Hand-assisted laparoscopic surgery--HALS.

Laparoscopy traces its modern beginnings to the turn of the 19th century. In a 1901 presentation to the 73rd Congress of German Natural Scientists and Physicians, Georg Kelling described the use of lufttamponade (airtamponade) or pneumoperitoneum for management of abdominal bleeding. Kelling used a Nitze cystoscope to observe the intraabdominal effects of lufttamponade on a live dog and called the procedure “Coelioscopy.”[1] However, Kelling did not make any further reports on the use of lufttamponade or of “endoscopy of an unopened abdominal cavity” in animals or humans.[2]

It remained for Hans Christian Jacobaeus in a seminal 1912 paper to describe the use of laparoscopy as a diagnostic tool in humans.[3] Jacobaeus was an enthusiastic supporter of the procedure and was the first to call it “laparoscopy.”[2] However, with but few exceptions, open techniques dominated surgical thought for the next 70 years. Erich Mühe of Böblingen, Germany performed the world's first laparoscopic cholecystectomy on September 12, 1985.[4] Although Mühe's pioneering effort in laparoscopy was not well publicized at the time, it was a significant event that helped energize the laparoscopic revolution of the late 1980s.

A striking reduction in morbidity and patient discomfort was noted when the patient outcomes of laparoscopic cholecystectomy were compared with those of the open procedure. Patients who underwent laparoscopic cholecystectomy had significantly less postoperative pain, returned to full activity more quickly, and, all in all, benefited from the exchange of a large incision for several small puncture sites. Many persons in the early 1990s assumed that laparoscopic techniques would supercede open surgery in the majority of abdominal procedures.

However, following more than a decade of experience with laparoscopic cholecystectomy, standard laparoscopic surgery has not been as widely adopted for other major abdominal operations as initially expected. The reasons for the limited extension of laparoscopic techniques to other procedures are varied and include, among other reasons, a restricted ability to manipulate the diseased specimen, and reduced tactile feedback associated with a totally laparoscopic approach. In addition, visualization of the entire operative field may not be possible with videolaparoscopy, and substitution of a two-dimensional laparoscopic camera representation for the operative site results in a loss of normal stereoscopic vision. Finally, inconsistent clinical outcomes, the long duration of totally laparoscopic surgery, and concern for patient safety issues have all played a role in retarding the adoption of a totally laparoscopic technique to other procedures.

These restrictions of standard laparoscopic surgery helped instigate the development of laparoscopically assisted surgery (LAS) for the gastrointestinal tract. After initial laparoscopic examination and preparation, laparoscopic-assisted surgery uses a small mini-incision made over the site of the intestinal pathology. The involved intestine is delivered through this incision and excision of the diseased segment is performed. Anastamosis of the remaining intestine is accomplished extracorporeally with standard techniques and normal stereoscopic vision. The reanastamosed bowel is returned to the abdominal cavity and the mini-incision closed. A disadvantage of the LAS method is that pneumoperitoneum is lost when the mini-laparotomy incision is opened to carry out the resection. After reanastamosis, the mini-incision has to be closed and pneumoperitoneum reestablished to put the last touches on those tasks necessary for completion of the operation.

Hand-assisted laparoscopic surgery (HALS) is a somewhat different technique than that of laparoscopic-assisted surgery. With HALS, a sleeve appliance is used to maintain pneumoperitoneum while the operator's hand is inserted through a small incision into the abdomen. As in standard laparoscopic surgery, the surgeon visualizes the operative field with a video monitor but, in addition, has the advantage of a human hand at the operative site. The assisting hand of the surgeon with its 7 degrees of freedom can provide exposure, traction, palpation, and digital dissection of the operative specimen. Importantly,the thumb and forefinger of the intracavitary hand are immediately available to secure hemostasis in the event of a major intraoperative bleed. Because HALS allows for the maintenance of tactile sensation and promotes a degree of hand-eye coordination, this variation in laparoscopic surgery has been easier to master for surgeons exclusively trained in open surgery.[5,6]

Because of the above, hand-assisted laparoscopic surgical techniques have the potential to:

facilitate laparoscopic surgery;

reduce operative time;

shorten the “learning curve” associated with laparoscopic surgical procedures;

improve safety;

allow accurate digital dissection of operative specimens.

Initial experience with HALS, however, has been limited to a few major centers, and little substantive investigation has been conducted into its proper application. A need exists to research the basic issues of hand-assisted procedures and establish training methods to avoid the erratic development that characterized early laparoscopic general surgery. New design concepts for HALS instrumentation are called for, and it is likely that many of the devices will require extensive research and capital expenditure. Strategies need to be worked out to optimize hand-assisted laparoscopic techniques.

For example, seemingly simple issues, such as appropriate operating table height and table orientation, need to be studied because operating room setup is different for HALS than it is for standard laparoscopic surgery or for classic open surgery. Furthermore, 1 hand within the abdomen and 1 hand out of the abdomen can be awkward and may contribute to operator fatigue during long, complex operative procedures. Whether the assisting hand is the operating surgeon's hand or the assistant surgeon's hand also needs to be elucidated. It may be that this particular issue will only be decided on a case-by-case or disease-by-disease basis.

According to early reports, the assisting-hand site should be considered as an operating port and triangulated with the other laparoscopic operating port so that the 2 ports form equal azimuth angles with the laparoscopic viewing port.[7] Positioning the operating ports at equal angles to the viewing port allows a surgeon to most ergonomically address the target organ. However, if the assisting hand is too close to the target organ, it can obscure vision of that organ and make operative movements difficult. If the assisting hand is too far from the target organ, hand fatigue may become a significant factor in the safe completion of the procedure. Also, it is necessary to examine the potential risk for injury to other organs by the intracavitary hand-wrist-forearm combination of the surgeon during a HALS operation.[8]

A preliminary overview of HALS suggests the necessity for investigation into the following:

devices or techniques to ease withdrawal of the operating hand or the insertion of instruments into the abdomen;

development of hand- or finger-activated and controlled instruments for HALS;

devices to permit change of the intracavitary hand from right to left, or vice versa, expeditiously and safely;

creation of effective maneuvers or instruments for control of major intraoperative hemorrhage;

design of a comfortable seal about the intra cavitary hand to minimize muscle fatigue, numbness, and swelling;

optimization of the effective reach of the intracavitary hand.

Because hand-assisted laparoscopic technology is in its infancy, a pressing need exists to develop suitable studies to explore its potential. In addition, only a few standard operative instruments are suitable for HALS, and new instrumentation needs to be developed for this technique. An ergonomically friendly environment should be developed for the practice of hand-assisted laparoscopic surgery. Lastly, newer methods to promote surgical education and to disseminate knowledge of the capabilities of hand-assisted laparoscopic surgery are needed.

In conclusion, it is critical for all those involved in laparoscopy to recognize that different ways are available to perform laparoscopic surgery. Minimally invasive surgery does not inherently mandate a totally standard laparoscopic approach. All reasonable options that promote patient care and well-being should be investigated. For these reasons, the integration of hand-assisted laparoscopic surgery into the minimally invasive surgical armamentarium is necessary and should be explored.