Hand-assisted versus straight laparoscopic sigmoid colectomy on a training simulator: what is the difference? A stepwise comparison of hand-assisted versus straight laparoscopic sigmoid colectomy performance on an augmented reality simulator.

BACKGROUND: We hypothesized that simulator-generated metrics and intraoperative errors may be able to differentiate the technical differences between hand-assisted laparoscopic (HAL) and straight laparoscopic (SL) approaches.
METHODS: Thirty-eight trainees performed two laparoscopic sigmoid colectomies on an augmented reality simulator, randomly starting by a SL (n = 19) or HAL (n = 19) approach. Both approaches were compared according to simulator-generated metrics, and intraoperative errors were collected by faculty.
RESULTS: Sixty-four percent of surgeons were experienced (>50 procedures) with open colon surgery. Fifty-five percent and 69% of surgeons were inexperienced (<10 procedures) with SL and HAL colon surgery, respectively. Time (P < 0.001), path length (P < 0.001), and smoothness (P < 0.001) were lower with the HAL approach. Operative times for sigmoid and splenic flexure mobilization and for the colorectal anastomosis were significantly shorter with the HAL approach. Time to control the vascular pedicle was similar between both approaches. Error rates were similar between both approaches. Operative time, path length, and smoothness correlated directly with the error rate for the HAL approach. In contrast, error rate inversely correlated with the operative time for the SL approach.
CONCLUSIONS: A HAL approach for sigmoid colectomy accelerated colonic mobilization and anastomosis. The difference in correlation between both laparoscopic approaches and error rates suggests the need for different skills to perform the HAL and the SL sigmoid colectomy. These findings may explain the preference of some surgeons for a HAL approach early in the learning of laparoscopic colorectal surgery.