Hand-Assisted Left Colectomy

INDICATIONS

The main limitation of laparoscopic surgery is loss of tactile feedback. Hand-assisted surgery provides many benefits of laparoscopic surgery, while allowing surgeons to retain tactile feedback, better retraction with a trained hand, and ability to do blunt dissection with fingers when needed. These advantages have been shown in randomized clinical trials as shorter operative time and less conversion with similar perioperative outcome measures compared with straight laparoscopy.

Indications for hand-assisted left colectomy are the same for laparoscopic left colectomy: colon cancer, diverticular disease, and Crohn’s colitis. When deciding laparoscopic versus hand-assisted approach, several factors are taken into consideration: body habitus, location, nature, and complexity of pathology, and extent of planned surgery. In obese patients with heavy intraperitoneal and pericolonic fat, adequate exposure and traction can be difficult. Hand port access can be valuable in this case. If the patient has history of complicated diverticulitis such as colovesicular fistula, and pelvic inflammation and fibrosis is expected, hand access gives surgeon ability to use fingers for blunt dissection. In elective sigmoid resection for diverticulitis, especially in complicated diverticulitis, hand-assisted sigmoidectomy has been shown to have lower conversion rate and shorter operative time, although having equivalent outcome. Conversion from straight laparoscopic to hand-assisted laparoscopic surgery rather than laparotomy, when intraoperative difficulty is encountered, is another utility of this approach.

Laparoscopic colectomy has been shown to have a long learning curve. Hand-assisted left colectomy can be a bridge between open colectomy and straight laparoscopic colectomy.

PREOPERATIVE PLANNING

Thorough history and physical examination is performed with attention to:
- Medical history of pulmonary disease such as chronic obstructive pulmonary disease (COPD) and eye disease such as glaucoma. Patients with severe COPD are not likely to tolerate pneumoperitoneum. These patients need to be informed of high likelihood of early conversion to open procedure, if end tidal CO₂ started to increase after pneumoperitoneum was established. Steep Trendelenburg position during laparoscopic procedure has been shown to increase intraocular pressure in time-dependent manner. In patients without preexisting eye disease, this has been shown not to affect visual health, but in patient with known glaucoma, caution should be taken to minimize time in steep Trendelenburg position.
- Surgical history and abdominal scars: patients with significant surgical history pose two types of challenges. First is altered anatomy that will hinder particular operative steps. For example, in a patient with distant history of gastric cancer and Billroth II gastrojejunostomy, taking down splenic flexure can be difficult. It is advisable to gather as much as information preoperatively from operative reports, if available, and any imaging study. Second is intra-abdominal adhesions. In a patient with history of multiple laparotomies or previous complex operation, it is advisable to use the old scar to create vertical hand port incision rather than a Pfannenstiel incision.
For patients with complicated diverticulitis (e.g., colovesicular fistula) or locally advanced sigmoid colon cancer, consider bilateral ureteral stent placement at the beginning of the case. It is our preference to use them selectively.
For patients with a large abdominal subcutaneous fat, it is prudent to mark the stoma site, in case unexpected intraoperative course necessitates creation of a temporary stoma. This is usually done in the preop holding area with patient standing up.

SURGERY

Room Setup and Patient Position

Typical room set up is shown in Figure 12-1.
Gelpad or beanbag is used on the table to stabilize the patient during steep Trendelenburg position. Both arms are tucked, and hands are protected by foam pads or baby diapers. In heavy patients, it is wise to test the security by placing the patients in extreme positions before prepping. If necessary, heavy-duty tapes can be placed around the patient’s chest and the table.
The patient is placed in modified lithotomy position, with hip extended close to 180° relative to torso. This prevents the range of the surgeon’s elbow from being restricted by patient’s flexed thigh. Care should be taken not to hyperextend the hip.
Flexible sigmoidoscopy is ready and available throughout the case.
Surgeon stands between patient’s legs, and the assistant (operating) surgeon stands on the patient’s right side during laparoscopic portion.

Incisions and Port Placement

A Pfannenstiel incision is created two finger breadths above the pubic symphysis. If the patient has a natural skin crease slightly above or below, create the incision along the crease for better cosmesis. The length of the incision depends on surgeon’s hand size, and it is typically 8 cm for 7½ glove size. The anterior fascia is opened transversely. The fascial incision is made with each end curved up, so that it avoids dividing the inguinal ligament inadvertently. The anterior fascia is separated from rectus superiorly and inferiorly. The posterior fascia is opened longitudinally, and peritoneum is entered sharply. Peritoneum is entered at superior aspect of the incision to try to avoid potential
bladder injury. Once an adequate incision is created to permit the surgeon’s hand, a supraumbilical trocar is inserted with hand guidance. Then, abdomen is insufflated. Three additional 5 mm trocars are placed with optional 5 mm trocar in left upper quadrant as shown in Figure 12-2.