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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Hand-assisted laparoscopic versus open approach in colorectal surgery: a systematic review

AG Aalbers, A Doeksen, MI Van Berge Henegouwen, and WA Bemelman.

Review published: 2010.

Link to full article: [Journal publisher]

CRD summary

This review concluded that hand-assisted laparoscopic surgery had the advantages of laparoscopic surgery over open surgery in colorectal disease. The authors' conclusions should be interpreted with a caution given the limited quality and small sample size of included studies.

Authors' objectives

To compare hand-assisted laparoscopic surgery versus open approach in colorectal surgery.


The following databases were searched without language restrictions from inception to October 2008: MEDLINE, EMBASE and the Cochrane Library. Search terms were reported. The ‘related articles’ feature of PubMed was also used. Reference lists of relevant publications were screened.

Study selection

Studies that compared hand-assisted laparoscopic surgery with open colorectal resection in patients with benign or malignant colorectal disease were eligible for inclusion. Eligible studies had to report at least one of the following outcomes: operative time, number of trocars used, conversion to open surgery, incision length, intra-operative blood loss, time to passage of flatus, use of analgesia or pain score, overall postoperative morbidity, in-hospital mortality, length of hospital stay, and/or number of lymph nodes in resection specimen.

In included studies, most patients underwent segmental colectomies or total (procto) colectomies, while some patients underwent all procedures. The included studies were published between 1995 and 2007.

Two reviewers independently assessed studies for inclusion, with any disagreement resolved by consensus.

Assessment of study quality

The quality of included studies was assessed using the criteria of randomisation, allocation concealment, eligibility criteria specified, blinding, baseline comparability, intention-to-treat analysis, follow-up and similar non-trial treatment.

Two reviewers independently performed validity assessment.

Data extraction

Data were extracted on mean with standard deviation and event rate, as well as statistical significance of between group comparisons. Study authors were contacted for missing data where necessary.

Two reviewers independently performed data extraction.

Methods of synthesis

The studies were combined in a narrative synthesis, supported by accompanying data tables.

Results of the review

Three randomised controlled trials (RCTs) and four non-RCTs were included in the review (n=571 patients, range 24 to 208). Randomisation and allocation concealment were adequate in three studies. Five studies specified eligibility criteria. Four studies used intention-to-treat analysis. Blinding of patients and care provider was not adequate in any study. Only two studies had blinded outcome assessment. Baseline comparability of groups was adequate in four studies.

Operative time was significantly longer during hand-assisted laparoscopic surgery compared with open surgery (four out of seven studies); the additional median operative time ranged from 13 to 81 minutes. However, there was significantly less intra-operative blood loss (two out of five studies) and a significantly shorter period of analgesia use (two out of three studies). The conversion rate to open surgery in the hand-assisted laparoscopic surgery groups ranged from 0 to 10% (five studies).

Compared with open surgery, hand-assisted laparoscopic surgery was significantly associated with a shorter time to passage of flatus (two out of the four studies), which was on average one day advance. Hospital stay was also significantly shorter in the hand-assisted laparoscopic group (four out of the seven studies), with an average gain that ranged from two to four days.

Postoperative morbidity was significantly lower for hand-assisted laproscopy surgery (one out of seven studies).

The number of lymph nodes in the resection specimen was significantly higher in the hand-assisted laproscopy group (one out of three studies).

Results for other outcomes were also reported.

Cost information

One study reported that the median costs of a hand-assisted laparoscopic surgery procedure ((3.387 euros) were significantly greater than an open surgery (1.721 euros; p< 0.001). There was no significant difference in the median overall costs between the two procedures (16.728 euros versus 13.405 euros; p= 0.095).

Authors' conclusions

Hand-assisted laparoscopic surgery had the advantages of laparoscopic surgery over open surgery in colorectal disease.

CRD commentary

The inclusion criteria of the review were clear. Relevant databases were searched. Efforts were made to find published studies but not unpublished studies, thereby introducing the potential for publication bias. No language restrictions were applied in the search, which minimised the risk of language bias. Sufficient attempts were made to minimise the reviewer biases and errors in the review process.

Appropriate criteria were used to assess study quality. No adequate details were provided for the characteristics of included patients. Given the diversity of included studies, a narrative synthesis was appropriate.

The authors' conclusions should be interpreted with a caution given the limited quality and small sample size of included studies.

Implications of the review for practice and research

Practice: The authors stated that hand-assisted laparoscopic surgery provides an excellent treatment option particularly for indications where an incision to extract the resection specimen is required.

Research: The authors stated that further research is required to demonstrate whether there are additional advantages (e.g. lower incidences of adhesions and wound dehiscence) of hand-assisted laparoscopic surgery over open surgery in colorectal disease.


Not stated.

Bibliographic details

Aalbers AG, Doeksen A, Van Berge Henegouwen MI, Bemelman WA. Hand-assisted laparoscopic versus open approach in colorectal surgery: a systematic review. Colorectal Disease 2010; 12(4): 287-295. [PubMed: 19320665]

Other publications of related interest

Aalbers AG, Biere SS, van Berge Henegouwen MI, Bemelman WA. Hand-assisted or laparoscopic-assisted approach in colorectal surgery: a systematic review and meta-analysis. Surgical Endoscopy 2008;22(8):1769-1780.

Indexing Status

Subject indexing assigned by NLM


Colectomy /economics /methods; Health Care Costs; Humans; Laparoscopy /economics /methods; Length of Stay; Postoperative Complications; Recovery of Function; Rectum /surgery



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 19320665