Hartmann's Reversal Research Articles

The suspended ileal loop for difficult Hartmann's reversal.

Hartmann's reversal can be complicated by the presence of dense adhesions in the upper part of the abdominal cavity, difficulties in freeing the splenic flexure with the risk of splenic tears, a lack of sufficient colonic length, the risk of ureteral lesion, or the risk of lesions of the vascular arcade. We propose a technique which consists of interposing an adapted segment of ileal loop between the end of the proximal colon and the rectum to restore intestinal continuity. Two patients had Hartmann procedure, the first for a Hinchey stage 4 perforated diverticulitis and the second for a colorectal fistula due to ischemia of the proximal colonic segment. Hartmann's reversal was expected to be difficult, so a suspended ileal loop was used. The outcomes were uneventful, and functional results were satisfactory. A suspended ileal loop could be used as a salvage procedure in some cases of potentially difficult Hartmann's reversal.

Hartmann's reversal is associated with worse outcomes compared to elective left colectomy: A NSQIP analysis of 36,794 cases

BackgroundHartmann's reversal (HR) is associated with significant technical difficulty and morbidity. Using the ACS-NSQIP database, we assessed the outcomes of HR as compared to elective left colectomy (LC). MethodsThe 2016–2019 ACS-NSQIP datasets were queried to identify patients undergoing HR and elective LC. Patients’ demographics, comorbidities, and short-term surgical outcomes were evaluated using both univariable and multivariable methods. ResultsThe study included 7,632 HR cases and 29,162 LC cases. The HR group had more patients with ASA grade III (50% vs. 42.4%). HR had more open-operative cases (69.4 vs. 18.5%) and longer mean operative times (213 vs. 191 min) than LC. Postoperatively, the HR group had a longer mean hospital stay (5.5 vs. 4.1 days) and higher complication rate (18.3% vs. 10.3%). HR was associated with increased odds of having a concurrent ileostomy (OR 2.11), deep space/organ infection (OR 1.55), and at least one complication (OR 1.56). ConclusionHR is a more challenging operation with patients who fared worse than their LC counterparts. Consideration should be given to alternatives of the index Hartmann's procedure.

Reversal of Hartmann's procedure: timelines, preoperative investigations and early outcomes. A single Australian institution's ten-year experience.

Real-world data on outcomes following Hartmann's reversal is necessary to help optimize the patient experience. We have explored the timing between the index operation and its reversal; what investigations were carried out prior to this, and the associated short-term outcomes. A retrospective study of all patients who underwent Hartmann's reversal from 2010 to 2020 within a tertiary referral centre in Melbourne, Australia. One hundred from a total of 406 (25%) who underwent an emergency Hartmann's procedure had a subsequent reversal. Complete patient data was available for 83 of these patients. The average patient age was 60 years, and the median time for reversal was 14.0 (IQR 10-23) months. Seventy-nine of 83 (95%) reversals had a preoperative endoscopic evaluation of both their rectal stump and a complete colonoscopy. Stoma stenosis (n=2), patient refusal (n=1) and emergency reversal (n=1) were cited reasons for not undergoing preoperative endoscopic evaluation. A third (n=28, 34%) had a computed tomography prior to reversal; the majority was due to their underlying cancer surveillance (n=21, 75%). Reversal was associated with a morbidity rate of 47% (n=39). Surgical site infections (SSIs) (n=21, 25%) were the most common type of complications encountered, with the majority being superficial (n=15, 71%). SSIs were associated with steroid use (5/21 versus 4/62, p=0.03) and greater hospital length of stay (6 versus 10 days, p=0.03). Only a quarter of emergency Hartmann's procedures within our institution were reversed. A significant proportion developed postoperative complications. Surgical site infection was the most common morbidity.

Functional outcome after Hartmann's reversal surgery using LARS, COREFO & QoL scores

BackgroundFunctional complaints after colorectal surgery have a profound effect on quality of life (QoL). Our goal was to investigate the prevalence of functional complaints and quality of life after Hartmann's reversal surgery. MethodA cross-sectional study was performed where one hundred nineteen patients were included. All patients underwent Hartmann's reversal procedure between 2007 and 2019. All patients were asked to complete 3 validated questionnaires related to bowel function in benign and colorectal cancer surgery as well as general QoL. ResultsThe response rate was 67%. Among responders, 32.8% reported LARS-like symptoms whereas 25% had significant COREFO Scores (>15). Higher LARS and COREFO scores were significantly associated with worse global QoL and several QoL domain scores (p < 0.05). ConclusionThis study highlights the prevalence of bowel dysfunction after Hartmann's reversal surgery. Patients undergoing this procedure show similar functional complaints compared to those in literature who had a resection without colostomy.

Laparoscopic Hartmann's reversal has better clinical outcomes compared to open surgery: An international multicenter cohort study involving 502 patients.

BackgroundHartmann's procedure (HP) is used in surgical emergencies such as colonic perforation and colonic obstruction. “Temporary” colostomy performed during HP is not always reversed in part due to potential morbidity and mortality associated with reversal. There are several contributing factors for patients requiring a permanent colostomy following HP. Therefore, there is still some discussion about which technique to use. The aim of this study was to evaluate perioperative variables of patients undergoing Hartmann's reversal using a laparoscopic and open approach.MethodsThe multicenter retrospective cohort study was done between January 2009 and December 2019 at 14 institutions globally. Patients who underwent Hartmann's reversal laparoscopic (LS) and open (OS) approaches were evaluated and compared. Sociodemographic, preoperative, intraoperative variables, and surgical outcomes were analyzed. The main outcomes evaluated were 30‐day mortality, length of stay, complications, and postoperative outcomes.ResultsFive hundred and two patients (264 in the LS and 238 in the OS group) were included. The most prevalent sex was male in 53.7%, the most common indication was complicated diverticular disease in 69.9%, and 85% were American Society of Anesthesiologist (ASA) II‐III. Intraoperative complications were noted in 5.3% and 3.4% in the LS and OS groups, respectively. Small bowel injuries were the most common intraoperative injury in 8.3%, with a higher incidence in the OS group compared with the LS group (12.2% vs. 4.9%, p < 0.5). Inadvertent injuries were more common in the small bowel (3%) in the LS group. A total of 17.2% in the OS versus 13.3% in the LS group required intensive care unit (ICU) admission (p = 0.2). The most frequent postoperative complication was ileus (12.6% in OS vs. 9.8% in LS group, p = 0.4)). Reintervention was required mainly in the OS group (15.5% vs. 5.3% in LS group, p < 0.5); mortality rate was 1%.ConclusionsLaparoscopic Hartmann's reversal is safe and feasible, associated with superior clinical outcomes compared with open surgery.

A nutritional screening threshold for optimal outcomes after Hartmann's reversal.

Determining is nutritionally replete enough for Hartmann's reversal (HR) can be controversial and multifactorial. While there are many preoperative nutritional screening tools, the impact of malnourishment on HR has not been evaluated. The study aims to clarify how often patients undergoing HR are high risk for malnourishment at the time of surgery and how this impacts postoperative outcomes. From 2012-2019, all elective HRs were identified in ACS-NSQIP. Patients were categorized in a malnourished group if they met one of the following criteria: (1) BMI < 18.5kg/m2, (2) albumin < 3.5g/dL, or (3) > 10% body weight loss in the last 6months. Bivariate associations of preoperative demographics and postoperative outcomes were analyzed. Multivariable logistic regression was performed to identify independent predictors for 30-day mortality and organ space wound infection. 8878 procedures were evaluated (well-nourished = 7116 and malnourished = 1762). The malnourished group had higher mortality (p < 0.001), shorter operating time (p < .001), longer length of stay (p = 0.016), and higher rates of infection (p = 0.011), reintubation (p = 0.002), bleeding (p < 0.001), sepsis (p = 0.001), and reoperation (p = 0.018). In multivariate regression models, malnourishment was an independent predictor for mortality (OR = 2.72, p < 0.001) and wound infection (OR = 1.19, p = 0.028). A large percentage of patients undergoing HR were classified as being high-risk for malnutrition. Malnourishment was associated with some worse postoperative compilations including death and wound infection. Surgeons should routinely use preoperative screening for malnutrition to identify and attempt to optimize nutritional status prior to undergoing Hartmann's Reversal.

Factors Predicting the Reversal of Hartmann's Procedure.

Aim This paper investigates the risk factors preventing the reversal and nonreversal of Hartmann's procedure, as a surgical technique that has been performed in our clinic for ten years. Methods The study involved a ten-year Hartmann's procedure followed up at our center. The patients were divided into Hartmann reversal and nonreversal groups. Groups were examined in terms of age, gender, diagnosis, stage of malignancy, ASA score, comorbidity, perioperative morbidity-mortality, and the length of the operation. Results Age (p < 0.001), ASA score (p < 0.001), stage in case of malignancy (p = 0.002), and comorbidities (p < 0.001) were significant risk factors. The ratio of patients without any comorbidities to those with one or more comorbidities was 2.63 (95% CI 1.12–6.20). Among the malignant patients, the ratio of early-stage patients to advanced-stage patients in the group with reversal of Hartmann's colostomy was 2.82 (95% CI 1.30–6.10). In addition, the ratio of older patients to younger patients in group 2 was 0.95 (95% CI 0.92–0.98). A univariate analysis revealed that younger patients, those with lower ASA scores, those without comorbidities, and those with early-stage malignancy had a greater chance of closure of the stoma. Conclusion Although Hartmann's procedure is performed in emergency surgery, the nonreversal of the colostomy is a problem in itself. It should be kept in mind that patients who have high risks are likely to have a permanent stoma.

Is laparoscopy a reliable alternative to laparotomy in Hartmann's reversal? An updated meta-analysis.

The aim of this study was to perform a systematic review of the literature on and updated meta-analysis of surgical postoperative complications after laparoscopic Hartmann's reversal (LHR) and open Hartmann's reversal (OHR). Studies comparing LHR versus OHR published from inception until June 2020 were selected and submitted to a systematic review and meta-analysis. Articles were searched in the MEDLINE and Cochrane Trials Register databases. Meta-analysis was performed with Review Manager 5.0. Twenty-three retrospective comparative studies (including 5 case-controlled studies) with a total of 3139 patients with LHR and a total of 10,325 patients with OHR were included. Meta-analysis showed that LHR was significantly associated with a decreased rate of revision surgery (OR = 0.73, 95% CI = 0.60-0.89, p < 0.001), anastomotic leakage (OR = 0.61, 95% CI = 0.49-0.75, p < 0.00001), postoperative morbidity (OR = 0.53, 95% CI = 0.47-0.58, p < 0.00001), intra-abdominal abscess (OR = 0.67 [0.52-0.87], 95% CI = , p = 0.003), wound abscess (OR = 0.53 [0.46-0.61], 95% CI = , p < 0.00001), and postoperative ileus (OR = 0.46, 95% CI = 0.29-0.72, p = 0.0008), respectively. Conversely, mortality was comparable between LHR and OHR. These results suggest that LHR significantly improved surgical postoperative outcomes. However, considering the low level of evidence, further randomized trials are required to validate these findings.

Is length of the rectal stump predictive for postoperative outcome in Hartmann's reversal surgery? A multicenter experience of 105 consecutive cases.

Although Hartmann's procedure is commonly performed, subsequent reversal is less frequent. The most common reasons for reversal surgery are advanced age, comorbidities, and perceived surgical difficulties. The main objective of this study was to investigate if the length of the rectal stump influences the outcome of Hartmann's reversal surgery. We conducted a retrospective case study analyzing data from 105 patients who underwent Hartmann's reversal procedure between 2007 and 2019 in two centers. We evaluated patient demographics, length of rectal stump, intraoperative surgical details, short-term and long-term outcomes. From 2007 to 2019, 105 patients underwent Hartmann's reversal surgery. Short-term morbidity rate was 58% (61 patients), including 16% (17 patients) with severe postoperative complication (Clavien-Dindo ≥ 3). Anastomotic leakage rate was 2.9% (3 patients). Long-term complications were present in 41% (43 patients) of which abdominal wall defect was the most frequent complication. The mean length of the rectal stump was 15cm. In almost 1 out of 5 patients (17%) the rectal stump was shorter than 10cm. The three anastomotic leakages appeared in the long rectal stump group (3.6% vs. 0%, p = 0.273). The complication rate for patients with a short rectal stump was similar to those with a longer rectal stump (50% vs. 63%, p = 0.275). Smoking, high ASA score, obesity, and advanced age did not influence the outcomes of the reversal procedure either. Length of the rectal stump is not a predictive factor for postoperative complications after Hartmann's reversal surgery.

Is it possible to restore digestive continuity in all patients after a Hartmann procedure? Multicentric retrospective experience in 360 consecutive patients

BackgroundHartmann's procedure (HP) remains controversial because more than half of patients will not recover, thus maintaining a permanent stoma. The aim of this retrospective multicentric study was to evaluate independent predictive factors for Hartmann's reversal (HR) after HP. MethodsAmong all consecutive patients who underwent HP between 2009 and 2016 in three hospitals, we included patients who survived for up to 6 months. The primary outcome was to identify independent predictive factors for HR, and the secondary outcomes were to assess both mortality and morbidity rates within 90 days. ResultsAmong the 283 patients alive at 6 months, 189 (67%) underwent HR. Indications for HP included complicated diverticulitis in 142 patients (54%), malignancy in 52 patients (13%), colonic ischemia in 16 patients (12%), and miscellaneous in 69 patients (21%). Independent risk factors for HR in multivariate analysis included an age under 70 years (OR 3.78 95% CI [1.88–7.60]), ASA score below 3 (OR 2.04 95% CI [1.0.6–3.92]) and absence of neurological comorbidity (OR 4.31 95% CI [0.1–0.47]). HR was associated with a 1.6% mortality rate within 90 days, and 23 (12%) developed severe postoperative complications (Dindo-Clavien ≥ III), requiring reintervention in 19 of them (82%). At the end of follow-up, 2.6% had a definitive stoma. ConclusionThis study suggests that HR is possible in 2/3 of patients, especially if they are young, without neurological comorbidities and with a low anesthetic risk. In selected patients, the morbidity and mortality rates are similar to elective colonic resection.

A comparative study between open versus laparoscopic Hartmann reversal: A single-center experience and analysis.

As one of the most challenging procedures in colorectal surgery, Hartmann reversal (HR) carries a burden of morbidity and mortality. We report our experience and compare open and laparoscopic HR.Between December 2012 and January 2020, 30 patients who underwent Hartmann reversal were reviewed. All patients either received laparoscopic or open reversal.Of the 87 patients who underwent Hartmann operation (HO), 30 patients received HR (Laparoscopic Hartmann Reversal, [LHR], n = 20; Open Hartmann Reversal, Open Hartmann Reversal [OHR], n = 10). There were 15 males and 15 female patients. The mean operation time was 223.8 minutes (range 115–350 minutes) with mean blood loss of 252.5 mL (range 0–700 mL). There was no conversion from LHR to OHR, and there was no ileostomy formation. Mean time to flatus was 5.0 days (range 2–13 days). There were 15 early postoperative complications and 5 late postoperative complications, but only 1 case of grade 3A. No anastomosis leakage was reported.HR is an operation that can be performed safely in well-selected patients. Minimally invasive techniques, such as LHR, is an attractive option resulting in shorter operation time, less blood loss, less pain, and shorter hospital stay.

Advanced application of transanal total mesorectal excision in the frozen pelvis: a novel application in a challenging Hartmann's reversal.

Advanced application of transanal total mesorectal excision in the frozen pelvis: a novel application in a challenging Hartmann's reversal.

Comparison of outcomes between laparoscopic and open Hartmann's reversal: A single-center retrospective study in Japan.

Laparoscopic Hartmann's reversal (LHR) has recently been reported to be safer and more feasible than open Hartmann's reversal (OHR); however, there is limited data on the outcomes of LHR compared with those of OHR from Asian countries. Therefore, we aimed to clarify the postoperative outcomes of LHR compared with OHR, and additionally compare the patient outcomes post-LHR according to the previous Hartmann's procedure (HP) approach. Patients who underwent OHR and LHR between January 2006 and September 2020 in a single center in Japan, were retrospectively evaluated. Patient characteristics and perioperative data were collected from the medical and surgical records and assessed. Overall, 15 and 19 patients underwent OHR and LHR, respectively, between January 2006 and September 2020. LHR was associated with less blood loss (median: 15 mL vs 185 mL; P < .001) and shorter hospital stays (9 days vs 14 days; P=.023) than OHR. There was no significant difference in postoperative complications between LHR and OHR (26.3% vs 40.0%, P=.475). However, two severe anastomotic complications in LHR were observed in patients with the stump below the peritoneal reflection. No significant difference in outcomes was observed between LHR patients who underwent open and laparoscopic HP. LHR resulted in positive outcomes regarding estimated blood loss and postoperative hospitalization, compared with OHR. Although the postoperative complications between LHR and OHR were not significant, patients with the stump below the peritoneal reflection may be at a high risk of anastomotic complications.

Laparoscopic Hartmann reversal: experiences from a developing country.

PurposeLaparoscopic surgery is considered a promising approach for Hartmann reversal but is also a complicated major surgical procedure. We conducted a retrospective analysis at a city hospital in Vietnam to evaluate the treatment technique and outcomes of laparoscopic Hartmann reversal (LHR).MethodsA colorectal surgery database in 5 years between 2015 and 2019 (1,175 cases in total) was retrieved to collect 35 consecutive patients undergoing LHR.ResultsThe patients had a median age of 61 years old. The median operative time was 185 minutes. All the procedures were first attempted laparoscopically with a conversion rate of 20.0% (7 of 35 cases). There was no intraoperative complication. Postoperative mortality and morbidity were 0 and 11.4% (2 medical, 1 deep surgical site infection, and 1 anastomotic leak required reoperation) respectively. The median time to first bowel activity was 2.8 days and median length of hospital stay was 8 days.ConclusionWhen performed by skilled surgeons, LHR is a feasible and safe operation with acceptable morbidity rate.

Effects of Laparoscopic Hartmann Reversal on Short-term Operative Outcomes Among Vietnamese Patients

Abstract Background The reestablishment of continuity after Hartmann operation is considered a major surgical procedure with high morbidity and mortality. The optimal interval time between the Hartman procedure and reversal is controversial. Our study aimed to evaluate the effectiveness of laparoscopic Hartmann reversal and to determine the optimal timing of operation. Methods All patients who underwent laparoscopic Hartmann reversal from 2008 to 2019 (11 years) at the University Medical Center (UMC) in Ho Chi Minh City were recruited and divided into 2 groups according to the interval time (≤ 4 or &gt; 4 months). The short-term operative outcomes of these groups were compared. Results There were 66 patients who underwent laparoscopic Hartmann reversal (mean age: 63.2 years old); ∼ 77% of them had colorectal cancer, and 17% had complicated diverticular disease. The mortality rate, anastomotic leakage rate, and overall complication rate were 0%, 1.5%, and 13.2%, respectively. Early operation was performed in 36 patients, and late reversal in 28 patients. There was no difference in mortality, anastomotic leakage, operative complications, and hospital stay between the two groups. Conclusion Laparoscopic Hartmann reversal was effective with acceptable morbidity and mortality at the UMC. There was no observed impact of the interval time between the Hartmann procedure and laparoscopic Hartmann reversal on the short-term operative outcomes.

Indocyanine Green Fluorescence Identification of Ureters in Robotic Hartmann Reversal

Introduction: Hartmann reversal is a complex surgical procedure associated with significant morbidity. Injuries of the urinary tract can occur in 10% to 15% of primary colorectal resections and complex reconstructive surgeries. Indocyanine green (ICG) intraureteral injection has been advocated recently for ureteral identification during pelvic surgery. Decreasing the rate of ureteral injuries directly impacts length of stay, costs, morbidity, and mortality rate. This video illustrates the utility of intraureteral ICG during a Hartmann reversal procedure in a complex pelvis. Materials and Methods: Intraureteral injection of ICG was used in five patients, three Hartmann reversals and two rectal bulky tumors. All patients underwent robotic procedures except one patient with a bulky and perforated rectal tumor combined with a left pelvic kidney. This specific video highlights a patient who underwent a laparoscopic Hartmann procedure for pelvic abscess caused by a perforated sigmoid diverticula. A Hartmann reversal was performed 2 months later. A robot-assisted Hartmann reversal was carried out and off-label bilateral intraureteral infusion of ICG was performed. A 5F ureteral catheter was inserted in both ureters before surgery, 10 cm beyond the ureteral orifice and then retracted back to 2 cm. When requested, 25 mg of ICG were dissolved in 10 mL of saline and injected into both ureters. ICG reversibly binds to proteins of the urothelial layer. ICG is a fluorescent dye, made of hydrophobic molecules that usually is injected intravenously and binds to plasma proteins and is excreted by liver. It becomes fluorescent when excited by the robotic laser light (Firefly Fluorescence Endoscope System; Intuitive Surgical, Inc., Silicon Valley in Sunnyvale, CA). Injection time was 15 minutes and ICG helped identify the right ureter that was slightly medialized and adherent to the rectal stump. A peristomal hernia was present and treated by direct suture after an adhesiolysis. After dissecting the rectal stump from the right ureter and pelvic wall, the rectal stump was re-transected and a colorectal end-to-end mechanical anastomosis was performed. A perianastomotic suction drainage was placed in the pelvis. Both ureteral catheters were removed at the end of the procedure. Results: Neither ureteral injuries nor ICG-related intraoperative and/or postoperative adverse events, nor renal failures were experienced in all the treated cases. A transient hematuria was observed in two patients. Conclusions: Use of intraureteral ICG may be a safe and helpful procedure to identify ureters in complex pelvic and colorectal surgery. It can serve as a valid tool in preventing iatrogenic ureteral injuries. No competing financial interests exist. Runtime of video: 7 mins 52 secs

Hartmann's Reversal Through Transanal Hand-Sewn Anastomosis With Rectal Mucosectomy for a Challenging Case: Case Report

Introduction Despite the advances in surgical techniques, Hartmann's reversal is often considered a difficult procedure, and the stoma cannot be restored in up to 40% of the cases. We report a patient with a challenging case of severe dense adhesions and a short rectal stump who recovered successfully after undergoing Hartmann's reversal through rectal mucosectomy and transanal hand-sewn anastomosis. Case presentation A 39-year-old man had multiple bowel injuries, including rectum, bladder, and ureter laceration, due to a stab wound. He underwent Hartmann's procedure with a short rectal stump. One year and 9 months later, Hartmann's reversal was performed. In the operative field, severe dense adhesions were observed in the pelvic cavity. Therefore, complications, including fistula, were likely to occur. Thus, we minimized the dissection around the rectal stump and avoided stapled anastomosis. Proctotomy was performed behind the rectal stump, and the proximal colon was inserted into the rectum. Rectal mucosectomy was performed for the rectum above the expected anastomosis site. Colorectal hand-sewn anastomosis was performed on the rectum, 3 cm from the anal verge. The patient recovered well after the surgery, and has remained healthy, without any discomfort, except for frequent defecation. Conclusion Rectal mucosectomy and transanal hand-sewn anastomosis were performed in a complex case of Hartmann's reversal, resulting in the patient's successful recovery without complications. This study recommends the preceding surgical technique for similar cases.

Link between postoperative ileus and anastomotic leakage: A structural equation modelling approach

IntroductionPostoperative ileus(POI) and anastomotic leakage(AL) are highly associated but the direction of this link is unknown. Indeed, it has traditionally been stated that AL leads to POI(secondary POI). The objective was to statistically determine the best model of link between POI and AL by comparing different Structural Equation Models(SEM). MethodsThis is a retrospective analysis of a prospective multicentric database from the Francophone Group for Enhanced Recovery after surgery(GRACE) including patients undergoing colorectal resection or Hartmann reversal between 2014 and 2017. The main outcome measure was the occurrence of postoperative ileus defined by the absence of Gastrointestinal (GI)-3 recovery in or after postoperative day 4 and the occurrence of AL. ResultsAmong the 2227 patients included, 223 patients experienced POI (10 %) and 72 patients experienced anastomotic leakage (3.2 %). In all the models, POI was significantly increased in case of male gender, older age, opioids consumption, right colectomy, chronic obstructive bronchopneumopathy disease and performance of a stoma, and reduced by Enhanced Recovery Programs (ERP) compliance ≥ 70 % and intake of Non-Steroidal Anti-Inflammatory Drugs. Open surgery was not significantly associated with POI in all the models. In contrast, the male gender was the only factor increasing AL in the model drawn with ERP risk factors for AL. In all the models, POI was highly associated with AL and statistical analyses advocate for POI leading to AL. ConclusionThe findings of the present large study suggest that the more statistically probable model is the one in which POI come first before AL.

Laparoscopic Versus Open Hartmann Reversal: A Case-Control Study.

Background Laparoscopic reversal of Hartmann's procedure (LHR) offers reduced morbidity compared with open Hartmann's reversal (OHR). The aim of this study is to compare the outcome of laparoscopic versus open Hartmann reversal. Materials and Methods Thirty-four patients who underwent Hartmann reversal between January 2017 and July 2019 were evaluated. Patients underwent either LHR (n = 17) or OHR (n = 17). Variables such as numbers of patients, patient's age, sex, body mass index (BMI), comorbidities, ASA (American Society of Anesthesiology) score, indication for previous open sigmoid resection, mean operation time, rate of conversion to open surgery, length of hospital stay, mortality, and morbidity were retrospectively evaluated. Results The two groups of patients were homogeneous for gender, age, body mass index, cause of primary surgery, time to reversal, and comorbidities. In 97% of the cases, HP was done by open surgery. Our data revealed no difference in mean operation time (LHR: 180.5 ± 35.1 vs. OHR: 225.2 ± 48.4) and morbidity rate, although, in OHR group, there were more severe complications. Less intraoperative blood loss (LHR: 100 ± 40 mL vs. OHR: 450 ± 125 mL; p value <0.001), shorter time to flatus (LHR: 2.4 days vs. OHR: 3.6 days; p value <0.021), and shorter hospitalization (LHR: 4.4 vs. OHR: 11.2 days; p value <0.001) were observed in the LHR group. Mortality rate was null in both groups. Discussion. LHR is feasible and safe even for patients who received a primary open Hartmann's procedure. We suggest careful patient's selection allowing LHR procedures to highly skilled laparoscopy surgeons.

Outcomes of colostomy takedown following Hartmann's procedure: successful restoration of continuity comes with a high risk of morbidity.

Restoration of bowel continuity following a Hartmann's procedure is a major surgical undertaking associated with significant morbidity. The aim of this study was to review the authors' experience with Hartmann's reversal. This was a retrospective review of consecutive patients from institutional databases who were selected to undergo open or laparoscopic Hartmann's reversal at two tertiary academic referral centres and a public safety net hospital (2010-2019). The main outcome measure was the rate of successful stoma reversal. Secondary outcomes included 30-day postoperative outcomes and procedural details. One hundred and fifty patients underwent attempted reversal during the study period, which was successful in all but three patients (98%). Patients were 59% Hispanic and 73% male, with a mean age of 48.7±14.1years, mean American Society of Anesthesiologists classification of 2.2±0.6 and mean body mass index (BMI) of 28.6±5.3 kg/m2 , with 39% of patients having a BMI>30 kg/m2 . The mean time interval between the index procedure and reversal was 14.4months, 53% of the index cases were performed at outside institutions and the most common index diagnoses were diverticulitis (54%), abdominal trauma (16%) and colorectal malignancy (15%). In 22% of cases a laparoscopic approach was used, with 42% of these requiring conversion to open. Proximal diverting stomas were created in 32 patients (21%), of which 94% were reversed. The overall morbidity rate was 54%, comprising ileus (32%), wound infection (15%) and anastomotic leak (6%), with a major morbidity rate (Clavien-Dindo≥3) of 23%. Hartmann's reversal remains a highly morbid procedure. Our results suggest that operative candidates can be successfully reversed, but there is significant morbidity associated with restoration of intestinal continuity, particularly in obese patients. A laparoscopic approach may decrease morbidity in selected patients but such cases have a high conversion rate.