C. T. Ong1, Z. Sun1, M. A. Adam1, J. Kim1, B. F. Gilmore1, B. Ezekian1, U. P. Nag1, C. R. Mantyh1, J. Migaly1 1Duke University Medical Center,Durham, NC, USA
Introduction:
Hand-assisted laparoscopic surgery (HALS) is gaining wider application in colorectal procedures as it bridges the divide between open and laparoscopic technique. However, there are concerns for whether this hybrid approach carries the complications of the open approach while sacrificing the perioperative benefits of completely minimally invasive technique. Our aim was to compare outcomes between HALS and open colectomy and delineate predictive factors for selecting the HALS technique.
Methods:
Adult patients who underwent elective open or HALS colectomies from the 2012-2013 combined National Surgical Quality Improvement Program dataset were selected. Short-term perioperative outcomes were compared between 1:1 propensity-matched groups. A subset analysis was performed in those who received segmental colectomies only. Multivariable logistic regression modeling was used to determine predictors of utilizing either operative approach.
Results:
In total, 8,791 patients were included. 2,707 (30.8%) patients received planned open colectomies and 6,084 (69.2%) received HALS. Independent predictors of utilizing HALS include male sex (OR 1.17, p=0.006), increasing BMI (OR 1.01, p=0.02), a benign indication for surgery (OR 1.48, p<0.001), and total abdominal colectomy compared to segmental (OR 10.39, p<0.001), while younger age, black race, ASA class >3, inflammatory bowel disease, and surgery requiring low pelvic anastomosis were predictive of open surgery (all p<0.05). After matching for clinical, disease, and treatment factors, HALS was associated with lower rates of overall complications (13.6% vs 21.5%, p<0.001), wound complications (8.8 vs 13.8%, p<0.001), anastomotic leak (3.1% vs 4.7%, p=0.014), transfusion requirement (5.0% vs 10.7%, p<0.001), postoperative ileus (8.8% vs 18.0%, p<0.001), length of stay (median 4 vs 6 days, p<0.001), and readmissions (6.9% vs 11.4%, p<0.001), without requiring longer operative time (median 148 vs 150 minutes, p=0.111). When examining those undergoing segmental resection only, HALS was still associated with improved rates of overall complications, wound complications, respiratory complications, postoperative ileus, anastomotic leak, transfusion requirement, length of stay, and readmissions (all p<0.05).
Conclusion:
Compared to open colectomy, hand-assisted laparoscopic surgery is associated with improved perioperative outcomes without requiring longer total operative time. In cases considered too difficult for a totally minimally invasive approach, HALS provides a more favorable alterative than the traditional open approach.