The controversy regarding hand-assisted colorectal resection

The technique of hand-assisted colectomy was introduced in the 1990s but initially was not widely embraced by the minimally invasive community [1, 2]. However, in the past 4–6 years the popularity of hand-assisted methods has increased considerably. One reason for the surge in interest was the publication of the Clinical Outcomes of Surgical Therapy (COST) findings, which suggested that laparoscopic colectomy for cancer was associated with comparable oncological outcome and improved short-term results [3]. Many surgeons who had not been performing laparoscopic colectomy now felt it was safe to do so and, thus, began utilizing minimally invasive methods. Another important reason for the increased utilization of handassisted methods in recent years was the introduction of secondand third-generation devices that are far easier to use and are more versatile than the initial devices. As the use of hand-assisted techniques has increased, a rift has developed in the minimally invasive world regarding the appropriateness and need for hand-assisted methods. Strong proponents believe that hand-assisted methods are appropriate for all left-sided colorectal resections whereas others feel strongly that, for an experienced minimally invasive surgeon, there is no need for hand-assisted methods at all. Until recently, the relatively sparse published literature on the subject has been insufficient to settle the dispute. However, the recent multicenter randomized study presented at the 2007 American Society of Colon and Rectal Surgeons (ASCRS) meeting sheds further light on the subject. This study suggested that handassisted colectomy is associated with time savings of 33 and 57 min for left segmental colectomy and total abdominal colectomy, respectively. Importantly, the shortterm clinical outcomes of hand-assisted procedures were comparable to those obtained using straight laparoscopic methods [4]. The mean incision length for the hand-assisted group was 8.2 cm as opposed to 6.1 cm for the laparoscopic group. Despite these findings, the controversy continues. Laparoscopic ‘‘purists’’ believe that there is little or no place for hand-assisted methods because the straight laparoscopic approach results in a smaller final incision. Since the whole point of laparoscopy is to minimize abdominal wall trauma, they can find no acceptable rationale for ‘‘giving back’’ incision length to accommodate hand methods. Some feel that the abdominal wall trauma incurred with hand-assisted operations more resembles an open rather than a minimally invasive operation. They maintain that, with the proper skills and training, straight laparoscopic resections are feasible and clearly preferable to hand-assisted approaches. Straight laparoscopic proponents also worry that surgeons who exclusively learn handassisted methods will never master the two-handed technique and are not likely to cross the bridge to straight laparoscopic resection. Thus, a cadre of hand-assisted surgeons is likely to arise who will be doing a second best type of resection. Hand-assisted proponents believe that, clinically, for the majority, the recovery and morbidity of hand-assisted patients is very close to if not the same as patients that undergo straight laparoscopic resection. Further, they point out that the difference in overall incision size between the two approaches is not that great. Supporters also believe S. Stein New York Presbyterian Hospital, New York, NY, United States