Gelport

The Gelport kit contains the Alexis® wound retractor, which is a pair of plastic rings connected by a flexible skirt that holds the abdominal incision open and provides the base for the second component, and the Gelseal® cap, which snaps onto the outer ring of the wound retractor to provide a gas‐tight seal through which a hand or laparoscopic ports can be placed. The abdominal incision is made initially, and then the flexible ring of the wound retractor is inserted into the abdomen, leaving the rigid ring outside (Figure 85.2). The outer ring is rotated inward to shorten the skirt and pull the rings tight against the abdominal wall. Once the gel cap is snapped onto the outer ring, the abdomen is gas tight (Figure 85.3). The gel expands enough to allow insertion of a hand through its central slit (Figure 85.4), but also will occlude the incision with nothing passing through it. In addition, ports can be passed through the central slit in the gel, or through a separate stab incision in the gel. An instrument can be passed through the gel alone, or when the hand is in place. See Video 85.1, which demonstrates use of the Gelport kit during a HALS nephrectomy.

Dextrus Access Port

The Dextrus Access Port is also a two‐piece device. The base is a fixed‐length wound retractor composed of an inner flexible ring and an outer rigid ring connected by an elastic skirt that holds the abdominal incision open and provides the base for the second component. The outer cap is a pair of locking rings that snap onto the base and close an iris valve to provide gas occlusion. The fixed‐length wound retractor, which is available in three sizes to accommodate abdominal walls of varying thickness, is inserted into the abdominal incision by slipping the flexible inner ring inside the abdomen (Figure 85.5), with the tension from the elastic sheath holding the rigid outer ring stable on the abdominal wall. The outer cap is then snapped onto the wound retractor. For intra‐abdominal use, the hand is inserted to the desired depth and the iris valve is tightened around the forearm by turning the outermost ring clockwise and fixing it in place by way of ratcheted teeth (Figure 85.6). Slight inward movements of the forearm can be made, but large movements require that the iris valve be opened a bit. Similarly, pulling back or removing the forearm necessitates tightening the valve to prevent gas leak. The valve can be completely occluded (Figure 85.7) or it can be tightened around a port or laparoscopic instrument.

Adjuncts

Fluid can sometimes track up the intra‐abdominal forearm and soak through the surgeon’s gown above the glove. Double gloving does not necessarily prevent this and some additional barrier is recommended. We have found the simplest and most effective to be a Steri‐Drape™ Small Towel Drape 1000 (3 M Company, St. Paul, MN, USA). The adhesive strip is wrapped around the wrist and the rest of the drape trails down over the forearm, covered by a second glove over the hand and adhesive strip (Figure 85.4). The second glove should be dark to minimize glare. The Dextrus Access Port comes packaged with a plastic wrap that serves the same function. Other surgeons have overcome the fluid problem by using a disposable fluid‐impervious gown.

Surgical instruments can be placed into the abdomen for use by the intra‐abdominal hand. Small, open surgical instruments, including Atson forceps and short Satinsky clamps, have been used intra‐abdominally during HALS. Of these, the most useful may be hand‐held bulldog clamps for temporary vascular occlusion.

Choice of position for surgeon, HALS device, and ports

Although the application of HALS to retroperitoneoscopic surgery has been reported, it is not a widely performed technique. This section, pertaining to technique, will not address retroperitoneoscopic HALS, although the few reported series are included in the section on results. See Video 85.1, which demonstrates our technique for nephrectomy using HALS.

Either the primary or the assistant surgeon can use their hand intra‐abdominally. When the primary surgeon’s hand is intra‐abdominal, direct manual dissection is possible. However, the primary surgeon then has only one hand free to manipulate a laparoscopic instrument. If the assistant’s hand is in the abdomen, the primary surgeon can use two laparoscopic instruments and the intra‐abdominal hand is used primarily for retraction. This distinction is important because it can alter port placement. Figure 85.8 indicates the most common HALS device and port arrangements for HALS renal surgery when the surgeon’s hand is intra‐abdominal. Figure 85.8a is the most typical arrangement for left‐sided renal surgery by a right‐handed surgeon. The nondominant (left) hand is placed through the HALS device in the periumbilical midline. This allows simultaneous retraction of bowel and finger dissection of the kidney. The assistant operates the videolaparoscope through a port at the level of the umbilicus, 1–2 cm lateral to the edge of the HALS device (2 in Figure 85.8a), and an instrument placed through a lateral assisting port (4 in Figure 85.8a). The surgeon’s working port is placed 1–2 cm below the costal margin (3 in Figure 85.8a), on the line that extends from the videolaparoscope port to the patient’s ipsilateral shoulder. There is more variation for right‐sided renal surgery by a right‐handed surgeon. Some, including these authors, recommend an arrangement that is the mirror image of the left‐sided procedure (Figure 85.8b). The right hand is used intra‐abdominally, which allows retraction of the liver by the back of the hand while dissecting the kidney. The surgeon’s left hand is used to manipulate laparoscopic instruments, which some right‐handed surgeons find awkward. The ability to use either hand intra‐abdominally is valuable, and if an “ambidextrous” approach is used when starting out with HALS, then it is quickly learned. Some portions of the procedure are facilitated by using a different hand in the abdomen, on either side, so it is helpful to be ready to use either hand intra‐abdominally.

An alternative for right nephrectomy by a right‐handed surgeon is depicted in Figure 85.8c. Here, the surgeon’s left hand is placed through the HALS device and the right hand operates an instrument through the working port (3 in Figure 85.8c). The assistant operates the videolaparoscope (2) and an assisting instrument (4). Some place the HALS device obliquely in the ipsilateral lower quadrant when using this approach. A number of HALS device placements have been described, including midline (supra‐, peri‐, and infra‐umbilical), paramedian, subcostal, lower quadrant oblique (“muscle‐splitting” Gibson incision), and transverse suprapubic (Pfannenstiel). Each will be associated with slightly different port placements, depending on whether the intra‐abdominal hand is the surgeon’s or assistant’s, and whether the left or right hand is preferred. The general principles that guide device and port placement in HALS are: maximization of effectiveness of the hand, minimization of videolaparoscope obstruction by the hand, and centering the videolaparoscope between instruments rather than working with the hand and instruments all off to one side. Use of a 30° videolaparoscope is very useful during HALS to reduce obstruction of vision by the intra‐abdominal hand.

Tips and tricks

HALS facilitates transfer of skills from open surgery to laparoscopic surgery. Although this is an easier step to make than that from open surgery to standard (non‐hand‐assisted) laparoscopic surgery, HALS does require a distinct skill set. In this section, some techniques that are different from those used in open surgery and standard laparoscopic surgery are highlighted.

A laparoscopic port can be inserted through both the Gelport and the Dextrus Access Port, and the Gelport will accommodate several ports or a hand and additional ports. This allows inspection of the abdomen laparoscopically before secondary port placement. Ports can be inserted under direct visualization, or a hand can be placed through the HALS device and the ports can be inserted directly onto the intra‐abdominal hand (Video 85.1). This maneuver should be performed only with noncutting trocars and only after visual inspection has confirmed the inner abdominal wall to be free of adhesions.

After placing the HALS device and ports, a laparotomy pad is placed into the abdomen. This can be used to soak up fluid and blood, either by itself (when it is not yet saturated) or by compressing it with the hand and using a laparoscopic aspirator to remove fluid through the pad. Some surgeons place a hemostat on the blue tag of the laparotomy pad to prevent its complete placement into the abdomen. We prefer to place the entire pad inside the abdomen to allow its unrestricted use, but we do cut off part of the blue tag and clamp it to the drapes as a visual reminder that a pad is inside the abdomen.

Performing multiple tasks simultaneously with the intra‐abdominal hand takes greatest advantage of its presence. Retraction and exposure can be obtained in several directions at once, or the hand can simultaneously retract and dissect. One of the most useful multitasking hand positions is the “C” position (a term coined by Stephen E. Strup MD) for dissection medial to the lower pole of the kidney and at the renal hilum (Figure 85.9). Using the left hand for left renal surgery, or the right hand for right renal surgery, the forearm is placed parallel to the great vessels, palm lateral, wrist flexed 45–90°, index finger lifting the kidney, thumb exerting inferomedial traction on tissue, and the middle fingers extended. This position allows simultaneous retraction of bowel with the back of the hand, elevation of the lower pole, and dissection with the fingers. When the hand is elevating the lower pole, an irrigator–aspirator probe or some other instrument can be placed through an assisting port to help in the dissection.

When dissecting out the renal hilum, the renal artery and vein can be encircled en bloc with the thumb and forefinger of the intra‐abdominal hand. After sharply dissecting tissue cephalad to the renal vein, it is usually easy to bluntly place the index finger cephalad to the renal vein, wiggle it in a posterior direction until the psoas muscle is touched, and then scoop inferiorly to gather up the entire renal hilum. This maneuver is safe as long as a careful touch is used, sensing resistance that indicates an early branch or an accessory vessel. Encircling the hilum in this way provides the ability to rapidly control it in case of vascular injury, and with this added confidence the subsequent hilar dissection can proceed rapidly. This maneuver is less useful if the intention is to remove the adrenal gland with the specimen (on the left side), as it is not safe to perform blunt dissection medial to the adrenal gland.

Series

In urology, HALS is most commonly applied to nephrectomy. The first reported use of HALS in urology was for radical nephrectomy [4], as was the first use of a commercial HALS device in urology [8]. In one of the earliest large series of HALS for radical nephrectomy, Stifelman et al. [11] reported 95 HALS radical nephrectomies for large specimens. The mean operative time was 158 min and the major complication rate was only 4%, with a rate of conversion to open surgery of 3%. The oncologic efficacy of HALS radical nephrectomy has been confirmed in several series with long‐term follow‐up. Bandi et al. [12] reported 5‐year recurrence‐free survival of 90% after 65 HALS radical nephrectomies with more than 3‐year follow‐up. Harano et al. [13] reported a 4‐year recurrence‐free survival of 88% in a series of 96 patients. At the University of Michigan, the 5‐year recurrence‐free survival in a series of 108 patients with a mean tumor size of 6.9 cm was 82% [14]. Kawauchi et al. [15] reported a 5‐year recurrence‐free survival of 92% among 123 patients. Recently, Park et al. [16] provided updated follow‐up of the largest series reported to date of HALS radical nephrectomy with long‐term follow‐up. Their multi‐institutional series from 26 centers in Korea involving 197 patients demonstrated a 5‐year recurrence‐free survival of 95% with a median follow‐up of 69 months.

There have been 21 series (containing 10 or more patients) of HALS nephroureterectomy for upper tract urothelial neoplasms (not including series that have been updated by subsequent ones) published through 2015 [17–37]. In the total of 832 patients described in these series, the operative time averaged 253 min, with 7% major and 13% minor complication rates overall (when reported). Conversion to open surgery was required in only 2.1% of cases. The nonvesical recurrence rate was 13% with 24‐month mean follow‐up. A description of the long‐term outcome of HALS nephroureterectomy for urothelial carcinoma from the University of Michigan includes 62 patients with a median follow‐up of 77 months: the 5‐year cancer‐specific survival was 89% for low‐grade disease and 72% for high‐grade disease [38].

Many of the recently reported series of donor nephrectomy have been with HALS. Among the 14 such series containing 100 or more patients, reporting 2850 patients in total, the mean operative time was 174 min and the mean warm ischemia time 2.7 min [39–52]. The minor and major complication rates were 7.2% and 3.0%, respectively, with a conversion to open surgery in only 0.8% of patients. In the studies that reported convalescence, the mean time to return to nonstrenuous activity levels was 24 days. In the largest series to date, Rajab and Pelletier [53] reported long‐term follow‐up of nearly 1500 patients. Of patients, only 0.9% experienced graft loss within one month of transplant. A total of 1.4% of patients developed delayed graft function with subsequent recovery of function. 10‐year death‐censored graft survival was approximately 80%. Of the first 200 HALS donor nephrectomies performed at the University of Michigan, the 1‐month, 1‐year, and 3‐year actuarial graft survival rates are 97%, 95%, and 94%, respectively [42]. On review of 480 consecutive cases of HALS donor nephrectomy, Gabr et al. [54] reported a ureteral complication rate of 3.7%, and noted that ureteral complications were associated with increased donor age and the lack of ureteral stent placement at the time of transplant.

Other reports of HALS for renal surgery include partial nephrectomy [55–59], heminephrectomy (horseshoe kidneys, duplicated upper tracts, etc.) [60–63], bilateral nephrectomy [64–72], and bilateral partial nephrectomy [73]. Bilateral nephrectomy for autosomal dominant polycystic kidney disease is particularly challenging with standard laparoscopic techniques, and is perfectly suited to HALS. Other difficult maneuvers, such as radical nephrectomy with associated excision of renal vein or vena caval thrombus [74–79], and removal of kidneys with xanthogranulomatous pyelonephritis or other inflammatory or unusual conditions [76, 80–85], are facilitated by HALS.

HALS in urology is most commonly applied to renal surgery, but there have been reports of its use for other organs as well. Similar to its use for bilateral nephrectomy, HALS facilitates multiorgan removal for other entities [86–89]. Laparoscopic adrenalectomy is usually well‐performed with standard transperitoneal or retroperitoneoscopic techniques, but in cases of large specimens or as an alternative to conversion to open surgery, HALS does have a role in the management of adrenal disease [90–94]. Minimally invasive cystectomy is growing in popularity. Even when using standard or robot‐assisted techniques, many surgeons prefer to create at least part of the urinary diversion via a mini‐laparotomy. Given this, several groups have reported using this mini‐laparotomy incision for a HALS device, and performing the cystectomy or pelvic exenteration with HALS techniques [95–100]. HALS for other procedures, such as ureterolysis [101], retroperitoneal lymph node dissection [102], and resection of local renal cell carcinoma recurrences [103], has been described.

Comparisons to other techniques

Although HALS has been reported via the retroperitoneoscopic route for renal surgery [20, 28, 31–33, 104–111], this is not a commonly performed technique. Because of this, when assessing the role of HALS in urologic laparoscopy, this chapter considers it to be a transperitoneal approach. Transperitoneal HALS, standard transperitoneal laparoscopy, and standard retroperitoneoscopy all have advantages and disadvantages. In this section, comparisons between the techniques are presented.

Wolf et al. [112] reported the initial comparison of hand‐assisted and standard transperitoneal laparoscopic nephrectomy in 1998, using the first hand‐assisted (n = 13) and standard (n = 8) transperitoneal laparoscopic nephrectomies performed at the University of Michigan and the University of Wisconsin. The mean operative time for hand assistance was 90 min shorter than that for standard laparoscopy. This comparison suggests that early in a surgeon’s experience, HALS “shortens the learning curve” for transperitoneal nephrectomy. A subsequent report from the University of Michigan made the same comparison after more experience had been gained, and revealed that after an experience of approximately 20 laparoscopic radical nephrectomies, the advantage of HALS over standard laparoscopy in terms of operative time fell to only 30 min [113].

A recent meta‐analysis of studies comparing HALS to open and standard laparoscopic approaches for urologic procedures produced similar results to previous publications [114]. This meta‐analysis reviewed 62 studies of donor nephrectomy [30], radical nephrectomy [21], and nephroureterectomy [14], which totaled 5446 patients. For donor nephrectomy, HALS was associated with less intraoperative blood loss when compared with open and standard laparoscopic approaches. Length of stay was shorter compared to the open cohort, while operative and warm ischemia times were shorter compared to the standard laparoscopic group. Yuan et al. [115] limited their meta‐analysis to donor nephrectomy and included 4 additional years of studies with over 2000 patients total, and found similar results. They noted no increase in donor complications or recipient graft function.

In a randomized trial of HALS versus standard donor nephrectomy (20 in each group), Bargman et al. [116] found that operative time was significantly less with the standard approach (219 vs. 200 min, P = 0.02), but that there were no differences in estimated blood loss, warm ischemia time, length of postoperative stay, analgesic use, rate of complications, pain scores on postoperative days 1 and 2, or quality‐of‐life scores at 1 and 3 months. Of note, all nephrectomies in this series were performed by a surgeon with extensive experience in both HALS and standard laparoscopy, including more than 100 laparoscopic donor nephrectomies and more than 500 other laparoscopic renal operations prior to the study period. This is consistent with the data reported above; with experience, some advantages of HALS over standard laparoscopy (such as reduced operative time) diminish.

There have been two prospective trials involving HALS for radical nephrectomy. Nadler et al. [117] in a comparison of standard transperitoneal, standard retroperitoneal, and HALS (11 in each group; not randomized but prospectively enrolled in alternating fashion) found that operative time was significantly lower in the HALS group, and that hospital stay and time to normal daily activity were significantly shorter in the standard transperitoneal group. Intraoperative blood loss, postoperative narcotic use, and time to oral intake were similar in all three groups. Although there were no differences in early complications, incisional hernias occurred only in the HALS group. In a multi‐institutional randomized trial comparing HALS (9 patients) versus standard transperitoneal laparoscopic (12 patients) radical nephrectomy, Venkatesh et al. [118] found no differences in operative time. Although the meta‐analysis by Wadström et al. [114] was not able to compare HALS to standard laparoscopy because of a limited number of studies, they did report improved blood loss and length of stay with HALS when compared to open radical nephrectomy.

As noted above, series of surgeons’ early experience with standard laparoscopic and HALS nephrectomy often suggest a lower complication rate with HALS [112, 119], but as experience is gained the overall complication rates of the two approaches become similar. However, the intra‐abdominal hand does appear to reduce some specific complications, in particular the need to convert to open surgery. Silberstein and Parsons found this in their meta‐analysis [120]. At the University of Michigan, 196 standard laparoscopic radical nephrectomies were compared with 154 HALS radical nephrectomies [121]. There were no conversions to open surgery from HALS but conversion to open surgery occurred in the standard laparoscopic group in 0.8% of nonobese, 3.0% of obese, and 17% of morbidly obese patients. The difference was statistically significant in the latter two groups. In addition, the availability of HALS provides an alternative to conversion from standard laparoscopy to open surgery; converting to HALS from standard laparoscopy may allow the procedure to be completed in a minimally invasive fashion [122, 123].

Conversely, some complications appear to occur more commonly in association with HALS than with standard laparoscopy. Troxel and Das [124] noted a 6% rate of incisional herniation at the HALS site in a series of 50 HALS radical nephrectomies. Terranova et al. [125] reviewed 54 patients undergoing HALS renal surgery, and reported complications related to the HALS incision in 9.3%, including infection, herniation, skin incisional breakdown, fascial dehiscence, and enterocutaneous fistula. Montgomery et al. [126] reviewed 424 consecutive HALS renal procedures and reported similar findings, including infection in 6.8%, incisional hernia in 3.5%, and fascial dehiscence in 0.5% of HALS incisions. Although direct comparative data are limited, some reports suggest an increased wound complication rate with HALS compared to standard laparoscopy. Overall, wound infections and hernias appear to occur less frequently in association with HALS than with open surgery, but more often than in association with standard laparoscopy. In one literature compilation which included 56 reports, there was a significantly greater wound complication rate associated with HALS compared to standard laparoscopy (1.9% vs. 0.2%, P < 0.05) [127].

Data comparing the duration and intensity of convalescence after HALS compared to standard laparoscopy are less consistently reported than more objective outcomes, and are subject to bias in retrospective studies. In both of the prospective trials involving HALS for radical nephrectomy described above, there was some measure of a longer and/or more intense recovery period in the HALS patients. Nadler et al. [117] found the hospital stay to be 2.1 days after standard transperitoneal laparoscopy compared to 3.4  days after HALS radical nephrectomy. Narcotic use tended to be less in the former group, but the difference was not significantly different. In their multi‐institutional randomized trial comparing standard transperitoneal laparoscopic and HALS radical nephrectomy, Venkatesh et al. [118] found a significantly longer time to return to normal activity and to work in the HALS group, although there were no differences in hospital stay or narcotic use. In a retrospective but large comparison of the two approaches to radical nephrectomy (113 standard laparoscopic, 158 HALS), Matin et al. [128] found longer hospital stay (4 vs. 2 days) and more narcotic use in the HALS group. In another retrospective but large study (147 standard laparoscopic and 108 HALS), Gabr et al. [121] found that hospital stay was longer (by a mean of 0.4 days) and time to return to nonstrenuous activity was greater (by a mean of 3.1 days) in the HALS group.

In addition to patient‐related outcomes, HALS appears to have a distinctive surgeon‐related impact. Johnston et al. [129], describing a survey of 25 urologists involved in lapararoscopic fellowship programs, reported that HALS was associated with significantly more hand/wrist, forearm, and shoulder pain compared to standard laparoscopy. Conversely, there was significantly more neck pain associated with standard laparoscopy. There was no significant difference between the approaches in terms of lower back pain. Gofrit et al. [130] found similar results in a survey of 73 members of the Endourology Society. HALS was associated with more pain involving the fingers, hand/wrist, and forearm/elbow than standard laparoscopy, while standard laparoscopy was associated with more complaints about neck pain. There were no major differences with regards to shoulder, upper back, and lower back pain. This survey also included questions about robotic surgery. Overall, robotic surgery was associated with the fewest complaints of pain and HALS was associated with the most. The work of Ost et al. [131] suggests one possible mechanism for the increased hand, wrist, and forearm pain with HALS. These investigators used oxygen sensors to measure oxygen saturation in the hand during HALS nephrectomy, and found that a report of hand pain during HALS nephrectomy was associated with hypoxia of the hand, down to 56–88% local oxygen saturation.

Overall, then, published data suggest that HALS is generally faster than standard transperitoneal laparoscopy, but that the difference decreases with increasing surgeon experience. The relative impact of HALS on operative time also appears to vary with the specific procedure. For advanced procedures, HALS appears to reduce the likelihood of conversion to open surgery, and converting to HALS is a good alternative to converting to open surgery when standard laparoscopy cannot be continued. There are important disadvantages of HALS to be acknowledged. The larger incision for HALS is associated with rates of infection and herniation that probably exceed those for standard laparoscopy. The intensity and duration of postsurgical recovery is slightly greater with HALS compared to standard laparoscopy, although the magnitude of the difference between HALS and standard laparoscopy is much less than that between HALS and open surgery. Finally, the surgeon pays a price during HALS in terms of increased upper extremity pain compared to standard or robot‐assisted laparoscopy.