Laparoscopic Hartmann Procedure Reversal

Updated: Jun 08, 2017
  • Author: Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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Overview

Background

Laparoscopic Hartmann procedure reversal (LHPR) is a challenging operation involving the closure of a colostomy following the formation of a colorectal anastomosis. In most instances, the purpose of an LHPR is to restore continuity of the bowels after dissection of the rectosigmoid colon and sigmoid colon. The procedure is associated with various risks; thus, knowledge of optimal surgical techniques may facilitate enhanced patient outcomes. [1]

Surgical approaches to LHPR include conventional open surgery, multiport laparoscopic surgery, and single-port laparoscopic surgery. The laparoscopic approach offers significant advantages over the open approach in terms of decreased morbidity (eg, surgical site infection [2] ) and mortality, reduced duration of postoperative hospitalization, shorter operating time, and more rapid achievement of normal bowel function. [3, 4]  A combined transanal-laparoscopic approach to LHPR has also been described, but further study will be required to determine its utility. [5]

In addition, LHPR is performed in patients experiencing complications of colostomy.

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Indications

When evaluating a patient is evaluated for LHPR, at least one medical comorbidity will be present in the form of a colostomy from the original Hartmann procedure.

It has been demonstrated that most patients who undergo LHPR are considered relatively healthy (American Society of Anesthesiologists [ASA] class I or II). Fewer patients undergoing LHPR are considered moderately healthy (ASA class III), and only a fraction of patients are categorized as ASA class IV. [3]

Most patients undergoing a LHPR initially underwent the Hartmann procedure for complicated acute diverticulitis with fecal or purulent peritonitis or, less commonly, for tumor perforation. [3]

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Contraindications

Before one proceeds with LHPR, multiple factors should be considered, including assessing the patient for comorbidities known to be associated with postoperative morbidity and mortality in patients with colorectal disease. These include the following [3, 6, 7] :

  • ASA class III or higher
  • Preoperative sepsis
  • Poor functional health status
  • Preoperative albumin levels below 3.5 U/L
  • High body mass index (BMI)
  • Disseminated malignancy
  • Dyspnea
  • Thickness of subcutaneous fat (ratio of fat thickness to total thickness ≥0.42)
  • Smoking

The interval between the primary Hartmann procedure and prospective subsequent Hartmann procedure reversal should also be considered. Morbidity and mortality are higher when the Hartmann procedure reversal is performed sooner than 6 months after the primary Hartmann procedure. [8] Thus, for optimal outcomes, the reversal should be performed at least 6 months after the primary procedure is performed.

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Technical Considerations

Procedural planning

It is necessary to both consider and prepare for the possibility of conversion from LHPR to open Hartmann procedure reversal; such conversion may be influenced by myriad surgical factors and limitations, including intra-abdominal adhesions, obesity, malignancy, and thickness of subcutaneous fat (ratio of fat thickness to total thickness ≥0.42). [9, 7]

Various circular stapler sizes should be on hand; the usual range of sizes is 25-31 mm, with the 28-mm stapler being the most frequently used size. Extreme caution must be used in removing the stapler transanally after a successful end-to-end anastomosis. [10, 11]

Complication prevention

Complication prevention measures include the following:

  • Removal of any remaining sigmoid colon in patients whose pathology stemmed from diverticulitis [11]
  • Stent-facilitated identification of the ureters and subsequent dissection of associated blood vessels [12]
  • Ligation of proximal vasculature via ultrasonic dissection [12]
  • Postoperative intravenous administration of heparin to prevent lower-extremity blood clots [13]
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Outcomes

Primary goals of LHPR are as follows:

  • To restore optimal digestive functionality
  • Closure of the ostomy site
  • To establish anatomic uniformity in the gastrointestinal tract through the anastomosis of the remainder of the descending colon with the rectal stump

Compared with open Hartmann procedure reversal, minimally invasive LHPR is associated with significantly lower morbidity and mortality, shorter postoperative hospital stay, decreased operating time, and a lower rate of postoperative complications, including (but not limited to) anastomotic leakage, hematomas/abscesses, transit disorders, ileus, cardiopulmonary depression, surgical site infections, and hernias. [9, 3, 14]

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