Hand-assisted advanced laparoscopic procedures. Placement of the hand assist device is essential

We read with interest the article by De Maria et al. [2] on hand-assisted laparoscopic bypass. The authors concluded that hand-assisted laparoscopic bypass did not improve clinical outcome and was associated with increased costs compared to open gastric bypass for the surgical treatment of obesity. The highest incidence of ventral hernias can be found in patients with aortic aneurysms. In a retrospective study,we analyzed intermediate-term results of hand-assisted laparosocopic (HALS) aortic aneurysm surgery. Because of the well-known problems with alterations in connective tissue metabolism in these patients,we wanted to evaluate whether the minimal invasive approach caused a reduction in the incidence of ventral hernias. A total of 182 aneurysm patients were operated on using hand-assisted laparoscopy with a hand-assist device inserted through a small midline incision like the one described by de Maria et al. [2]. In 48 cases,a ventral hernia developed at the site where the hand-assist device had been inserted. The proportion of these cases (18.7%) is still lower than the 30% incidence of ventral hernias in aneurysm patients reported in the literature,but the benefit of minimal invasive access is certainly lost because a substantial number of patients require reoperation due to abdominal wall problems. For our HALS patients with a low transverse Pfannenstiel incision or a miniaccess in the left lower flank region like the one performed for laparoscopic sigmoid resection,wound-related problems could be detected in less than 2% (Fig. 1). This can probably be explained in part by the routine use of self-retaining retractors with subsequent transient skin and muscle ischemia. Therefore,we changed our protocol and the whole aortic HALS case was performed under pneumoperitoneum [4,5]. The miniincision for the hand-assist device must be placed strategically in a way that wound-related problems are reduced and the patient can have the benefit of a total laparoscopic procedure. It is well-known from open surgery that any kind of incision in the upper abdomen can compromise ventilatory function,causes more pain even compared to a thoracotomy,and has an increased incidence of ventral hernias. As in HALS donor nephrectomies,as well as in our aortic cases,the minilaparotomy for the HALS device has to be placed in the lower abdomen. All aspects of the operation are performed under pneumoperitoneum,including suturing of an aortic anastomosis without the need for self-retaining retractors. HALS is a technique that facilitates and accelerates complex laparoscopic operations,reduces the conversion rate to open surgery when total laparoscopic procedures are performed,and is superior to any miniincision surgery in which a midline laparotomy is required