Rate of Utilization of Hand-Assisted Laparoscopic Methods Is Directly Proportional to Bmi

Elizabeth A Myers, DO, Daniel L Feingold, MD, Tracey D Arnell, MD, Linda Njoh, MSc, Vesna Cekic, RN, Joon Ho Jang, MD, Daniel D Kirchoff, MD, Samer Naffouje, MD, Sonali Herath, BS, Jon Kluft, BS, Richard L Whelan, MD. St. Luke’s Roosevelt Hospital Center, New York, NY, USA; College of Physicians and Surgeons, Columbia University, New York, NY, USA

INTRODUCTION: Some MIS surgeons believe the use of hand-assisted (HA) laparoscopic methods will lead to decreased use of laparoscopic-assisted (LA) methods. Another opinion is that the incision length (IL) will always be shorter for LA vs. HA methods. The impact of BMI on the choice of MIS method and the overall IL has not been studied. This study assessed the utilization of HA and LA methods in regards to BMI by a group of 3 colorectal surgeons who primarily used MIS techniques. A second purpose was to determine the relationship between surgical method and IL in the setting of colorectal resection (CR).

METHODS: A retrospective analysis of 1122 patients who underwent CR during an 11 year period was performed. Patients were placed in 1 of 3 categories: LA, hand-assisted or hybrid laparoscopic (HHL), or open. Both laparoscopic and open methods are used in hybrid resections (incision length usually <11cm). Because of the similarity in IL of Hand and Hybrid cases (difference ≤ 1 cm) these cases were grouped together. Overall and BMI specific utilization rates and mean incision sizes were determined and the results compared.

RESULTS: Overall, the utilization rate for each surgical method was: LA, 60%; HHL, 25% (Hybrid 17 pts/Hand 263 pts), and open, 15%. The mean BMI of patients was significantly higher in the HHL vs. LAP group (P<0.0001). The utilization rate for HHL methods was directly proportional to BMI: BMI <18.5, 9.7%; BMI 18.5-24.9, 22%; BMI 25-29.9, 29%; BMI 30-34.9, 36%; BMI 35-39.9, 41%, and BMI ≥40, 58%. Except for patients with BMI ≥35, HHL methods were rarely used for right/transverse CR’s. In contrast, HHL methods were used for 54% of sigmoid and rectosigmoid CR’s, and 40% of LAR’s and APR’s. IL was directly proportional to BMI for all surgical methods: the most dramatic difference was noted in the LA group (BMI < 18.5, 4.57 cm vs. BMI ≥40, 11.45 cm) whereas lesser differences were noted for the HHL (BMI <18.5, 8.33 cm vs. BMI ≥40, 11.14). For patients with BMI ≥40, no difference in IL was noted between HHL vs. LAP methods (P=0.85), whereas IL was significantly greater using HHL when the BMI was <40 (P<0.0001). The mean difference in IL between the HHL and LA methods was 4.3 cm when BMI <40. The mean LOS was 1 day longer for the HHL vs. LA group (p=0.11).

CONCLUSIONS: The use of both HHL and LA methods was associated with an overall MIS utilization rate of 85%. Most cases were done with LA methods. HHL methods were used primarily for sigmoid/LAR cases and the rate of use increased with rising BMI. For both methods, IL increased with BMI. At BMI ≥40 there was no difference in mean IL’s for HHL and LA cases. The mean IL difference between methods was 4 cm. LOS was 1 day longer for HHL. HHL and LA methods are not mutually exclusive. Together, they may increase the number of MIS cases done. HHL methods may facilitate MIS in high BMI patients.
 

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