AT THE ANNUAL MEETING OF THE CENTRAL SURGICAL ASSOCIATION
CHICAGO (FRONTLINE MEDICAL NEWS) – A nationwide analysis comparing straight versus hand-assisted laparoscopic colectomy appears to have resulted in a draw.
Despite being used more commonly in patients with higher body mass index and comorbidities, hand-assisted laparoscopic surgery (HALS) resulted in a significantly shorter operative time than did straight laparoscopic surgery (LAP) (171 minutes vs. 178.8 minutes; P < .001).
On the other hand, LAP was associated with a significantly shorter length of stay (5.9 days vs. 6.0 days; P < .001), fewer complications (15.9% vs. 18.2%; P = .006), fewer specifically superficial skin infections (4.1% vs. 5.4%; P = .007), and less prolonged postoperative ileus (7.5% vs. 9.1%; P = .01).
The differences were statistically significant likely because of the high volume of patients in each group, but are unlikely to be clinically significant in terms of patient care, senior study author Dr. I. Emre Gorgun said at the annual meeting of the Central Surgical Association.
CSA incoming president Dr. Scott A. Gruber, chief of staff at the John D. Dingell VA Medical Center in Detroit, agreed. “There were very, very small differences. I think they were trying to show that the two [approaches] are virtually equivalent,” he said in an interview. “Each has its advantages and disadvantages, but the HALS technique was used in more complex, more high-risk patients,” Dr. Gruber said.
HALS bridges the learning gap between open and straight laparoscopic surgery, which has been slow to gain adoption in colorectal surgery because it is technically demanding and has a steep learning curve, said Dr. Gorgun , a colorectal surgeon at the Cleveland Clinic. HALS allows surgeons to regain tactile sensation and manual retraction, enabling them to perform even more complex operations more effectively.
Studies also suggest that HALS reduces conversion rates and preserves the short-term benefits of LAP, though a nationwide comparison of short-term outcomes using the two techniques has been absent.
To fill this knowledge gap, the investigators used the 2012 colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program ( ACS NSQIP ) database to identify 7,843 patients who underwent LAP colectomy (n = 4,656) or HALS colectomy (n = 3,187).
At baseline, the HALS group was significantly older than the LAP group (61.5 years vs. 60 years), had a higher body mass index (28.6 kg/m2 vs. 28 kg/m2), was more likely to be hypertensive (49.8% vs. 45.1%), and to be American Society of Anesthesiologists class III (42% vs. 37.4%) and class IV (2.8% vs. 2.7%). Steroid use for inflammatory bowel disease was significantly higher in the LAP group (6.5% vs. 5.4%).
Mortality rates were similar in the LAP and HALS groups (0.52% vs. 0.50%; P = .94), Dr. Gorgun reported.
Multivariate logistic regression adjusted for comorbid conditions lessened the degree of differences between the two groups, but continued to favor HALS for shorter operative time (odds ratio, 0.94) and favor LAP for shorter hospital stays (OR, 1.05) and less superficial surgical site infections (OR, 1.31), less prolonged post-operative ileus (OR, 1.25), and overall morbidity (OR, 1.16).
“Both LAP and HALS approaches are used in minimally invasive colorectal surgery based on their respective contributions and complement each other,” Dr. Gorgun concluded. “Implementing the best approach to decrease postoperative complication rates and increase use of MIS [minimally invasive surgery] will play a role in improving patient care and overall quality of health care.”
Dr. Gorgun, his coauthors, and Dr. Gruber reported having no financial conflicts