Abdominal Hartmann reversal versus combined transanal/abdominal approach: Outcomes and technical notes

Abstract

Background: Hartmann’s reversal (HR) is one of the most technically challenging operations in colorectal surgery. A small percentage of HR operations are performed laparoscopically. The pelvic dissection is the key point of the procedure and can be demanding when the rectal stump is extraperitoneal and if the pelvic condition is complex. Methods: A retrospective observational single-center study was designed to analyze the outcomes of patients with an extraperitoneal rectal stump who underwent HR from January 2015 to December 2020 at IRCCS Sacro Cuore Don Calabria Hospital in Negrar of Valpolicella. The patients were divided into two groups: group 1 underwent a purely abdominal Hartmann’s reversal (A-HR) and group 2 underwent a combined transanal and abdominal Hartmann’s reversal (TA-HR). Results: Forty-two patients were divided into the groups as follows: 22 (52.3%) patients in the A-HR group versus 20 (47.62%) patients in the TA-HR. The transanal approach did not significantly affect the operative time. The rate of rectovaginal fistula was higher in the TA-HR group (65% vs. 4.5%). The anastomosis was performed mechanically in all A-HR cases and 50% of TA-HR patients (P < 0.01). No difference in temporary stoma creation was found. The rate of complications was lower in the TA-HR group (P = 0.05). The A-HR group was statistically significantly associated with redo surgery (P = 0.04). Stoma failure rate at the end of the follow-up did not differ between the two groups. Conclusions: Transanal Hartmann reversal seems to be a safe approach in patients with a complex pelvis and extraperitoneal rectal stump.