Hand-assisted laparoscopic (HAL) surgery involves the intra-abdominal placement of a hand through a minilaparotomy incision while pneumoperitoneum is maintained. The HAL approach is thought to facilitate colonic mobilization while maintaining the benefits of laparoscopic surgery. Laparoscopic colectomy lends itself to hand-assisted techniques. Most surgeons make an abdominal incision near the end of a laparoscopic-assisted colectomy to extract the specimen. This incision is often utilized to divide the mesentery or to fashion the anastomosis. Supporters of the hand-assisted technique believe that the hand should be placed through the wound to facilitate dissection and mobilization of the colon. By 1992, a number of surgeons began to make this incision early in the operation to facilitate dissection and return tactile sensation to the procedure. The hand can be used, similar to an open procedure, to palpate organs or tumors, reflect structures atraumatically, retract sutures, identify vessels, dissect bluntly, and to provide finger pressure to bleeding points while proximal control is obtained. The development of new sleeveless hand-assisted devices provides for hand exchanges without the loss of pneumoperitoneum, thus, allowing the operation to proceed without interruption. In addition, these devices protect the wound, act as a retrieval site for the specimen, and serve as the portal for construction of the extracorporeal anastomosis (1).

Randomized trials by the HALS Study group (2,3) and by Targarona et al. (4) demonstrated that HAL resection provides similar results to traditional laparoscopic colectomy with fewer conversions. Kang et al. (5) performed a study comparing hand-assisted versus open colectomy and showed that the hand-assisted approach resulted in shortened postoperative ileus, shortened length of stay, and smaller incision size with no difference in operative time or complications. A multicenter randomized prospective study group showed that hand-assisted left and total colectomy takes less time than laparoscopic and results in equivalent short term outcomes (6).

The procedures that can potentially benefit most from the hand-assisted technique are those operations that already require the creation of a minilaparotomy for their completion. More specifically, hand-assisted right hemicolectomy for cancer or benign disease involves extracorporeal bowel division and creation of the anastomosis after complete mobilization of the bowel. The approach was developed to balance the competing demands of optimizing patient benefits and simplifying the procedure, such that it may be more readily taught and learned. A completely laparoscopic approach, with creation of an intracorporeal anastomosis, still requires an extraction incision to remove the specimen and risks spillage of bowel contents, takes longer, costs more (uses more stapler reloads), and is technically more demanding with no demonstrated benefit to the patient. Thus, HAL right hemicolectomy will be described here as a viable and safe alternative to open right hemicolectomy.