Laparoscopic Hartmann Procedure

Updated: Aug 11, 2014
  • Author: Todd A Nickloes, DO, FACOS; Chief Editor: Kurt E Roberts, MD  more...
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Overview

Overview

Background

The origins of intra-abdominal laparoscopic surgery can be traced to 1901, when Georg Kelling reported his attempts to control hemorrhage of the gastrointestinal (GI) tract in an experimental setting with "Lufttamponade" (air tamponade), while observing the process through a cystoscope placed within the peritoneal cavity. [1] Over the following 8 decades, this technology was slow to advance in the realm of general surgery, not gaining momentum until the burgeoning of laparoscopic biliary surgery.

Over the past 20 years, advances in fiber optic technology, lens modifications, and energy delivery systems have allowed the application of laparoscopic technology to fields of surgery where its use was once inconceivable. The study of laparoscopic colorectal surgery reported by Lujan et al in 2002, [2] more than a century after the original laparoscopic leap, lends credibility to the accuracy of this approach and clarity to the complexity involved.

Although progress has been slow, several technological milestones have allowed clinicians to apply this significantly less invasive modality to treatment of the most complex pathologic conditions. Compared with its open equivalent, laparoscopic colectomy with Hartmann-style distal remnant and end colostomy, though challenging in terms of both patient selection and surgical technique, can produce improved outcomes with less morbidity and greater patient satisfaction. [3, 4]

Reversal of the procedure is discussed in more detail elsewhere (see Laparoscopic Hartmann Procedure Reversal). [5]

Indications

In assessing any candidate for surgery, including laparoscopic surgery, the first step is to consider medical comorbidities. Before initiation of any surgical ventures in patients who are unstable or have been inadequately resuscitated, any such comorbid conditions should be corrected to the extent possible.

A key issue in determining a patient's candidacy for laparoscopic surgery centers on matching the patient to the surgeon. Patients who have medical or surgical histories involving the abdominal cavity or have more complex pathologies may require a more technically demanding operation and therefore should be matched to surgeons who possess more advanced laparoscopic skills.

It is also important to remember that conversion of any laparoscopic procedure to an open procedure should be considered not a failure but, rather, a reflection of the limitations imposed on the surgeon by the technology at hand. Such limitations may be viewed as an impetus for the development of new technologies and procedures.

For laparoscopic colectomy with Hartmann-style pouch and end colostomy, the surgeon should possess good laparoscopic skills in the following key technical areas:

  • Mobilization of the splenic flexure and descending colon
  • Ligation of the feeding vessels at their points of origin
  • Control and containment of the offending pathology

As a result of ongoing advances in energy application, manipulation devices, and visualization capabilities, laparoscopic surgery is now an option for many patients who previously would not have been considered suitable candidates.

Contraindications

In general, a laparoscopic colectomy of any style is performed under elective conditions. However, a Hartmann procedure—that is, a colectomy with end colostomy and closure of the distal segment—is generally performed under emergency or urgent situations. Accordingly, the combined laparoscopic Hartmann procedure is used in a limited patient population.

Although the laparoscopic Hartmann procedure is not frequently performed, its use has been increasing as laparoscopic technology has advanced and surgeons have become more adept in their surgical techniques. A study comparing the laparoscopic approach with the open approach found that the 2 techniques yielded similar outcomes. [6] However, multiple relative contraindications exist.

The surgeon’s proficiency with laparoscopic colorectal surgery is the paramount consideration. [7] If the procedure cannot be performed safely and efficiently, the benefits of laparoscopic surgery (eg, decreased recovery time, shorter hospital stay, lower incidence of postoperative ileus, and smaller incisions) will not be realized.

Patients who need a Hartmann procedure are acutely ill and often have multiple comorbid conditions. In these patients, sepsis with hemodynamic instability may pose a relative contraindication.

Adequate surgical intervention provided over a minimized operating time allows timely delivery of appropriate resuscitative measures (eg, intravenous [IV] fluid resuscitation and antibiotic administration) in a more controlled setting. The increased technical demands of laparoscopy add operating time and complexity to a situation where prompt intervention and management could be vital. This factor, again, is directly related to the experience and ability of the operating surgeon.

The efficacy of laparoscopic lavage for the control of fecal or purulent peritonitis continues to be debated. [6, 8] Retrospective studies show that laparoscopic lavage is adequate in the setting of perforated diverticulitis (Hinchey class III/IV); however, the extent to which the contamination spreads complicates the clinical situation. Fecal contamination that is largely confined to 1 quadrant of the abdomen poses less of a challenge for laparoscopic lavage than fecal contamination that is disseminated throughout all 4 quadrants.

As with all laparoscopic surgical procedures, intra-abdominal adhesions or scar tissue from previous abdominal operations may preclude a laparoscopic approach. Inability on the part of the patient to tolerate insufflation of the abdomen (pneumoperitoneum) is also a contraindication. Morbid obesity, though not an absolute contraindication, can increase the make any laparoscopic procedure more complicated and should therefore be taken into account.

An increase in the number of diverticular attacks before the scheduled operation does not constitute a contraindication for a laparoscopic surgical approach. However, research has demonstrated the occurrence of 3 or more episodes of diverticulitis before the time of surgery is associated with a significant increase in the rate of conversion from laparoscopic to open. [4, 9]

Technical Considerations

The following measures may be considered for optimizing the results of a laparoscopic Hartmann procedure:

  • Preoperative placement of lighted ureteral stents facilitates identification of the ureters during mobilization of the rectum and the left colon; this reduces the operating time and makes the procedure safer
  • Steep rotation and placement in the Trendelenburg position may be necessary to facilitate visualization and traction; accordingly, the patient must be secure on the operating table
  • Hand ports, though not always necessary, can further expedite the procedure, both by providing additional access for manipulation and tactile impressions and by helping in the creation of the ostomy site
  • Ultrasonic dissection allows rapid ligation of all but the largest vessels, which may be clipped and then divided
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Technique

Laparoscopic Approach to Hartmann Procedure

After being placed in the supine modified lithotomy position, the patient is prepared and draped in a sterile fashion. Preoperative placement of illuminated ureteral stents decreases the degree of difficulty and adds a certain measure of safety during dissection of the descending colon from its retroperitoneal attachments. Appropriate trocar placement (see the images below) is key; trocar positions may vary, depending on whether the surgeon intends to employ a completely intracorporeal technique or a hand-assisted technique.

Images demonstrate significant difference in incis Images demonstrate significant difference in incision size between open and laparoscopic approaches to Hartmann procedure.
Orientation of laparoscopic instruments within int Orientation of laparoscopic instruments within intraperitoneal cavity.

Access to the abdominal cavity is gained by means of a Veress needle, an Optiview trocar, or open technique. A large-diameter (eg, 10-12 mm) trocar is inserted at the umbilicus. The abdomen can be surveyed through this port via a 0o laparoscope; this allows assessment of the colonic target, the level of disseminated contamination, and the degree of adhesions and thus helps guide further trocar placement.

After adequate pneumoperitoneum is achieved, 2-3 more port sites are established in the right upper quadrant, the right lower quadrant, and (optionally) the suprapubic region. The ports placed in the right upper and lower quadrants are positioned lateral to the semilunar line so as to avoid the rectus muscle (10-12 mm and 5 mm trocars are used).

Dissection is carried out laterally along the peritoneal reflection (white line of Toldt) to mobilize the affected sigmoid or descending colon (see the image below). Placing the patient in the Trendelenburg position (ie, with the head down) and rotating the bed toward the operating surgeon (ie, with the right side down) allow the viscera to fall away from the field of dissection and thereby provide some degree of traction on the target organ. Typically, the splenic flexure must also be mobilized to free the distal segment of the colon sufficiently.

Illustrated view of intraperitoneal space during m Illustrated view of intraperitoneal space during mobilization of colon.

During this portion of the procedure, reverse Trendelenburg positioning with rightward rotation assists the operating surgeon with visualization and mobilization. Occasionally, the surgeon may need to use an operating hand port. If this is the case, consideration must be given to the proposed ostomy site, and the hand port should be placed in this position to permit easier removal of the colonic specimen.

Medially, dissection should progress through the mesentery in the distribution of the inferior mesenteric artery (IMA), which gives rise to the left colic, sigmoid, and superior rectal arteries. Determining the proximal margin of resection is important because it affects which, if any, tributaries of the IMA can be salvaged.

Dissection through the lateral peritoneal reflection can be carried out with either an ultrasonic dissector or an electrocautery. A linear vascular stapler or an ultrasonic dissector can be used medially in the dissection through the mesentery for ligation of the vasculature. The left ureter should be easily identified with the lighted stents and thereby avoided during the dissection.

After adequate mobilization, the target area of the bowel is divided distally with a linear gastrointestinal (GI) stapler, and the left and right edges of the rectal stump are marked with 0 polypropylene to facilitate identification for later reanastomosis. The proximal stapling and division can be accomplished with either an intracorporeal or an extracorporeal technique. [10]

Regardless of the technique chosen, the diseased portion of the bowel (see the images below) is brought out of the abdomen through the proposed ostomy (hand port) site. If the resection was performed intracorporeally, a laparoscopic bag device may be inserted and deployed in the abdomen. The specimen is placed in the bag and removed from the abdomen through the proposed ostomy site.

Illustration of portion of colon that would be rem Illustration of portion of colon that would be removed with diseased or nonviable bowel near splenic flexure.
Illustration of segment of distal colon that would Illustration of segment of distal colon that would be removed in setting of low sigmoid disease or perforation.

After the diseased colon has been removed from the abdomen, copious irrigation and lavage should be undertaken to minimize the residual bacterial load from the contamination. All laparoscopic instruments and ports are then removed, and each of the sites is closed. The end colostomy is then brought out through the ostomy (hand port) site and matured in a standard fashion (see the image below).

Schematic representation of colon and rectum after Schematic representation of colon and rectum after Hartmann procedure. Distal colon terminates as colostomy and remains in discontinuity with rectal stump.

Complications of Procedure

A laparoscopic Hartmann procedure, like any other laparoscopic procedure, carries the risk of certain complications associated with minimally invasive techniques in general. As for adverse consequences of the laparoscopic Hartmann procedure in particular, there are few data from large prospective studies on specific complication rates for this operation. However, a few small series have provided some insight.

One study demonstrated 3% mortality and 23% morbidity. [6] Morbidity included wound infections (deep and superficial), ureteral injury, postoperative bleeding, and stomal retraction. Elective laparoscopic left colon resections carry a reported total morbidity of 15-30%. [6] However, the reliability of these conclusions is limited by the small sample sizes. Further study and evaluation are needed for more accurate assessment of complication rates. [11, 12]

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Periprocedural Care

Equipment

The operating theatre must be large enough to accommodate the equipment and personnel needed for the operation. Essential equipment includes the basics for any surgical case—namely, a ventilator and other pertinent anesthesia equipment, an operating table, a back-table instrument setup, and a suction and irrigation system. Essential personnel in the operating room (OR) include a surgeon (with or without an assistant), an anesthesiologist or nurse anesthetist, and circulating and scrub nurses.

Laparoscopic surgery requires additional specialized equipment. A video camera and laparoscope are necessary to visualize the intracorporeal environment. The laparoscope is connected to 1 or more monitors that project the intra-abdominal image in a location that is within the operating staff’s line of sight. The operating surgeon is located on the patient's right for most of the case; therefore, a monitor should be placed at the left foot of the table and at the left head of the table.

Laparoscopes come in various sizes and optical angular views to accommodate different vantage points. In a laparoscopic Hartmann procedure, a 0o scope is commonly used for most of the case, but a 30o or 45o laparoscope may prove beneficial at certain points. The scope angles employed and the sequence in which different angles are used are functions of the surgeon’s technique and level of comfort with certain instruments. A light source is attached to the laparoscope illumination for the intra-abdominal cavity.

A CO2 insufflator provides the level of pneumoperitoneum required to create the appropriate working space. This machine also monitors the intra-abdominal and flow pressures. Normal insufflation pressures may range from 12 to 15 mm Hg.

Laparoscopic instruments are designed with the functional portion of the instrument attached to a shaft that can range from roughly 20 to 45 cm in length; this design allows intracorporeal maneuvers to be carried out in restricted spaces. Each surgical instrument used in an open surgical case has its laparoscopic counterpart (eg, scissors, graspers, needle holders, and electrocautery).

Trocars/cannulas are needed to act as working ports for the laparoscopic instruments. They come in various diameters and lengths, which provide the flexibility required to accommodate the patient's body habitus and the desired task.

In a laparoscopic Hartmann procedure, larger (10-12 mm) ports are needed for passing larger equipment (eg, linear staplers or ultrasonic dissectors) into the field; these instruments are used for resection of the diseased colon segment and ligation of its vasculature in the mesocolon. Smaller (5 mm) ports are sufficient for sites that host only graspers, dissectors, or scissors. Depending on the number of trocar sites available, laparoscopic retractors can be used to assist in exposure during the dissection.

A laparoscopic suction/irrigator, which can be easily connected to the stationary irrigation and suction system in the OR, is needed to achieve appropriate lavage of the abdomen during the operation.

Patient Preparation

Patient preparation includes adequate anesthesia and appropriate patient positioning.

Anesthesia

As with all intra-abdominal laparoscopic procedures, general anesthesia is required. Intraoperative monitoring with arterial catheterization is often beneficial. Drainage of the urinary bladder via a catheter helps the surgeon visualize the pelvis during mobilization and facilitates intraoperative assessment of volume status and end-organ perfusion.

Application of a long-acting local anesthetic (eg, bupivacaine) to the port sites before incision helps control postoperative pain. Additional modalities often used in open procedures, such as incisional continuous local anesthesia delivery devices and epidural infusions, are frequently unnecessary in laparoscopic colon surgery.

Positioning

The low lithotomy position, with the upper extremities tucked securely at the patient's side and the lower extremities suspended via stirrups, is the most versatile position for laparoscopic colon surgery. Because the operating surgeon will be on the patient's right side, monitors should be placed at the left foot of the bed and the left head of the bed.

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