Hartmann's Reversal: Laparoscopic Technique

Abstract

Introduction: Hartmann's procedure (HP) consists of sigmoidectomy, rectal stump closure, and terminal colostomy. It was originally designed for and performed only in case of neoplastic obstructions. However, over time, indications have expanded and nowadays include complicated diverticulitis, traumatic colonic lesions, volvulus, and perforated rectosigmoid tumors. So there have been a growing number of patients undergoing HP, especially due to the increasing prevalence of sigmoid diverticular disease in the general population. Potentially, all these patients are waiting for their continuity to be restored. The original aim of this procedure was to reduce mortality due to anastomotic dehiscence in an emergent operation for neoplastic obstruction. However, reestablishing continuity after Hartmann's procedure (Hartmann's reversal [HR]) is considered a major surgical procedure and carries serious risk of both morbidity and mortality, ranging from 5% to 50%.1,2 This surely explains why a large proportion of patients undergoing HP will not have their bowel continuity restored. Spreading of laparoscopic expertise along with the documented advantages of minimally invasive approach (decreased postoperative pain, morbidity, hospital stay, and faster return to daily activities) in colonic surgery have lead to its application to procedures, such as HR. Since the first report of laparoscopic HR (LHR), there have been a growing number of publications in the world literature.3–19 This video shows the technique of laparoscopic restoration of bowel continuity after HP. Surgical Technique: The first step of the technique involves mobilization of the colostomy site. This is excised at the mucocutaneous junction circumferentially, until the peritoneum is entered. The edge of the stoma is revised to take away excessive scar tissue. An appropriately sized anvil of a circular stapler is then inserted into the colonic lumen and secured with a purse-string reabsorbable suture. The colostomy site is now used as port site for the establishment of pneumoperitoneum and a trocar or a hand-assist device can be placed for the camera. Three operative trocars are used: a 12-mm trocar in the right lower quadrant, a 10-mm in the right upper quadrant, and a 10-mm in the umbilicus. With the patient in the steep reverse Trendelenburg position, the rectal stump is identified. This step can be facilitated by a suture thread placed at the first surgery (Hartmann) or by transanally inserting a circular stapler, Hegar, dilators, or a rigid sigmoidoscope at HR. Lysis of adhesions is performed with sharp scissor dissection and minimal use of electric current to prevent any injury to the bowel. It is also important to minimize the risk of vascular injury during pelvic dissection, in a subsequent step of the procedure. In case the rectal stump is too long and includes a few folding of the distal sigmoid colon, the latter can be excised using a linear stapler and the specimen brought out through the colostomy site where the hand-assist device can been placed. Subsequently, with the patient in the Trendelenburg position, mobilization of the left colon proximal to the colostomy and take down of the splenic flexure is accomplished, by freeing the lateral attachments, to ensure a tension-free anastomosis with the rectal stump. An end-to-end colorectal anastomosis is created with an appropriately sized endoluminal circular stapler, possibly avoiding a stapler with diameter less than 28–29 mm. The pelvic cavity is filled with the saline solution and the air leak test is done by insufflating the air in the rectum while visualizing the anastomosis. The stoma wound is left partially open. Results: During the 8-year study period, 20 patients underwent laparoscopic HR. The median age was 65.4 years. Ten patients (50%) had undergone surgery for perforated diverticulitis, 3 (15%) for cancer, 7 (35%) for other reasons (volvulus, post-traumatic perforation, sigmoid perforation from foreign body). Previous HP had been performed laparoscopically in only three patients. The median operative time was 162.5 minutes. All the procedures were completed laparoscopically. The intraoperative complication rate was nil. Postoperative mortality and morbidity were 0% and 10%, respectively (one pneumonia, one bowel obstruction from postanastomotic stenosis, which required resection and re-do of the anastomosis). The median time to first flatus was 3 days, to normal diet 5 days. The median hospital stay was 9 days without readmissions. We followed-up the patients for a median of 44 months: when asked, all 20 (100%) said they would undergo the operation (LHR) again; 3 (15%) had been re-operated of laparoscopic mesh repair for incisional hernia. Conclusions: When performed by experienced surgeons, LHR is a feasible, safe, and reproducible operation, which allows early return of bowel function, early discharge, and fast return to work for the patient. It has a low morbidity rate. Drs. Valentino Fiscon, Giuseppe Portale, Antonio Mazzeo, Giovanni Migliorini and Flavio Frigo have no conflicts of interest or financial ties to disclose. Runtime of video: 5 mins 30 secs