Hand-assisted Laparoscopy: Expensive but Considerable Step Between Laparoscopic and Open Colectomy.

PURPOSE: Hand-assisted laparoscopic colectomy (HALC) and laparoscopic-assisted colectomy (LAC) have been shown to have comparable short-term outcomes while there are limited data regarding costs. The aim of our study was to compare the short-term outcomes and costs of HALC and LAC. MATERIALS AND METHODS: In total, 46 patients who underwent HALC or LAC for benign or malignant disease between January 2011 and December 2014 at our institution were included in the study. Patients were randomized into HALC or LAC group. Patients' demographics and characteristics, operative details, short-term outcomes, and costs were evaluated. RESULTS: There were 25 patients in LAC group and 21 patients in HALC group. Patient's demographics and characteristics and short-term outcomes were comparable between the LAC and HALC groups. Conversion rate was significantly lower in the HALC group (4.7% vs. 28%, P=0.03) while surgical costs ($1706.83±203.70 vs. $1304.93±305.67, P=0.038) and total costs ($2427.18±254.27 vs. $2044.03±215.22, P=0.021) were significantly higher in HALC group. CONCLUSIONS: HALC is associated with increased surgical and total hospital costs, and decreased rate of conversion. Although it is more expensive, HALC may be helpful by providing a step between LAC and open surgery before considering conversion.

Does laparoscopy reduce splenic injuries during colorectal resections? An assessment from the ACS-NSQIP database.

BACKGROUND: Nearly half of all incidental splenectomies caused by iatrogenic splenic injury occur during colorectal surgery. This study evaluates factors associated with incidental splenic procedures during colorectal surgery and their impact on short-term outcomes using a nationwide database. METHODS: Patients who underwent colorectal resections between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database according to Current Procedural Terminology codes. Patients were classified into two groups based on whether they underwent a concurrent incidental splenic procedure at the time of the colorectal procedure. All splenic procedures except a preoperatively intended splenectomy performed in conjunction with colon or rectal resections were considered as incidental. Perioperative and short-term (30 day) outcomes were compared between the groups. RESULTS: In total, 93633 patients who underwent colon and/or rectal resection were identified. Among these, 215 patients had incidental splenic procedures (153 open splenectomy, 17 laparoscopic splenectomy, 36 splenorraphy, and 9 partial splenectomy). Open colorectal resections were associated with a significantly increased likelihood of incidental splenic procedures (OR 6.58, p < 0.001) compared to laparoscopic surgery. Incidental splenic procedures were associated with increased length of total hospital stay (OR 1.25, p < 0.001), mechanical ventilation dependency (OR 1.62, p = 0.02), transfusion requirement (OR: 3.84, p < 0.001), re-operation requirement (OR 1.7, p = 0.005), and sepsis (OR: 2.03, p = 0.001). Short-term advantages of splenic salvage (splenorraphy or partial splenectomy) included shorter length of total hospital stay (p = 0.001) and decreased need for re-operation (p < 0.001). CONCLUSIONS: Incidental splenic procedures during colorectal resections are associated with worse short-term outcomes. Use of the laparoscopic technique decreases the need for incidental splenic procedures.

Outcomes associated with resident involvement in laparoscopic colorectal surgery suggest a need for earlier and more intensive resident training.

PURPOSE: The aim of this study is to determine if resident involvement in a large cohort of laparoscopic colorectal surgery (LCS) cases negatively impacts outcomes and ultimately increases costs. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent LCS between 2005 and 2010. Patients were classified into two groups: postgraduate year (PGY; resident involvement) or Attending Only. A subgroup analysis was then conducted among the individual PGY levels (1-2, 3-5, ≥6) and Attending Only group. RESULTS: A total of 4,836 patients were included in the PGY group and 2,418 in the Attending Only group. Mean operative time (163.9 ± 66.7 vs. 140.7 ± 67.2 minutes, P < .001) and length of hospital stay (5.8 ± 5.4 vs. 5.6 ± 5.4 days, P = .015) were significantly longer in the PGY group. Surgical and nonsurgical complications and overall morbidity and mortality rates were similar between the two groups. Each individual PGY group was associated with longer operative time (P < .001), and PGY ≥ 6 was associated with an increased length of stay (P < .001). CONCLUSION: Although resident participation in LCS does not affect overall mortality or morbidity, it may negatively impact hospital costs through increased operative time and length of hospital stay. Early and intensive laparoscopy training may be necessary for improving residents' laparoscopy skills before their involvement in LCS.