Dr. Michael O'Reilly and the ASG have been instrumental in the development of techniques for laparoscopic hand-assisted surgery.  These techniques are now widely used around the world.  Hand-assisted laparoscopic surgery allows greater tactile sense in the performance of challenging minimally-invasive surgery, many times avoiding an outright open operation.

Below is one of the papers submitted by Dr. O'Reilly and the ASG during the development of the techniques:

JOURNAL OF LAPAROENDOSCOPIC SURGERY
Volume 6, Number 4, 1996
Mary Anne Liebert, Inc.

Technique of Hand-Assisted Laparoscopic Surgery

MICHAEL J. O'REILLY, M.D., WILLIAM B. SAYE, M.D., SPENCER G. MULLINS, M.D., SHAWN E. PINTO, M.H.P., P.A.-C., and PETER T. FALKNER, R.A.

INTRODUCTION

ADVANCED LAPAROSCOPIC TECHNIQUES can be challenging to perform because the tactile sensation is limited with available laparoscopic instrumentation. Identification of structures such as vessels or ureters are critical to the safe performance of laparoscopic colon resections, splenectomies, or biopsies of retroperitoneal masses. Described is a technique of placing the surgeon's hand intraabdominally while maintaining pneumoperitoneum during laparoscopic procedures. The hand allows for excellent exploration, proper exposure, finger dissection, and meticulous hemostasis. The videolaparoscopic technique, with its attendant 18X magnification, allows for meticulous dissection. In our first 50 hand-assisted laparoscopic procedures to date our experience reveals a short hospital stay, a short time of return to preop status, and minimal morbidity (Table 1).

^aNo deaths, no infusions, no conversions to formal laparotomy.

TECHNIQUE

Hand-assisted laparoscopic surgery is performed with the patient under general anesthesia in the low lithotomy position. A cephalosporin is given intravenously for wound prophylaxis. A Foley catheter and orogastric tube are placed. Pneumoperitoneum is achieved with a 10-mm Hasson cannula placed at the umbilicus utilizing the open technique.¹ Videolaparoscopic inspection of the abdominal cavity is performed. A 7-8 cm oblique muscle-splitting incision (tailored to the size of the surgeon's hand) is placed in the lower abdomen (Fig. 1). The elasticity of the patient's tissue ultimately maintains pneumoperitoneum around the surgeon's hand as it is moved around the peritoneal cavity. The muscle is split, the fascia is divided, and the peritoneum freed from the fascia. It is important to dissect the peritoneum to such an extent that it is redundant and will fit snugly around the surgeon's wrist. The rectus muscle forms the medial border of the wound. The sling effect of the rectus muscle on the surgeon's hand helps maintain pneumoperitoneum. Remember the abdominal muscles are not transected. If CO₂ leaks around the surgeon's hand a 1-0 nylon suture can be placed approximating the skin and subcutaneous tissue around the surgeon's wrist or forearm.

Fig.1. A 7-8-cm incision in the left lower quadrant, Richardson Retractors in place.

The exact location of the incision depends on the size of the patient and the procedure to be performed. Generally the incision is placed below the level of the umbilicus, on the left side for a left colon resection (Fig. 2), on the right side for a right colon resection or splenectomy (Fig. 3). The medial extent of the incision extends 2-3 cm onto the lateral part of the ipsilateral rectus muscle. The incision is oriented obliquely caudad with the lateral extent approximately one-half the distance between the umbilicus and ipsilateral anterior iliac spine.

Fig.2. Left colon resection. S, surgeon, A, assistant.

Fig.3. Right colon resection. S, surgeon, A, assistant

The surgeon's hand is inserted through the muscle-splitting incision. Accessory ports are placed as needed. The surgeon stands between the patient's legs for a right colon resection, splenectomy, and for retroperitoneal biopsies inserting the left hand into the right-sided incision (Fig. 3) The surgeon stands on the left side of the patient for a left colon resection inserting the left hand into the left-sided incision (Fig. 2) The intraabdominal hand performs a proper exploration of all abdominal viscera. The hand provides tactile sensation of all structures, including the uterers, blood vessels, liver, and appreciation of pathologic lymph nodes. Utilizing the hand for retraction, meticulous dissection is performed. Hemostasis is obtained with clips. A pretied loop is placed on larger vessels, such as the IMA or splenic artery. If the surgeon prefers, a wound protector (Vi-Drape Wound Protector, 5" ring) may be placed into the wound after the dissection is completed to protect the wound during removal of the specimen (Fig 4). Maintaining pneumoperitoneum is not necessary and is not possible during this step of the procedure (Figs 5 and 6)

Fig.4. Vi-Drape wound protector, 5-in. ring.

Fig.5. Insertation of surgeon's hand into muscle-splitting incision. Richardson Retractor used to stretch tissue.

Fig.6. Mobilization of left colon for resection through a left lower quadrant incision with wound protector in place.

After completion of the procedure when hemostasis is assured, the lower abdominal incision is closed in layers with absorbable suture. The fascia of all port sites 10mm or greater are closed with absorbable suture. The skin incisions are closed with staples.

DISCUSSION

Advanced laparoscopic procedures ( i.e., splenectomy, colon resection, or biopsies of retroperitoneal masses) are not commonly performed because of the difficulty in achieving exposure or in identifying vascular structures.² Hand-assisted laparoscopic surgery not only allows for improved feasibility, it offers comparable and often improved postoperative outcomes, which include decreased length of stay and early return to preoperative status ( Table 1)^3,4 This technique allows the surgeon to use his or her best "instrument" - the hand. The advantage of intraabdominal hand use is preservation of tactile sensation, which is lost in pure laparoscopic techniques. With the surgeon's hand the proper exploration of the entire abdomen can be performed avoiding otherwise necessary preoperative testing, such as ultrasound or CT scans of the liver in cancer cases to detect metastatic disease. Careful manual palpation allows for improved appreciation of anatomical structures, such as ureters and blood vessels. Dissection of the colon, especially mobilization of the splenic flexure, is much easier and quicker with the use of the hand (Fig. 7). Transient or little ileus has been observed in our patients resulting in a short length of hospital stay accompanied by an early return to preop status.^5,6

Fig.7. Left colon resection as viewed from patient's side. Wound protector in left-sided incision during specimen extraction (U.S. Surgical, Norwalk, CT).

The applications for hand-assisted laparoscopy are widespread and include splenectomy, colon resections, small bowel resections, and biopsy of suspicious tissue (pancreatic, periarortic, etc.) for pathologic diagnosis that it unobtainable via CT guidance or conventional laparoscopic approaches. Our current experience has led us from optimism to enthusiasm concerning this technique...an enthusiasm that has been shared by our patients. In conclusion, the described technique offers significant benefits in the performance of advanced laparoscopic procedures, and should be added to the armamentarium of the advanced laparoscopic surgeon for the treatment of a variety of surgical conditions.

REFERENCES

¹ Hasson HM: Modified instrument and method for laparoscopy. Am J Obstet Gynecol 1971;110:886-887.

² Swanstrom LL: Beyond access: Advanced exposure techniques and organ manipulation in endosurgery. Surg Endosc 1995;9:1165-1168.

³ Lehman JF, Wisman JS: The effect of epidural analgesics on the return of peristalsis and the length of stay after elective colonic surgery. Am Surg 1995;61:1009-1012.

⁴ Senagore AJ,Luchtefeld MA, Mackeigan JM: What is the learning curve for laparoscopic colectomy? Am Surg 1995;61:681-685.

⁵ Puente I, Sosa JL, Sleeman D, et al: Laparoscopic assisted colorectal surgery. J Laparoendosc Surg 1994;4:1-7.

⁶ Yee LF, Carvajal SH, de Lorimier AA, Mulvihill SJ: Laparoscopic splenectomy: The initial experience at University of California. Arch-Surg 1995;130(8):874-879