Hand-Assisted Laparoscopic Colectomy for Complicated Colorectal Disease in Emergency Settings

Abstract

Background and Objectives:

The safety and effectiveness of laparoscopic approaches for emergency colorectal surgery are not yet fully established, though their use is increasing with studies reporting laparoscopic colectomy is safe and feasible for appropriately selected patients. Hand-assisted laparoscopy (HAL) involves inserting one hand into the abdomen through a small incision, offering advantages that may facilitate laparoscopic procedures in emergencies. This study reports our experience with emergency HAL colectomy.

Methods:

This was a retrospective review of consecutive colorectal emergency cases treated with HAL colectomy in a tertiary referral center. Patient demographics, indications for surgery, operative details, and postoperative outcomes were analyzed. Survival rates were calculated for cases with malignancy.

Results:

From February 2015 to July 2019, HAL was applied to all emergency colectomy cases in patients with an American Society of Anesthesiologists (ASA) score of I–III. A total of 50 patients treated with HAL colectomy for complicated colorectal disease were reviewed. Twenty-five patients (50%) had an obstruction which required an intraoperative decompression procedure or intraoperative antegrade colonic irrigation. Thirty-eight patients (76%) had perforation. There were 2 cases of open conversion (4%). The median duration of the operation was 160 minutes. The median amount of estimated blood loss was 250 mL. The median time of postoperative stay was 12 days. The postoperative complication rate associated with the operation was 26% (13/50). There were 2 postoperative mortalities.

Conclusion:

HAL appears to be a feasible option in emergency colectomy for ASA I–III patients and may be beneficial in specific surgical practice contexts.

INTRODUCTION

The first laparoscopic colectomy was performed in 1990, and only a few decades were needed to make it the gold standard in elective colorectal surgery for both benign and malignant diseases. Nowadays, it is generally preferred over open procedures for colorectal disease in elective settings, even for advanced lesions, because of its obvious advantages, including less pain, faster short-term recovery, and lower postoperative morbidity, with comparable oncologic outcomes in case of malignancy.^1,2

However, the safety and effectiveness of laparoscopic approaches for emergency colorectal surgery have not yet been firmly established. Although there are expectations that the reduced surgical stress associated with smaller incisions of minimally invasive techniques in elective surgery would also enhance recovery for patients in emergency situations,³ the adoption of laparoscopy as a primary procedure in emergency colorectal surgery has been hampered. It seems to result not only from insufficient evidence in the literature but also from the technical difficulties, which are inevitably magnified under emergency conditions.

Hand-assisted laparoscopy (HAL), a laparoscopic technique in which one hand is inserted into the abdomen through a small incision, was developed in the early 1990s with the purpose of mitigating the technical difficulties of conventional laparoscopy by preserving the benefits of direct sensation and movement of the human hand.⁴ Having one hand within the abdominal cavity can help overcome obstacles presented by emergency conditions and facilitate the continuation of laparoscopy.

We hypothesized that HAL may be suitable for patients requiring emergency colectomy due to obstruction or perforation resulting from complicated colorectal disease. The aim of this study was to report our experience of emergency HAL colectomy.

METHODOLOGY

Patients and Data Collection

This was a retrospective review of consecutive emergency colorectal cases treated with HAL colectomy at OOO Hospital, a tertiary referral center in the Republic of Korea, from February 2015 to July 2019. All procedures were performed by a single board-certified colorectal surgeon with extensive experience in both colorectal cancer and benign colorectal disease, and who is proficient in a range of surgical approaches, including HAL. The surgery was classified as an emergency case and included in the study when scheduled immediately after surgeon’s evaluation and performed as soon as the anesthesiologist and operating room staff were ready. Emergency surgery was indicated for patients with complete or near-complete bowel obstruction for any reason, a perforated viscus, fulminant colitis, ischemic colitis with accompanying transmural necrosis, or uncontrolled hemorrhage.

All data were retrieved from a prospectively compiled computer database. Patient demographics and clinical characteristics of the diseases were evaluated, including indications for surgery, operative details, and postoperative outcomes. Pathological findings were reviewed in cases of malignant disease. Overall and disease-free survival were also calculated for these cases.

Surgical Procedure

HAL colectomy was performed using the GelPort Laparoscopic System (Applied Medical, Rancho Santa Margarita, CA). The hand port was placed through a transumbilical midline incision, typically 7 cm in length, with 2 additional 12-mm trocars inserted for the camera and instrumentation. A 10-mm 30° rigid scope was used in all cases. The procedure typically required 2 people: an operating surgeon and an assistant for the scope. The assistant stood on the same side as the surgeon, toward the patient’s head. The hand port device was made of gel to allow hand insertion without air leakage, preventing the collapse of the pneumoperitoneum. The surgeon’s left hand was inserted through that, primarily to assist with tasks such as creating and maintaining the surgical field and providing tissue traction. The main procedure, including sharp dissection, was generally performed using a 12-mm trocar with instruments in the right hand, in the same manner as conventional laparoscopy. Occasionally, when the reach of the instruments was limited through the 12-mm trocar, an additional 5-mm trocar was inserted in a different quadrant of the abdomen (Figure 1).

Figure 1.

Surgeon’s position and port placement in HAL colectomy. Red line: transumbilical incision for HAL port (surgeon’s left hand); Green dot: 12-mm trocar for 10-mm camera; Blue dot: 12-mm trocar for instruments; Yellow dot: 5-mm trocar for assistant’s instrument (optional). (A) Surgeon’s position in left-sided cases. (B) Surgeon’s position in right-sided cases. (C) Transumbilical incision for the hand port. (D) Port placement in left-sided cases. (E) Final wound in left-sided cases.

During the operation, the hand port was used for various purposes beyond specimen extraction or extraperitoneal anastomosis. By removing the gel-top lid, the hand port could function as a minilaparotomy incision with the application of a wound retractor, facilitating procedures specifically tailored for emergency situations, such as decompression or irrigation (Figure 2).

Figure 2.

Various uses of the hand port. (A) Specimen extraction. (B) Use of the hand port for irrigation.

In cases of malignant disease, even for palliative procedures, colectomy was performed in accordance with the principles of curative resection, including en bloc resection, adequate lymphadenectomy with ligation of the lymphovascular pedicles, and clear resection margins. The primary principle for colectomy was to restore intestinal continuity as much as possible. However, Hartmann’s procedure or ileostomy formation was considered when the risk of anastomotic leakage was very high. This decision was made at the discretion of the surgeon during the operation. Intraoperative antegrade colonic irrigation was performed if necessary for anastomosis of an obstructed colon.

Conversion to open was defined as any extension of the incision for the hand port for a purpose other than specimen retrieval.

Perioperative Management

None of the patients underwent bowel preparation before surgery. All patients received subcutaneous low-molecular-weight heparin postoperatively to prevent deep vein thrombosis and used elastic compression stockings. Postoperative pain was managed in a traditional manner using patient-controlled analgesia. No multimodal pain management protocols were applied during the study period. Early mobilization was encouraged when vital signs were stable. Diet progression was based on the physical signs of bowel function.

Statistics

Because this was a descriptive study, only descriptive analyses were performed. Statistical values of continuous variables were presented as median and interquartile range (IQR). Survival curves for cases with malignant disease were calculated using IBM SPSS version 29.0 (IBM Corp., Armonk, NY).

Ethics

This study was approved by the Institutional Review Board of OOO Hospital (OOO 2022‐12‐021). The requirement for informed consent was waived due to the retrospective nature of the study.

RESULTS

During the study period, HAL technique was applied to all emergency cases involving patients with an American Society of Anesthesiologists (ASA) score of I–III on preoperative evaluation, who were expected to require colectomy. A total of 50 patients treated with emergency HAL colectomy for complicated colorectal disease were reviewed.

Table 1 shows the clinical characteristics and disease entities of all patients. The median age of the patients was 67 years (IQR, 58–79), with a nearly equal sex ratio. The median body mass index was 23.1 kg/m² (IQR, 21.4–25.4). More than half of the patients had comorbidities, including hypertension, diabetes mellitus, benign prostatic hyperplasia, dyslipidemia, asthma, Parkinson’s disease, and chronic kidney disease requiring dialysis. The ASA scores were III in 28 patients, II in 17 patients, and I in 5 patients. Eight patients had a history of abdominal surgery, with half of these being gynecologic procedures, such as total abdominal hysterectomy. The others included subtotal gastrectomy, laparoscopic cholecystectomy, and explorations for peritonitis. None of these patients had extensive abdominal adhesions requiring substantial adhesiolysis that might prolong the operation time. The pathologies responsible for the emergency were mainly located in the left-sided colon or rectum, with only 8 out of 50 cases involving right-sided pathologies. Half of the pathologies were benign, while the other half were malignant. Half of the patients (25/50) had obstructions that required intraoperative decompression procedures or intraoperative antegrade colonic irrigation. Two-thirds of the patients (38/50) had perforations. Of these 38, 20 had free perforations with abundant fecal spillage inducing panperitonitis and 18 had sealed perforations associated with large abscesses and severe inflammation in the adjacent tissues.

Table 1.

Clinical Characteristics of the Patients

Characteristics	Number (Total = 50)
Age	67 (58–79)*
Sex (Male : Female)	24 : 26
BMI (kg/m2)	23.1 (21.4–25.4)*
ASA class (I : II : III)	5 : 17 : 28
Comorbidities (Yes : No)	28 : 22
Details of comorbidities†
Hypertension	20
Diabetes mellitus	5
Chronic kidney disease	2
Asthma	2
Parkinson’s disease	2
Femur fracture	2
Cerebrovascular accident	2
Dementia	2
Dyslipidemia	2
Arrythmia	2
Major depressive disorder	2
COPD	2
Pulmonary tuberculosis	1
Guillain–Barré syndrome	1
Epilepsy	1
Liver cirrhosis	1
History of abdominal surgery (Yes : No)	8 : 42
Location of the main lesion (Right : Left)	8 : 42
Disease entity (Benign : Malignancy)	25 : 25
Obstruction	25
Perforation	38

BMI, body mass index; ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease.

*Median (interquartile range).

^†Only current conditions or existing sequelae are included; the total case count exceeds the number of patients due to overlapping conditions.

Details of the operative and perioperative outcomes are presented in Table 2. Eight patients underwent right hemicolectomy, 5 underwent left hemicolectomy, 13 underwent sigmoidectomy, another 13 underwent anterior resection, 5 underwent low anterior resection, and 6 underwent Hartmann’s procedure. The median duration of anesthesia and surgery was 210 minutes (IQR, 185–263) and 160 minutes (IQR, 130–215), respectively. The median estimated blood loss was 250 mL (IQR, 108–500). Two cases were converted to open (4%). The median hospital stay was 12 days (IQR, 7–18). Postoperative complications developed in thirteen patients (26%). Of these thirteen patients, 5 recovered with conservative management only, 6 required radiologic intervention for drainage, and the other 2 underwent reoperation. There were 2 postoperative mortalities, occurring on the 19th and 35th postoperative days.

Table 2.

Operative and Postoperative Outcomes

Characteristics	Number (Total = 50)
Operation
Right hemicolectomy	8
Left hemicolectomy	5
Sigmoidectomy	13
Anterior resection	13
Low anterior resection	5
Hartmann’s procedure	6
Anesthesia time (min)	210 (185–263)*
Operation time (min)	160 (130–215)*
Estimated blood loss (mL)	250 (108–500)*
Conversion to open	2
Hospital stay (days)	12 (7–18)*
Complication†
Superficial SSI	2
Deep SSI	5
Anastomosis leakage	2
Ileus	4
Pulmonary complication	1
Delirium	2
Hernia	0
Etc.	2
Mortality	2

SSI, surgical site infection.

*Median (interquartile range).

^†The total case count exceeds the number of patients due to overlapping complications.

When looking only at cases with malignancy (Table 3), the median age of the patients was 71 years (IQR, 57–80), which was slightly older than that of the whole group, with a higher male ratio. The obstruction ratio was higher, whereas the perforation ratio was similar to the those of total group. Thirteen cases, more than half, had stage IV disease, 8 had stage III disease, and the remaining four had stage II disease. Of the total 25 patients, 24 patients were operated due to adenocarcinoma, except one patient with lymphoma perforation. The median number of harvested lymph nodes was 20 (IQR, 16–28). The median operation time, estimated blood loss, and hospital stay were very similar to the total group. Two cases were converted to open, which means all the converted cases in this series were with malignant diseases. The reasons for conversion were also related to the existence of cancer, one was a limited field of vision because of tumor volume, and the other was ureter invasion that required the participation of a urologist. Postoperative complication rate of those with malignant disease was 28% (7/25), which was similar to that of the total group. Patients with malignancy were followed up for a median of 37.7 months (IQR, 8.5–65.4). During the follow-up period, 7 of 13 patients with stage IV disease died. Four patients with stage II disease had no recurrence. Two of 8 patients with stage III disease had recurrence of lung metastases. After salvage procedures for the lung, however, they were alive without recurrence until the last follow-up. Figure 3 shows the survival curves of these patients, the overall survival of all patients, and the disease-free survival of patients with stage I–III disease.

Table 3.

Characteristics and Outcomes of Patients with Malignant Disease

Characteristics	Number (Total = 25)
Age	71 (57–80)*
Sex (Male : Female)	15 : 10
BMI (kg/m2)	22.8 (21.1–24.0)*
ASA class (I : II : III)	2 : 11 : 12
Obstruction	21
Perforation	16
Location of the main lesion (Right : Left)	3 : 22
Operation
Right hemicolectomy	3
Left hemicolectomy	3
Sigmoidectomy	1
Anterior resection	10
Low anterior resection	3
Hartmann’s procedure	5
Stage (I : II : III : IV)	0 : 4 : 8 : 13
Operation time (min)	195 (153–225)*
Estimated blood loss (mL)	300 (105–500)*
Conversion to open	2
Histology
Lymphoma	1
Adenocarcinoma	24
Harvested lymph nodes	20 (16–28)*
Hospital stay (days)	12 (8–16)*
Complication	7†
Superficial SSI	0
Deep SSI	2
Anastomosis leakage	1
Ileus	2
Pulmonary complication	1
Delirium	1
Hernia	0
Etc.	1
Mortality	1
Median follow-up (months)	37.7 (8.5–65.4)*
Median follow-up stage I –III (months)	56.1 (11.8–77.8)*
Median follow-up stage IV (months)	16.3 (6.2–49.1)*

BMI, body mass index; ASA, American Society of Anesthesiologists.

*Median (interquartile range).

Figure 3.

Survival curves of patients with malignant disease. (A) Overall survival. (B) Disease-free survival.

DISCUSSION

A significant proportion of colorectal surgeries, approximately 10%–10%, are carried out in emergency settings due to the inherent nature of colorectal disease, which involves a hollow viscus organ containing microorganism-rich contents. In emergency situations associated with obstruction or perforation, the main option for colorectal surgery is still open.

As the main paradigm of colorectal surgery has shifted from open surgery to laparoscopy, and surgeons have become familiar with laparoscopy even more than open procedures, gaining confidence in advanced laparoscopic techniques, the use of laparoscopy in emergency settings has been increasing. The literature on emergency laparoscopic colectomy has grown exponentially since the mid-2000s, and these studies, reflecting decades of experience, have demonstrated it to be a safe and feasible option with acceptable outcomes for patients with complicated colorectal disease.^5–7 Recent comparative studies using large databases have shown better outcomes for laparoscopy, with lower complication rates compared to open surgery, and have proposed laparoscopy as a promising option to improve patient outcomes in emergent colectomy.^8,9 Notably, some studies attempted to adjust for confounding factors using various statistical methods to support the conclusion that the benefits of laparoscopy were not solely attributable to selection bias toward technically easier cases. Although most these studies were retrospective, registry-based, or single-centered, evidence justifying laparoscopic colectomy in emergency settings appears to be gradually accumulating, with additional randomized controlled trials planned.¹⁰ However, there remains significant resistance and hesitation to choosing laparoscopy as the primary option for colorectal emergencies universally, especially in real-world practice.

The theoretical benefits of laparoscopy with its smaller incisions in emergency colectomy are clear. Smaller incisions can reduce pain and trauma from the operation, which can otherwise add to the burden for patients already suffering from inflammatory processes related to complicated colorectal disease. Moreover, smaller incisions help reduce the wound area exposed to contamination, lowering the risk of wound complications, which are more common after emergency surgery,¹¹ particularly in cases of obstruction or perforation. Even when wound complications occur, the smaller laparoscopic incisions are undeniably easier to manage compared to the longer open surgery incisions. On the other hand, the challenges of using laparoscopy for emergency colectomy are also readily apparent. The operations would be technically more demanding due to the distortion of normal anatomy caused by obstruction accompanied by fecal stasis and upstream bowel dilation, perforation leading to gross spillage of fecal material, or severe inflammatory changes in the surrounding tissue. Intra-abdominal lavage to remove spillages may take longer and be less effective.¹² The operation time might be longer than open procedures, which could impose additional stress on critically ill patients.¹³

HAL has both advantages and disadvantages compared to conventional laparoscopy. A recent meta-analysis comparing HAL with conventional laparoscopic colorectal surgery in elective settings demonstrated HAL as a viable alternative, offering benefits such as a lower conversion rate and shorter operation times, although at the cost of increased incision length and higher postoperative complication rates.¹⁴ The authors suggested that the benefits are due to the lower technical difficulty with HAL, while the shortcomings are related to surgeons favoring HAL for more complicated surgical cases.

In emergency situations, the advantages of HAL might be maximized. A hand inside the abdomen, which preserves tactile sensation and enhances hand-eye coordination, can aid in navigating distorted anatomy and handling inflamed, fragile tissues. It also allows for blunt dissection between inflamed tissues with minimal injury and enables pressure-based bleeding control using the fingers. The hand port, functioning as a minilaparotomy without any extension from its initial size, can address various limitations of laparoscopy in emergency colectomy. For example, the entire small bowel can be retracted through the hand port without injuring or dissecting the mesenteric root, allowing for easy decompression through a small incision. In cases requiring intraoperative antegrade colonic lavage, the cecum can be brought to the hand port after minimal dissection of the right colon, and a Foley catheter can be inserted for antegrade irrigation through the appendiceal orifice. The hand port can also be utilized for irrigation in cases of perforation and fecal soiling. When the soiling is too abundant or solid to proceed with the procedure, fecal material can be removed through the hand port prior to initiating the main irrigation process. Warm saline can be poured directly through the hand port, allowing for thorough cleaning of intra-abdominal organs by hand without risk of damage from other instruments. This method is much faster and more effective than conventional laparoscopy, allowing for cleanup at a speed and effectiveness comparable to open procedures.

In this study, we report our techniques and experience with HAL colectomy in an emergency setting. During the study period, HAL was applied to all emergency colectomy cases in patients with an ASA score of I–III, regardless of the degree of obstruction or the extent of spillage associated with perforation. As a result, our series included cases of severe disease that may not have been performed laparoscopically had patients been “carefully selected” according to traditional recommendations. In this case series, only 6 patients underwent Hartmann’s procedure with end colostomy formation. All other patients received primary anastomosis without a diverting stoma; no protective ileostomies or colostomies were performed. Overall, primary anastomosis was achieved in 88% of cases. Two patients (4.5%, 2/44) experienced anastomotic leakage—one following an anterior resection and the other after a low anterior resection—both of whom required re-exploration and diverting ileostomy formation. One patient died from unresolved sepsis on postoperative day 19, while the other, who had obstructing sigmoid colon cancer, recovered well and underwent ileostomy takedown after completing adjuvant chemotherapy. None of the patients who underwent Hartmann’s procedure were able to undergo reversal, resulting in a final stoma rate of 14% (7/50). This stoma rate appears acceptable when compared to previously reported stoma rates of 37.5–46.8%.^15–17 The overall complication rate in this series was 26%, and the mortality rate was 4%, which are consistent with previously reported rates—including data from large databases such as the American College of Surgeons National Surgical Quality Improvement Program in the United States and the Bi-National Colorectal Cancer Audit in Australia—showing complication rates of 26.7–54.6% and mortality rates of 3.4–27.2% in similar emergency colectomy populations.^17–22 For patients whose primary pathology was malignant, although the sample size is too small to draw definitive conclusions, the long-term outcomes were also favorable. All patients with stage II–III disease survived after a median follow-up of 77.8 months, with disease-free survival rates of 100% for stage II and 67% for stage III.

The role of HAL technique in previous studies of laparoscopic emergency colectomy remains unclear. Some surgeons do not distinguish between laparoscopy and HAL, grouping them under the “laparoscopy” category, while others only restrict their findings to “straight” laparoscopy. HAL has rarely been emphasized as a distinct procedure, and only a few reports specifically address its application in emergency colectomy, including our previous report.^23–25

Despite the advantages of HAL mentioned above, it also has a limitation. HALS has a distinct learning curve compared to conventional laparoscopy or robotic surgery. Therefore, surgeons should first gain proficiency with the HAL technique in elective settings before applying it in emergency situations. Favorable outcomes in emergency colectomy are likely achievable only by surgeons with substantial prior experience performing HAL colectomy in elective cases. Conversion to open surgery still occurs, often due to factors related to the original disease, such as tumor volume and infiltration into adjacent organs. Patient selection remains a critical factor, even when the surgeon is highly experienced. It is clear that HAL cannot completely replace open surgery in all situations. An open approach, which minimizes anesthesia and operating time, remains the best option in hemodynamically unstable cases. Therefore, the true benefit of HAL in emergency colectomy and proper patient selection criteria should be evaluated thoroughly in further studies.

The main limitation of this study is its retrospective noncomparative design and small sample size. Nevertheless, the findings suggest the feasibility and efficacy of this approach. Future studies should aim to be prospective, multicenter, and involve a larger sample size.

In conclusion, we cautiously propose HAL as a treatment option for emergency colorectal surgery. HAL appears to be a feasible option in emergency colectomy for ASA I–III patients and may be beneficial in specific surgical practice contexts. For the experienced surgeon, HAL can be a reasonable option and a good method and the indications for laparoscopy could be expanded to more severe cases, thereby providing the benefits of minimally invasive surgery.