Cigdem Benlice, MD1, Meagan Costedio, MD1, Luca Stocchi, MD1, Xiaobo Liu, MS2, Maher A Abbas, MD3, Emre Gorgun, MD1. 1Cleveland Clinic, Digestive Disease Institute, Department of Colorectal Surgery, 2Cleveland Clinic, Department of Quantitative Health Sciences, 3Cleveland Clinic Abu Dhabi, Digestive Disease Institute
Introduction: Hand-assisted laparoscopic surgery (HALS) has gained acceptance as a viable option for patients undergoing colorectal resection. However the data remains limited on the potential advantages of HALS compared to open surgery. The purpose of this study was to compare the perioperative outcomes of patients who underwent colorectal resection with HALS or open surgery.
Methods: A database review was conducted using the 2012 colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).Patients were classified into two groups according to the final surgical approach: HALS vs. Open (planned). Groups were matched (1:1) based on NSQIP-derived morbidity and mortality probabilities. Multivariate logistic regression analysis was used for group comparison.
Results: 3506 cases were reviewed (1753 patients in each group). Operative time was significantly longer in the HALS group [163 (36-684) vs. 141 (30-1006) minutes, p<0.001]. Length of hospital stay was longer in the Open group [6 (1-112) days vs. 5 (1-79), p<0.001]. After adjustment for the listed comorbid conditions using logistic regression, overall morbidity and ileus rates were significantly higher in the Open group [(22.7% vs. 25.9%, OR: 1.5, p=0.0001) and (10.5% vs. 14.3%, OR: 1.3, p=0.02), respectively]. Superficial and deep surgical site infection rates were comparable between the 2 groups (p=0.08 and 0.13, respectively). Multivariable analysis showed that the following independent risk factors were associated with postoperative morbidity: open surgery, ASA class III and IV, disseminated cancer, preoperative steroid use, and presence of bleeding disorder (Table).
Conclusion: NSQIP targeted data demonstrated several short-term advantages to HALS compared to open colorectal resection including a shorter length of stay, less complications, and lower rate of ileus. Further adoption of the HALS technique will have significant positive impact on short-term outcomes following colectomy.
Table. Independent risk factors associated with postoperative morbidity
| Factor | Odds Ratio | 95% CI | P-value |
| Open vs. HALS | 1.457 |
1.205-1.762 |
0.0001 |
| Disseminated cancer (Yes vs. No) | 1.744 |
1.285- 2.368 |
0.0004 |
| Steroid use (Yes vs. No) | 1.582 |
1.16- 2.156 |
0.0037 |
| Bleeding disorder (Yes vs. No) | 1.571 |
1.059-2.331 |
0.0249 |
| ASA | <.0001 | ||
| II vs. I | 1.376 |
0.713-2.658 |
0.3414 |
| III vs. I | 2.118 |
1.087-4.125 |
0.0273 |
| IV vs. I | 2.403 |
1.093-5.282 |
0.0291 |
HALS: Hand-Assisted Laparoscopic Colectomy, CI: Confidence Interval, ASA: American Society of Anesthesiologists.