BM, 4.11 days). The HA mean length of stay (LOS) of 7.12±5.0 days was longer than for the LA pts (6.14±3.8 days; p=0.03) yet shorter than the OP LOS (11.5±10.6 days; p<0.0001). The overall morbidity rate for the three methods was: LA, 24.5%; HA, 38.4%, and OP, 48.7% (LA vs. OP; p=0.002, LA vs. HA; p=0.0021). The leak/abscess rates were: LA, 2.1%; HA, 2.9%; and OP, 3.8% (p=ns for all). There was no difference in the wound infection, bleeding, or cardiac complication rates.
Conclusions: The majority of SR’s were done using LA methods whereas HA methods were used for about 1/3 of cases. HA methods were used for higher BMI and higher risk pts (vs. LA patients). The HA LOS was 1 day longer than the LA group yet the HA and LA return of bowel function was similar. Except for BMI, the OP pts were the most challenging. Utilization of both HA and LA methods allows the great majority of SR cases to be done using MIS methods.