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Laparoscopic Hartmann Procedure Reversal Periprocedural Care

  • Author: Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS  more...
 
Updated: Jul 20, 2015
 

Patient Education and Consent

Patient instructions

When a patient is evaluated for LHPR, a careful explanation of the surgery and its associated risks must accompany patient education. This allows the patient to weigh the benefits and risks of surgery and to make an autonomous decision regarding whether to proceed with LHPR. Laparoscopic Hartmann procedure reversal (LHPR) carries a lower frequency of morbidity than open reversal does (12.2% vs 20.3%).[1]

Elements of informed consent

A patient’s decision is often expressed via their signing of an “informed consent” form, stating the details of the surgery and outlining all relevant information. A proper informed consent process benefits patients and providers alike by respecting the patient’s self-determination, enhancing the patient’s well-being, and fulfilling legal requirements.

Patients may wish to prepare an advance directive, in the forms of either a living will or durable power of attorney for health care.[11]

The process of informed consent begins with evaluation of the patient for adequate decision-making capacity. Crucial aspects to be included in the informed consent include the following:

  • Agreement with physician recommendations for optimal care
  • Right to refuse interventions
  • Choice among alternatives
  • Shared decision making

Specific information to discuss with LHPR candidates includes the following:

  • Specific characteristics of the procedure
  • Expected outcomes and potential complications
  • Alternatives to LHPR and associated risks and benefits [12]
  • The surgeon’s/institution’s individual record of annual case load, outcomes, morbidity, and mortality associated with LHPR as compared to other institutions [13, 14]
  • Changes in the operation caused by unanticipated findings/possibility for conversion to conventional/open Hartmann procedure reversal [13, 14]

The components of informed consent obtained by the authors' institutions is provided as an example of the aforementioned information to be discussed.[11]

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Equipment

Insufflation devices allow distention of the abdomen through the establishment of a pneumoperitoneum with gases such as CO2 (which is the most commonly used), O2, and NO, among others.[15] This causes expansion of the peritoneal cavity, which increases the available room for laparoscope manipulation. Great attention must be given to keeping intra-abdominal pressure below 12-14 mm Hg range in order to prevent complications such as gas embolism, subcutaneous or mediastinal emphysema, and hemodynamic instability

A fiberoptic-based light source facilitates the veritable transmission of anatomic structures within the abdominal cavity to the video monitor[15]

A small end-viewing camera transmits a visualization of the operative field from the endoscope to a viewing monitor. The video system must be carefully calibrated to allow identification of various anatomic entities without distortion.[15]

Optical fibers transmit light through the laparoscope, objective lens, quartz rod lens, image-reversal system, and eyepiece. A 30°-50° angulation range allows visualization straight ahead, left, right, up, and down. Varying scope diameters coincide with the varying sizes of common laparoscopic cannulas.[15]

To avoid condensation and subsequent fogging within varying parts of the laparoscopic apparatus, one may either preheat the laparoscope within a sterile sleeve or use an antifogging chemical before proceeding into the abdomen, along with different available smoke evacuators.[15]

An irrigation device consists of a compressed gas–based high-pressure cylinder connected to a fluid reservoir. Flow rate or the irrigation stream may be regulated by altering the pressure buildup within the cylinder.[15]

Trocars provide access ports into the abdomen while maintaining pneumoperitoneum continuity. The range from 3 to 12 mm in diameter. LHPR requires port sizes in the range of 10-12 mm to accommodate larger equipment.[15]

Circular end-to-end anastomosis (CEEA) staplers range from 23 to 31 mm in diameter.[15]

Manipulation devices include grasping devices, dissectors, scissors, and clip appliers, all of which may be available with different functional modifications for use with the laparoscopic devices.[15]

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Patient Preparation

The remaining rectal stump is examined via endoscopy and/or contrast enema in order to ensure sufficient mobilization.[16]

The patient undergoes a rectal enema on the day of surgery.[16]

Alvimopan, a peripherally acting mu opioid receptor antagonist, is administered to accelerate upper and lower GI recovery in patients undergoing colorectal resection.[17]

Prophylactic antimicrobial agents are administered as recommended by the Committee on Perioperative Care of the American College of Surgeons and by the Hospital Infection Control Practice Advisory Committee of the Centers for Disease Control and Prevention.[18, 19]

General anesthesia is used. The patient is placed into the modified lithotomy position.[4, 7]

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Monitoring and Follow-up

The healthcare team should follow the fast-track protocols in colorectal surgery in order to optimize the perioperative care and recovery of the patient.[18, 19]

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Contributor Information and Disclosures
Author

Juan L Poggio, MD, MS, FACS, FASCRS Associate Professor of Surgery, Director of Robotic Colon and Rectal Surgery, Division of Colorectal Surgery, Department of Surgery, Drexel University College of Medicine

Juan L Poggio, MD, MS, FACS, FASCRS is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

David E Stein, MD Chief, Division of Colorectal Surgery, Associate Professor, Department of Surgery, Director, Mini-Medical School Program, Drexel University College of Medicine; Chief, Division of Colorectal Surgery, Department of Surgery, Hahneman University Hospital; Consultant, Merck; Consultant, Ethicon Endo-Surgery; Consultant, Health Partners; Consultant, Cook Surgical

David E Stein, MD is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons, Association for Surgical Education, Pennsylvania Medical Society, Society for Surgery of the Alimentary Tract, Crohn's and Colitis Foundation of America

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Merck<br/>Serve(d) as a speaker or a member of a speakers bureau for: Merck.

William R Grier Drexel University College of Medicine

Disclosure: Nothing to disclose.

Adrian Yurij Kohut Drexel University College of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Surgeons of England, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Acknowledgements

Acknowledgments

We would like to thank Dr. Thomas Carus for providing media files 3, 4, 5, and 6. Dr. Carus is an internationally recognized expert in minimally invasive laparoscopic surgical techniques. He is a Professor of Surgery at the Department of General, Visceral and Trauma Surgery, Center for Minimally Invasive Surgery, Klinikum Bremen-Ost/ Gesundheit Nord GmbH, Germany.

References
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  2. Cohen ME, Bilimoria KY, Ko CY, Hall BL. Development of an American College of Surgeons National Surgery Quality Improvement Program: morbidity and mortality risk calculator for colorectal surgery. J Am Coll Surg. 2009 Jun. 208 (6):1009-16. [Medline].

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  8. Nickloes TA, Long C. Laparoscopic Hartmann procedure. Medscape Drugs & Diseases. Available at http://emedicine.medscape.com/article/1535079-overview. August 11, 2014; Accessed: July 13, 2015.

  9. Reversal of Hartmann's procedure. Gloucestershire Hospitals. Available at http://www.gloshospitals.nhs.uk/SharePoint999/Patient%20Leaflets/Colorectal/Reversal%20of%20Hartmann%e2%80%99s%20procedure%20GHPI0761_01_15.pdf. January 2015; Accessed: July 13, 2015.

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  17. Alvimopan. Medscape Drugs & Diseases. Available at http://reference.medscape.com/drug/entereg-alvimopan-342084. March 2013; Accessed: July 13, 2015.

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  27. Faure JP, Doucet C, Essique D, Badra Y, Carretier M, Richer JP, et al. Comparison of conventional and laparoscopic Hartmann's procedure reversal. Surg Laparosc Endosc Percutan Tech. 2007 Dec. 17 (6):495-9. [Medline].

  28. Haughn C, Ju B, Uchal M, Arnaud JP, Reed JF, Bergamaschi R. Complication rates after Hartmann's reversal: open vs. laparoscopic approach. Dis Colon Rectum. 2008 Aug. 51 (8):1232-6. [Medline].

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Positioning and room setup.
Trocar configuration. Abbreviations: LLQ, left lower quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.
Descending colon with the anvil. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
Placement of the single port trocar at the ostomy site. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
Connecting anvil with the rectal stump. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
Stapled colorectal anastomosis. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
 
 
 
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