The first reported case of manual assistance during a laparoscopic surgery is credited to Drs. Edward Tiley and James Boland, Roberto Kusminsky, and James Tierney. They were performing a laparoscopic splenectomy in May 1992 when they encountered bleeding from a short gastric vessel. During this episode, a small incision was made and a surgeon’s hand was introduced to help control the bleeding. The resulting incision was then used to deliver the intact spleen after dissection was complete. This successful operation led these surgeons to use this approach during subsequent surgeries. The group performed another HAL splenectomy by making a pfannenstiel incision, then the hand was inserted using a long obstetrical glove [12]. The group referred to this technique as laparoscopic minilaparotomy [13]. Their technique involved inserting a laparoscopic camera into the abdomen to visually assess the abdomen. The group reported that patients were tolerating diet and ambulating within 24–72 h in comparison to 6.5 days that was reported as the average for open surgical laparotomy. Tschada et al. then reported their use of “manual assistance” during a report of laparoscopic nephrectomies in 1995 [14]. In this abstract, the operative times for manual assistance cases were shorter compared to traditional laparoscopic cases (2.5–5 h vs. 4–6 h).

The incorporation of the surgeon’s hand into the operation certainly had significant advantages. During the initial surgery by Boland and colleagues it certainly allowed for important and expedient control of bleeding during the operation. Yet, the technique of inserting just the surgeon’s hand through an incision proved to have several disadvantages for the surgeon. First, the incision was sized to one particular surgeon meaning that if any other surgeon was involved in the procedure, the incision would have to be modified. This would be a particular problem if the initial incision was larger than a subsequent surgeon’s hand as the pneumoperitoneum would leak around the surgeon’s hand. Another limitation of this approach was that other instruments could not be placed through this incision as again, pneumoperitoneum would be lost by inserting a smaller instrument through this larger incision. Furthermore, many surgeons reported hand cramping during surgeries and would at times have to remove their hand to allow it to recover before continuing the operation [15].

One solution to these problems was the development of a port or sleeve type device that allowed a surgeon to insert and withdraw and even change operators while maintaining pneumoperitoneum. Although early devices did not always succeed in accomplishing these tasks, they paved the way for further innovation. The first device to be used was called the PnuemoSleeve (Dexterity, Atlanta, GA). Porcine surgeries were done in order to establish efficacy by Bannenberg et al. [15, 16]. These experiments allowed the surgeons to decrease operative time, allow for the exchange of hands and even allow the use of traditional open instruments to be used during the procedure. In one of the surgeries, the authors described the purposeful cutting of a renal vein to test the ability to control this with the intraoperative hand. They reported that this was “easily controlled by pressure with the thumb and forefinger while retracting the kidney laterally.” Clips were placed after the bleeding vessel was secured to ligate the bleeding vessel [15]. These animal studies then paved the way for use in humans using the PnuemoSleeve.

The first hand-assisted laparoscopic nephrectomy in a human using a hand-assist device (PneumoSleeve) was performed by Drs. Stephen Nakada and Timothy Moon at the University of Wisconsin in April of 1997 (Fig. 19.3). The patient was a 60 year-old woman with multiple sclerosis and recurrent stone disease who developed end-stage renal failure requiring hemodialysis. She had recurrent episodes of pyelonephritis and chronic right flank pain and had a past surgical history that included an open right pyelolithotomy and appendectomy. She had a right-sided nephrostomy tube in place at the time of surgery. The primary surgeon was left-handed and therefore the PneumoSleeve was placed in the midline just superior to the umbilicus by making a 7 cm incision. Two additional 12 mm ports were placed and a 5 mm port was used for the liver retractor. The specimen was removed intact through the midline incision. The surgery lasted 4 h and 18 min with 100 cc of blood loss. The patient was discharged on postoperative day 3 and returned to normal activity within 7 days. Subsequently a HALS radical nephrectomy was performed on a 4 cm RCC successfully by that same surgical team [17].

The development of the hand-assist devices (HADs) were paramount to the widespread application of HAL. These offered the ability to for the surgeon to insert and withdraw his hand through the procedure and for the exchange of surgeons to occur. They allowed the introduction and removal of other laparoscopic and traditional surgical instruments as well as sponges into the abdomen and withdraw them without losing pneumoperitoneum. We have already briefly introduced the PneumoSleeve as the first product of this type. Several other products were subsequently developed that allowed surgeons to accomplish these goals. HADs are generally divided into first and second-generation devices. The first generation devices included the HandPort, the IntroMit, and the PneumoSleeve. Second generation devices include the LapDisc, the OmniPort and the Gelport [18]. We will discuss these devices including their advantages and limitations in the following section.

The PneumoSleeve (Dexterity, Atlanta, GA) was the first device available in the United States [17, 19, 20]. The device used an adhesive plate that attached to the abdominal wall (Fig. 19.4). The surgeon then wore a sleeve that attached to the abdominal wall thus creating the seal. The set included an adhesive locking ring, a paper template, a protector-retractor, two sleeves, the Pneumo Dome. The laparoscopic ports were first placed and the location of the PneumoSleeve was inspected. The adherent base is placed on the abdomen. The paper template was then used to mark the planned incision. The size of the incision was based on the surgeon’s hand size. The protractor-retractor was inserted through the incision with the inner ring placed just inside the peritoneal cavity. This component served as a wound protector and helped to retract the edges to facilitate insertion of the surgeon’s hand through the wound. The sleeve component was then placed over the surgeon’s fingers. A dark glove was typically placed over the surgeon’s hand as light colored gloves tended to reflect too much light which obscured the surgeon’s visualization. The sleeve was then locked to the adherent base on the abdomen. Pneumoperitoneum is lost during the insertion process, however after the ring is locked it can be re-established [20–22].