Page 31 - Read Online

Donisi et al. Mini-invasive Surg 2021;5:38 https://dx.doi.org/10.20517/2574-1225.2021.55 Page 3 of 15

directly in contact with the structures. Clear pros of this approach are restoration of the tactile feedback and
better manipulation of tissues, such as better organ retraction, finger blunt dissection, exposure and control
of possible unexpected intraoperative bleeding and complications [14,15] , and a shorter operative time than
[16]
laparoscopy , while maintaining some of the advantages of MIS over the open approach, notably a lower
estimated blood loss and a shorter LOS. Among the cons, there is clearly the additional surgical trauma
posed by the mini-laparotomy, although this problem may be partially mitigated by using this technique in
operations which would already require an incision to retrieve the resected specimen. Moreover, despite the
handiness of having a direct access to the abdominal cavity, the presence of the hand may reduce the space
and range of movements of laparoscopic instrumentation and impair vision .
[13]

Fields of use
After its introduction, this technique was initially adopted in several different fields of surgery, in which a
pure laparoscopic approach was still striving to be undertaken. In esophagogastric surgery, HALS was
applied to both trans-hiatal esophagectomy and total and partial gastrectomy with good results in terms of
postoperative and oncological outcomes [17-19] . A trial was also made in bariatric surgery, but no advantages
were found over the open approach for gastric bypass in terms of incidence of incisional hernia and
reduction of LOS despite an increased cost . One of the areas in which HALS has had greater success is
[20]
colorectal, surgery in which an incision is needed anyway, no matter the approach, to extract the specimen
and possibly perform the anastomosis. HALS has been used for partial or total colectomy, anterior rectum
resection, and abdominoperineal resection, and it maintains the advantages of laparoscopy in terms of
bowel movements, refeeding, and hospital stay [21-24] . Another application of HALS was in the living-donor
nephrectomy, where it showed a shorter warm ischemic time than pure laparoscopy, while offering a
smaller incision and faster recovery than the open approach [25-28] . From initial reports, HALS appeared to
facilitate the laparoscopic approach, increasing the level of subjective safety and thus shortening the learning
curve.

HALS in the pancreatic surgery field
[30]
[29]
In pancreatic surgery, preliminary data were presented by Cuschieri and Gagner and Gentileschi , in the
early era of pancreatic laparoscopy, presenting the advantages of the hand-assisted technique over the
totally laparoscopic approach for such major procedures in terms of safety, exposure, and oncological
appropriateness. Furthermore, HALS can provide particular advantages in the case of malignancy, allowing
for palpation of the tumor and manual staging, and in the case of voluminous cystic lesions, which can be
more effectively removed en-bloc [31-35] .

The hand-assisted pancreatic resections were performed with the insertion of trocars along with a subcostal
mini-laparotomy, through which the non-dominant hand was inserted to provide traction and direct
palpation, while the demolition and reconstruction phase were both accomplished via laparoscopic
instrumentation by the dominant hand. In the case of Pancreaticoduodenectomy (PD), all three
anastomosis were performed intracorporeally , which is also because mini-laparotomy is usually located in
[30]
[36]
a position not favorable to be exploited for an open pancreatic anastomosis .
The HALS approach was mostly used to perform Distal Pancreatectomy (DP) because it is a relatively easier
procedure without need for complex anastomosis and therefore a greater effort has been put in trying to
make this procedure as less invasive as possible. Initial experience with totally laparoscopic DP has been
encouraging, stating a marked reduction of LOS, but, at the same time, relevant limitations were identified,
such as a long operative time and a high conversion rate [37,38] . At the beginning, trying to transition from a
purely open approach to a totally minimally-invasive procedure, HALS appeared to be a good compromise,
and several reports have been published stating its advantages [39,40] . Postlewait et al. reported a lower
[41]