A new multitool for hand-assisted advanced laparoscopic surgery (HALS)

Background: Hand-assisted laparoscopic surgery (HALS), which has become possible due to the introduction of effective hand-access devices, facilitates the execution of major operations. Over the past 2 years, we have been evaluating various designs for small instruments that can be used by the internal assisting hand. Here we report on the development, testing, and evaluation of a small reusable multitool that hangs from the little finger of the internal assisting hand of the surgeon when not in use. Methods: The Dundee Multitool (DMT) was designed to enable the internal deployment (by thumb extrusion) of a small dissecting forceps (pickup), needle driver, and scissors. The multitool hangs from the little finger of the internal assisting hand when not in use. The instrument was subjected to beta testing in the laboratory using HALS trainers. When testing was completed, it was used in major HALS operations after approval by the hospital and consent of the individual patients. Results: The DMT was found to work well. The various active instruments could be extruded from the casing with ease and functioned well in picking up tissues, intracorporeal suturing/tying, and the cutting of sutures and ligatures. Both in laboratory experiments and during clinical evaluation, suturing was easy when the active driving of the needle though the tissues was carried out by the external hand. The multitool needle driver, held by the internal hand as an assisting instrument in conjunction with active needle driving through the tissue edges by the dominant (external) hand, improved suturing efficiency (i.e., reduced execution time) by 30% when compared to total laparoscopic suturing. Conclusions: We have described a novel little-finger–hung multitool for HALS surgery that deploys with ease at any one time. It incorporates a needle driver, a dissecting forceps, and a suture scissors. The good functionality of the multitool has been confirmed by both laboratory experiments and clinical evaluation.     

Hand-assisted laparoscopic surgery (HALS): a report of 150 procedures

Background: This study was performed to evaluate the (long-term) morbidity associated with hand-assisted laparoscopic surgery (HALS) for various indications. Methods: HALS procedures for various indications were evaluated prospectively from 1995 to 2002. The primary outcome parameters were postsurgical complications and the development of incisional hernias. Results: Twenty-six splenectomies, 51 hand-assisted laparoscopic donor nephrectomies (HLDN), 34 segmental bowel resections, 29 proctocolectomies, and 10 emergency colectomies were evaluated. A Küstner or Pfannenstiel incision was used for handport placement. Minor complications (i.e., wound complications, urinary tract infection) occurred in 15%, 12%, 26%, 7%, and 33% of the patients after, respectively, splenectomy, HLDN, bowel resection, proctocolectomy, and emergency colectomy. Major complications (i.e., hemorrhage, anastomotic leakage) occurred in 15% and 12% of the patients after, respectively, bowel resection and proctocolectomy. Incisional hernias occurred in six patients (4%), all after a wound complication in the Küstner incision. Conclusion: HALS is fast, safe, and feasible for various indications, especially HLDN and (procto-)colectomies. Little advantage can be expected when HALS is applied in splenectomy and segmental bowel (sigmoid) resection.     

"蓝碟"手助技术在腹腔镜腹部手术的应用——附78例报告

目的探讨“蓝碟”（Lapdisc）手助器辅助腹腔镜手术（hand—assisted laparoscopic surgery，HALS）用于腹部手术的可行性。方法建立CO2气腹，根据病变部位和手术的要求，放置trocar和“蓝碟”手助器，对78例腹部疾病施行HALS，观察“蓝碟”手助器在腹部HALSA的实施过程，术中效果及术后临床效果。结果经Lapdisc完成70例HALS，术中出血量100—300ml，平均186ml；手术时间60—240min，平均140min；住院时间9—15d，平均10．2d。8例因腹腔镜下操作复杂危险而中转开腹。结论“蓝碟”手助器使用简单、感觉舒适，对切口提供完美保护，术中能维持良好的气腹状态。“蓝碟”简化传统腹腔镜的操作，可应用于绝大多数腹部外科疾病的HALS，安全可行。     

Hand-assisted laparoscopic colorectal surgery using GelPort

Background: An easily usable hand access device will optimize success in hand-assisted laparoscopic surgery (HALS). The authors describe their initial series of HALS colorectal resections using GelPort to evaluate their current technique and results with this new device. Methods: A retrospective study investigated 33 HALS colorectal procedures including total colectomy (n = 16) and low anterior resection (n = 10). All operative data, including intraoperative GelPort performance, were prospectively recorded and retrospectively analyzed. Results: In this study, 3 (9.1%) of 33 HALS procedures were converted to open surgery, and 4 (13.3%) of 30 HALS procedures required minimal enlargement of incisions to facilitate extracorporeal procedures. The operative time was 263 ± 85 min, and the blood loss was 282 ± 148 ml. There were no device malfunctions. Three major complications (9.1%) and 7 minor wound infections (21%) were noted postoperatively. The mean hospital stay was 7.9 ± 3.8 days. Conclusion: When performed with GelPort, HALS is safely and reliably applicable for various colorectal procedures.     

乙状结肠癌根治术手辅助腹腔镜与开腹手术围手术期疗效的对比

目的对比手辅助腹腔镜技术和传统开腹技术在乙状结肠癌治疗中的安全性及围手术期疗效。方法回顾性总结2009年1月至2010年6月在北京大学肿瘤医院结直肠外科施行乙状结肠癌根治性手术的115例患者的临床资料,其中手辅助腔镜（HALS组）62例,开腹组53例,对比两组手术的安全性及围手术期疗效。结果HALS组与开腹组术中清扫淋巴结总数分别为（15．1±4．6）枚和（16．8±6．4）枚（P=0．163）;两组的肿块切缘分别为（4．1±1．8）cm和（4．3±1．7）cre（P=0．601）：两组手术时间分别为（122．4±32．0）min和（126．7±37．4）min（P=0．510）。HALS组术中出血量（62．6±35．4）ml,明显少于开腹组的（168．9±137．1）ml（P=0．000）;术后围手术期并发症发生率1．6％（1／62．为肺部感染1例）,明显低于开腹组的11．3％（6／53,分别为吻合口瘘1例．腹盆腔感染2例和切口感染3例）（P=0．030）;术后胃肠功能恢复快[（2．3±0．8）d比（3.3±1．1）d,P=O．000];术后平均住院日缩短[（8．8±2．7）d比（12．6±8．0）d,P=0．001]。结论手辅助腔镜用于乙状结肠癌切除术与开腹手术相比,可达到同样的近期根治效果,并具有安全、微创的优势。     

Grasping and dissecting instrument for hand-assisted laparoscopic surgery

Background: The operative potential of hand-assisted laparoscopic surgery (HALS) could be enhanced by the introduction of a new generation of assisting instruments. These tools will have to meet specific requirements of shape, function, and safety of use. Methods: Problems related to the working environment of HALS and deriving projectual restrictions of HALS instruments were analyzed in order to develop and manufacture a working prototype with grasping and dissecting properties to assist during HALS procedures. The resulting instrument was mechanically and clinically tested in 22 HALS procedures. Results: The additional benefit of the new device was particularly appreciated during dissection and isolation of vascular pedicles (nephrectomies and splenectomies). It was shown to be safe and effective in providing the additional assistance it was designed for. Conclusion: The described grasping and dissecting instrument for HALS is of great value in assisting the surgeon during fine dissection, as required in selected procedures. New generation of HALS instruments should comply with the functional and safety issues analyzed in this report.     

Laparoscopic total colectomy: hand-assisted vs standard technique

Background: Although hand-assisted laparoscopic surgery (HALS) has been proposed as an alternative to laparoscopically assisted surgery (LAP), little is known about its role in total colectomy. The objectives of the study were to compare the outcomes in patients undergoing total colectomy via either HALS or LAP and to determine what benefits HALS might have in extensive colorectal procedures. Methods: We reviewed the data for 23 patients who underwent total proctocolectomy (TPC) or total abdominal colectomy (TAC) using either a HALS or LAP technique. Results: There were 12 HALS (five TPC, seven TAC) and 11 LAP (seven TPC, four TAC) for ulcerative colitis (n = 17), familial polyposis (n = 5), and colonic inertia (n = 1). One LAP was converted (9.1%). The operative time was shorter for HALS than for LAP (210 vs 273 min; p = 0.03). Blood loss and incision length were similar. Postoperative recovery and morbidity rates were comparable. Conclusion: HALS reduces the operative time but patient morbidity rates and recovery are similar to LAP. HALS may be preferable for extensive colorectal procedures such as TPC and TAC. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, 13–15 March 2003.     

脾破裂手助腹腔镜切除术的应用

目的:探讨手助腹腔镜技术在脾破裂切除术中的应用。方法:用手助腹腔镜技术为15例外伤性脾破裂患者行脾切除术。结果:14例顺利完成手术,1例术中大出血中转开腹,平均手术时间105min,术中平均失血110ml,平均住院6.5d。结论:手助腹腔镜技术治疗外伤性脾破裂是安全可行的,适用于无脑、胸损伤,血液动力学稳定的患者。     

手辅助腹腔镜手术在胃肠外科中的应用及适应证选择

尽管传统腹腔镜技术在胃肠道良恶性疾病中的应用逐步获得广泛的认可,但仍有学习曲线延长、手术时间延长、技术难度增加以及肥胖患者手术复杂性等不足。手辅助腹腔镜技术（HALS）作为介于开腹手术与腹腔镜手术的一种杂交技术．由于恢复了手的触觉以及手眼协调．弥补了传统腹腔镜手术的不足．同时部分保留了传统腹腔镜手术的微创优势,且手术时间及学习曲线明显缩短．在肥胖患者及复杂的胃肠手术中具有一定优势。但HALS手术也存在手对术野的阻挡和手疲劳等不足．HALS治疗恶性肿瘤的近远期疗效尚待更多的循证学研究加以证实。     

手辅助腹腔镜在结直肠肿瘤手术中的应用

目的探讨手辅助腹腔镜技术（HALS）在结直肠肿瘤手术中的安全性和有效性。方法回顾性分析接受HALS治疗的70例结直肠癌患者的临床资料。结果70例患者中男性38例．女性32例．中位年龄61岁。乙状结肠腺瘤4例,乙状结肠癌48例,降结肠癌3例,升结肠癌1例．直肠癌13例,全结肠切除1例。所有患者均顺利完成HALS,无中转开腹病例。手术时间为（126．0±22．5）min：术中出血（75．0±18．8）ml;平均清扫淋巴结（16．8±4．2）枚,术后平均住院9．4d。无围手术期死亡病例,术后1例患者出现吻合口狭窄,2例吻合口瘘,均经保守治疗好转。结论HALS用于结肠癌手术创伤小、易掌握、安全性高,具有良好应用前景。     

Ideal manipulation angle and instrument length in hand-assisted laparoscopic surgery

Background This study aimed to investigate the impact of manipulation angles and instrument length on task performance and muscle workload in hand-assisted laparoscopic surgery. Methods The standard task was to close a 5-cm enterotomy of porcine small bowel inside a hand-assisted laparoscopic trainer. Surgeons were instructed to place the sutures 3 to 5 mm apart and from the enterotomy edge. Ten surgeons participated in each experiment. In the first experiment, each surgeon performed one task for each of the following manipulation angles: 45°, 60°, 75°, and 90°. In the second experiment, each surgeon performed two sessions of three tasks using either standard-length (330 mm) or short (250 mm) needle holders in the external hand. Outcome measures were execution time (s), placement error score (mm deviation from exact placement), leaking pressure (mmHg), and muscle workload by upper extremities as measured by integrated electromyography (mV s). Results In the first experiments, the mean execution time was significantly longer with 90° angles than with 45° and 60° manipulation angles (1,074.9 vs 715.9 s and 657.9 s with p < 0.05 and p < 0.01, respectively). The 90° manipulation angle had the greatest muscle workload by the deltoid and trapezius of the extracorporeal and intracorporeal limbs and the extracorporeal dominant arm extensor and flexor groups. In the second experiment, the short instruments had a shorter mean execution time than the standard-length instrument (572.05 vs 618.75 s; p < 0.01). There was less muscle workload with the short than with the standard-length instrument by the extracorporeal dominant forearm extensor and flexor muscle groups and the deltoid of extracorporeal dominant and intracorporeal limbs. There were no significant differences in leaking pressure or placement error score between the different manipulation angles and instrument lengths. Conclusion The best ergonomic setup in hand-assisted laparoscopic surgery entails a manipulation angle of 45° to 60° and use of an instrument with a shorter shaft than standard laparoscopic length. The study of manipulation angle was presented at the 12th International Congress of the European Association for Endoscopic Surgery (EAES) and Other Interventional Techniques, Barcelona, June 2004; the experiment on instrument length was presented at the Technology Award Session, the 13th International Congress of the EAES, Venice, June 2005.     

手助腹腔镜扩大右半结肠切除血管骨骼化淋巴清扫术

目的探讨手助腹腔镜(HALS)能否模拟完成扩大右半结肠切除术中血管骨骼化淋巴结清扫。方法2001年11月至2004年9月由同一组医生对30例右半结肠癌患者分别完成HALS(腹腔镜组)和开腹手术(开腹组),各15例。分析比较两组患者的临床资料。结果腹腔镜组与开腹组的手术时间分别为(214.0±16.5)min和(245.0±24.6)min(t=2.248,P<0.05);术中出血量分别为(78.4±24.3)ml与(203.3±48.5)ml(t=4.927,P<0.05);术后肛门排气时间分别为(53.4±6.7)h与(67.3±9.7)h(t=2.530,P<0.05);术后住院天数分别为(11.5±1.11)d与(17.9±4.0)d(t=3.413,P<0.05);肠旁各站淋巴结数N1分别为(15.3±2.6)枚与(16.2±3.3)枚(t=0.48,P>0.05);N2分别为(5.6±1.6)枚与(5.9±2.2)枚(t=0.213,P>0.05),N3分别为(4.3±2.2)枚与(6.1±1.5)枚(t=1.429,P>0.05),两组患者术后并发症发生率分别为20.0%(3/15)与33.3%(5/15),(χ2=0.0227,P>0.05)。结论HALS可以很好地完成扩大右半结肠切除、术中血管骨骼化淋巴清扫这一高难度手术。     

Hand-assisted laparoscopic surgery versus open surgery for colorectal disease: a systematic review and meta-analysis

BackgroundLaparoscopic colorectal surgery remains one of the most challenging techniques to learn.MethodsThe authors collected studies that have compared hand-assisted laparoscopic surgery (HALS) and open surgery for the treatment of colorectal disease over the past 17 years. Data of interest for HALS and open surgery were subjected to meta-analysis.ResultsTwelve studies that included 1,362 patients were studied. In total, 2.66% of HALS procedures were converted to laparotomy. Compared with the open surgery group, blood loss, rate of wound infection, and ileus in the HALS group decreased, and incision length, recovery of gastrointestinal function, and hospitalization period were shorter. There were no significant differences in operating time, hospitalization costs, mortality, and complications, including urinary tract infection, pneumonia, and anastomotic leak, between the groups.ConclusionsHALS has the advantages of minimal invasion, lower blood loss, shorter incision length, and faster recovery, and it can shorten the length of hospitalization without an increase in costs. The drawbacks are that a small number of patients who undergo HALS may need to be converted to laparotomy, and the oncologic safety and long-term prognosis are not clear.     

经蓝碟(LapDisc)手助腹腔镜结直肠癌根治术

目的 探讨手助腹腔镜结直肠癌根治术的临床效果。方法 应用LapDisc手助腹腔镜技术完成27例结直肠癌根治术。结果 手术全部成功，无一例中转开腹。手术时间90～260min，平均140min。术中出血50～200ml，平均110ml。术后无死亡及吻合口漏等并发症。随访6～23个月，平均8．6月，未见切口种植复发。结论 手助腹腔镜结直肠癌根治具有安全、创伤小、术后恢复快及降低标准腹腔镜手术难度等优点，值得临床推广应用。     

Ergonomic assessment of optimum operating table height for hand-assisted laparoscopic surgery

Background  To investigate the influence of the working surface height on task performance and muscle workload in hand-assisted laparoscopic surgery. Methods  The standard task used was closure of 5-cm enterotomy inside a hand-assisted laparoscopic surgery trainer. Surgeons were instructed to place the sutures 3–5 mm apart and from the enterotomy edge. Ten surgeons participated in each experiment and one task was performed with each level. The first experiment compared the quality of task performance and muscle workload with the working surface at: elbow level, 10 cm above, 15 cm above and 10 cm below the elbow. Further narrower levels (5 cm below, at the elbow and 5 cm above the elbow) were investigated in the second experiment. Outcome measures were execution time (s), placement error score (mm), leakage pressure (mmHg), number of execution errors, muscle workload as measured by integrated electromyography (mV·s) and visual analogue score of back discomfort (mm). Results  The first experiment showed that 15 cm above the elbow level was associated with the longest execution time and similar quality of task performance. This level resulted in a higher workload of the deltoid of the extracorporeal limb, the arm extensor of the intracorporeal side and the trapezius and paraspinal muscles of both intra- and extracorporeal limbs. Also, the 10 cm above the elbow level was associated with increased muscle workload of the deltoid of extracorporeal limb and the trapezius of both limbs compared with the elbow height. The 10 cm below the elbow level was associated with increased back discomfort. The second experiment showed that 5 cm below the elbow height was associated with increased muscle workload of the arm flexor group of the intracorporeal dominant limb. Conclusions  The optimum table height for hand-assisted laparoscopic surgery allows the working surface of the extracorporal instrument handle to be at or 5 cm above the elbow level.     

手助腹腔镜肝血管瘤切除术

目的探讨手助腹腔镜下肝血管瘤切除的可行性及方法。方法经Lapdisc系统辅助腹腔镜完成8例肝血管瘤切除。术中切除步骤:(1)置入Lapdisc,游离肝脏;(2)解剖第一肝门,准备阻断;(3)阻断肝门,超声刀离断肝实质;(4)标本取出,创面处理。结果所有患者经Lapdisc辅助腹腔镜下顺利切除病灶,无中转开腹手术,手术时间(196·3±81·2)min,出血量(307·5±224·7)ml,住院时间(7·9±2·9)d。无胆漏、腹腔出血及感染等并发症。结论手助腹腔镜下肝血管瘤切除是安全可行的。     

Simulated hand-assisted laparoscopic surgery (HALS) in microgravity

INTRODUCTION: Previous simulation and porcine experiments aboard the reduced gravity program KC-135 turbojet have demonstrated that microgravity surgery is feasible. Ideally, surgical care in spaceflight will incorporate recent advances in care while remaining easy enough for a crew medical officer (CMO) lacking surgical proficiency or extensive surgical experience to perform. As a minimally invasive surgical technique, hand-assisted laparoscopic surgery (HALS) benefits the patient via smaller incisions, less pain, and faster recovery than traditional open surgery. HALS also helps less experienced laparoscopic surgeons perform laparoscopic surgery. METHODS: An inexpensive inanimate surgical simulator was constructed to evaluate the usefulness of HALS in microgravity. This simulator was utilized during brief periods of microgravity provided by parabolic flight on the KC-135. The simulator was successfully used by both a physician-astronaut and an experienced laparoscopic surgeon. Task completion included simulated surgery with exploration of the intestines and ligation of the appendix. RESULTS: Simulated HALS was successfully performed in microgravity. HALS effectively contained operative equipment and small amounts of introduced fluids within the simulated abdominal cavity. Astronaut and surgeon experience suggest that HALS could facilitate minimally invasive surgery (MIS) in microgravity. DISCUSSION: HALS holds promise as a surgical approach in microgravity, particularly as space travel extends beyond low earth orbit. HALS provides the benefits of MIS, facilitates MIS surgery by less surgically proficient or experienced CMOs, and contains equipment and fluid within the operative field. Simulation provides an easy, cost-effective platform to evaluate medical technology for space flight as well as a method to train CMOs on-orbit.     

Single-incision laparoscopic surgery for colorectal cancer

AIM: To determine the effect of single-incision laparoscopic colectomy(SILC) for colorectal cancer on short-term clinical and oncological outcomes by comparison with multiport conventional laparoscopic colectomy(CLC).METHODS: A systematic review was performed using MEDLINE for the time period of 2008 to December 2014 to retrieve all relevant literature. The search terms were "laparoscopy", "single incision", "single port", "single site", "SILS", "LESS" and "colorectal cancer". Publications were included if they were randomized controlled trials, case-matched controlled studies, or comparative studies, in which patients underwent single-incision(SILS or LESS) laparoscopic colorectal surgery. Studies were excluded if they were non-comparative, or not including surgery involving the colon or rectum. A total of 15 studies with 589 patients who underwent SILC for colorectal cancer were selected.RESULTS: No significant differences between the groups were noted in terms of mortality or morbidity. The benefit of the SILC approach included reduction in conversion rate to laparotomy, but there were no significant differences in other short-term clinical outcomes between the groups. Satisfactory oncological surgical quality was also demonstrated for SILC for the treatment of colorectal cancer with a similar average lymph node harvest and proximal and distal resection margin length as multiport CLC.CONCLUSION: SILC can be performed safely with similar short-term clinical and oncological outcomes as multiport CLC.     

手辅助腹腔镜结直肠癌术后切口疝的发生危险因素分析

目的:探讨手辅助腹腔镜(hand-assisted laparoscopic surgery,HALS)结直肠癌术后切口疝发生的相关危险因素,为预防术后切口疝的发生提供证据。方法:回顾分析2009年8月至2012年8月为142例患者行HALS结直肠癌切除术的临床资料,至随访结束时,根据手辅助口位置是否发生切口疝将患者分为切口疝组及无切口疝组,分析两组患者年龄、性别、体质指数(body mass index,BMI)、吸烟、伴随疾病、辅助切口位置、切口长度、是否感染等与切口疝发生相关的危险因素。结果:入选的142例患者中,13例至随访结束时发生切口疝,发生率为9.2%,合并糖尿病的患者术后切口疝发生率明显高于无糖尿病患者(P<0.01),切口疝组患者平均BMI、吸烟率亦高于无切口疝组,与左下腹低位横切口相比,正中切口术后疝的发生率较高。结论:肥胖、吸烟、糖尿病、切口位置与切口疝的发生密切相关,充分的围手术期准备,可有效减少切口疝的发生。     

Comparison of Gas-less laparoscopy-assisted surgery, hand-assisted laparoscopic surgery and pure laparoscopic surgery for radical nephrectomy

BACKGROUND: We report our experience with Gas-less laparoscopy-assisted surgery (Gas-less LAS), hand-assisted laparoscopic surgery (HALS) and pure laparoscopic surgery (LS) for renal carcinoma and compare the characteristics and usefulness of these methods. METHODS: Seventeen, 14 and 16 patients were subjected to Gas-less LAS, HALS and LS, respectively. The study started with Gas-less LAS and then gradually shifted to HALS and LS. We evaluated the operative and postoperative parameters for each group. The learning curve effect was evaluated based on data from the first 10 cases of each group, which were operated on by the same surgeon and operation team. RESULTS: The learning curve of operation times in the LS group demonstrated that the operation time for this procedure is acceptable even in early-stage cases. Differences in mean operative time between the three surgical groups, excluding the conversion cases, were not statistically significant; however, there was a significant difference in blood loss volume between the groups (P 相似文献