Need for Reappraisal of Hand-Assisted Laparoscopic Surgery for Colorectal Diseases in the Era of Desiring Small Incisions

Colorectal surgeons have many options for minimally invasive surgery (MIS), including standard laparoscopic surgery (SLS), single-port surgery, robotic surgery, a transanal total mesorectal excision (TME), and hand-assisted laparoscopic surgery (HALS). Traditionally, SLS is the most common type of MIS. However, nowadays, MIS using small incisions, for example, single-port surgery and transanal TME, seems to be attractive because we are living in an era when surgeons and patients desire smaller incisions. In this regard, HALS seems to be an unattractive type of surgery because a skin incision of at least 6–8 cm is required to insert the hand-port device. For proponents of SLS, HALS is difficult to accept because the hands rather than laparoscopic instruments are used. The penetration rate of HALS seems to be different in different countries. In northeast Asian countries, including Korea, Japan, and China, of the various types of MIS, SLS is dominant. However, among these countries, China seems to be something different. HALS seems to be relatively more popular in China than in the other two countries because China has more patients that require surgery per colorectal surgeon than the other 2 countries. In my opinion, some reasons the penetration rate of HALS is low, especially in northeast Asian countries, are as follows: (1) Patients with high body mass index (BMI) are less common than in Western countries [1-3]. Because MIS for patients with high BMI is more technically demanding, HALS is more commonly performed in the West than in Asia. (2) Standardization of placements of the hand-port device and laparoscopic instruments is more difficult in HALS than it is in SLS. In HALS, the concept of dominant and nondominant hand is very important. Generally, the nondominant hand should be inserted into the abdominal cavity; thus, the hand used for insertion depends on whether the surgeon is right-handed or left-handed. This is an important reason for difficulty in standardizing the procedure. (3) HALS is more comfortable for a left-handed surgeon than for a righthanded surgeon. Considering a better scope view and the usefulness of the position of the hand-port incision, the upper midline incision for a right colectomy and the lower midline incision for a left colectomy and an anterior resection are useful. (4) HALS is often misunderstood and many surgeons lack experience with the procedure. Standard laparoscopic surgeons generally have 2 options: SLS or open surgery. Even for experienced standard laparoscopic surgeons with high penetration rates of MIS, some types of MIS may be unreasonable for patients with T4 colorectal cancer, severe adhesion and ileus, and high BMI. HALS surgeons easily understand that HALS plays a key role as a type of surgery between SLS and open surgery. In a study [4] comparing 53 patients who underwent HALS and 45 patients who underwent SLS for right-sided colon cancer, the HALS group had significantly larger tumors (HALS: 6.0 cm vs. SLS: 3.3 cm, P < 0.001) and significantly higher TNM stage (HALS vs. SLS: stage 0, n = 2 vs. n = 11; I, n = 5 vs. n = 15; II, n = 28 vs. n = 9; III, n = 18 vs. n = 10, P < 0.001). However, no significant differences in the 5-year overall, disease-free, and cancer-specific survival rates between the HALS and the SLS groups were reported. Based on these results, the authors of that study concluded that HALS might be an acceptable alternative to SLS for patients with high BMI and those with advanced right-sided colon cancer. Cheong and Young [5] analyzed 121 HALS colorectal resections. Among the patients, 50.2% had high BMIs (BMI ≥ 25 kg/m), and 52.9% had prior histories of abdominal or pelvic surgeries. The conversion rate to a laparotomy was 5.7% and was influenced by neither high BMI nor prior history of abdominal or pelvic surgeries. The authors applied HALS both to the treatments of patients with various diseases, including colorectal cancer, diverticular disease, tubulovillous adenomas, and ulcerative colitis and to diCorrespondence to: Chang-Nam Kim, M.D. Department of Surgery, Eulji University Hospital, Eulji University School of Medicine, 95 Dunsanseo-ro, Seo-gu, Daejeon 35233, Korea Tel: +82-42-259-1335, Fax: +82-42-259-1335 E-mail: [email protected]