![Page 1: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/1.jpg)
Hand Assisted Surgery
Bradley R. Davis, MD, FACS, FASCRSAssociate Professor of Surgery
Director Surgical Education/Surgical Skills LabProgram Director Residency in General Surgery
University of Cincinnati
![Page 2: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/2.jpg)
Disclosures
• Paid Consultant for Ethicon Endo Inc.
![Page 3: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/3.jpg)
Challenges
![Page 4: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/4.jpg)
Challenges
– BMI– Adhesions– Complicated Diverticulitis– pT stage– Left vs Right sided resections
Delaney et al. Surg Endosc. 2005 Jan;19(1):47-54
![Page 5: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/5.jpg)
Challenges
• Two skilled surgeons• Experienced camera operator
– Multi quadrant surgery
• Training
![Page 6: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/6.jpg)
![Page 7: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/7.jpg)
Hand Assisted Laparoscopy• Not a Fad….• Not a Cult….• Not a Religion….• Not a Political Party…..
• Just a tool in the toolbox of MIS
![Page 8: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/8.jpg)
HA Lap Colectomy
Pros• Decrease operative times• Decrease conversion
rates• Adoption• Single surgeon• Undertake more complex
cases• Surgeon’s hand is a
GREAT tool
Cons• Fear of the unknown• Learning curve• Device costs• Hand port placement
– What if you have to convert?
![Page 9: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/9.jpg)
Hand Assisted Surgery
• If you are using an incision to extract specimen….why not use it the whole case
• Hand port incision can be used to perform the anastomosis
• Modern hand ports allow hand exchanges to occur rapidly – facilitate training
![Page 10: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/10.jpg)
Outcomes - Colectomy
Author Year Type Patients Comment
HALS 2000 RPT 59 Same as lap
Targarona 2002 RPT 54 Fewer conversions
Kang 2004 RPT 60 Better than open
Chang 2005 CCT 151 Fewer conversions
Milsom 2006 CCT 42 Fewer conversions
Boushey 2005 NRT 130 Same as lap TAC
Maartense 2005 RPT 60 Same as open IPAA
Marcello 2008 RPT 95 Same as lap
![Page 11: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/11.jpg)
Cost
Orenstein et al. Surg Endosc. 2011 May;25(5):1364-8.
![Page 12: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/12.jpg)
Complications
Cima et al. J Am Coll Surg. 2008 May;206(5):946-50
![Page 13: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/13.jpg)
HALS Long Term Outcomes
Sonoda et al. J Am Coll Surg. 2009 Jan;208(1):62-6.
![Page 14: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/14.jpg)
Conversions
• Most modern RCT – failure to show a decrease in conversion rate– Study authors EXPERTS– If you spend enough time trying – usually can
finish the job– Not all patients have read the studies– Most studies exclude our patients (BMI > 30)
![Page 15: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/15.jpg)
Conversions
Cima et al. J Am Coll Surg. 2008 May;206(5):946-50
![Page 16: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/16.jpg)
Conversions – Why?
Cima et al. J Am Coll Surg. 2008 May;206(5):946-50
![Page 17: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/17.jpg)
Conversions
Park et al. Surg Endosc. 2010 Jul;24(7):1679-85
![Page 18: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/18.jpg)
Effective
Orenstein et al. Surg Endosc. 2011 May;25(5):1364-8.
![Page 19: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/19.jpg)
EffectiveHALS LAP P value
Sigmoid/Left Colectomy
Operative Times (mins)
175 208 .021
Incision (cm) 8 6 .01
LOS 5.7 5.2 NS
Total Colectomy
Operative Times (mins)
127 184 .015
Incision(cm) 7.8 6.7 .09
LOS 6.9 8.9 NS
Marcello P, et al. Dis Colon Rectum. 2008 Jun;51(6):818-26
![Page 20: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/20.jpg)
Operative Times
• Hand assisted vs. straight laparoscopic colectomy results in:
– Shorter operative times– Similar clinical outcomes
Marcello P, et al. Dis Colon Rectum. 2008 Jun;51(6):818-26
![Page 21: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/21.jpg)
Complicated Diverticulitis
HALS (n=21) Straight Lap (n=21)
Operative Times (mins)177 255
Incision Length (cm) 5 9
Conversion 4% 14%*
LOS (days) 6 5*
Complications 24% 19%*
Lee et al. Dis Colon Rectum. 2006 Apr;49(4):464-9.
*p=NS
![Page 22: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/22.jpg)
Vogel at al. J Am Coll Surg. 2011 Mar;212(3):367-72
Effective
![Page 23: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/23.jpg)
The Unexpected
• Bleeding
• Stapler Misfire
• Difficulty identifying the lesion
![Page 24: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/24.jpg)
24
![Page 25: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/25.jpg)
Operative TechniqueLAP HAL
![Page 26: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/26.jpg)
![Page 27: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/27.jpg)
Vogel at al. J Am Coll Surg. 2011 Mar;212(3):367-72
![Page 28: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/28.jpg)
Hand Assisted Right Colectomy
![Page 29: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/29.jpg)
Laparoscopy for Rectal Cancer
• Low rectal transection • Cannot come across at 90 o
• Increase # firings EndoGIA– INCREASE LEAKS
• If you need an incision…use it throughout the case
Mid to Low Lesion
Brannigan et al. Surg Endosc. 2006 Jun;20(6):952-5
![Page 30: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/30.jpg)
HALS - When
• Early in learning curve• Complex Patients• Complex Disease
– Reoperative– Phlegmon/fistula– Pelvic pathology
• Operative Times – Complex Case
Just a tool in the toolbox of MIS
![Page 31: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/31.jpg)
31
![Page 32: Hand Assisted Surgery Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director](https://reader035.vdocuments.net/reader035/viewer/2022081513/56649e4e5503460f94b45889/html5/thumbnails/32.jpg)
Thank You