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Laparoscopic Hartmann Procedure Reversal Technique

  • 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
 

Approach Considerations

To ensure optimal patient outcomes, minimally invasive laparoscopic Hartmann procedure reversal (LHPR) should be performed instead of the conventional open equivalent, when circumstances permit.[20, 21] LHPR can be performed via a multiport approach or by means of single-incision laparoscopic surgery (SILS).[22]

Extreme adhesions surrounding the colostomy site and remaining rectal stump may necessitate conversion from the laparoscopic approach to the open approach. This possibility is dictated on a patient-by-patient basis, depending on unforeseen anatomic variations.

A catheter is placed for bladder drainage.

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Multiport Hartmann Procedure Reversal

The patient is placed in the modified lithotomy position. The surgeon and assistant stand on the patient's right, and the scrub nurse stands on the left side, with the monitor placed at the patient’s feet (see the image below).[7]

Positioning and room setup. Positioning and room setup.

The first trocar entry is created through the umbilicus with a 12-mm trocar in accordance with the Hasson technique. Pneumoperitoneum is established at 12 mm Hg. Additional port entries are established, depending on the configuration of the patient’s abdominal dome and the presence of intra-abdominal adhesions. The entry ports are configured in the following pattern (see the image below):

  • A 12-mm trocar is placed along the right lower quadrant
  • A 5-mm trocar is placed along the right superior paramedian position
  • An additional 5-mm trocar is placed along the left upper quadrant
Trocar configuration. Abbreviations: LLQ, left low Trocar configuration. Abbreviations: LLQ, left lower quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.

Adhesions are lysed with care to minimize electrical current use and avoid bowel injury. The small bowel is then mobilized, followed by mobilization of the rectal stump. The circular end-to-end anastomosis (CEEA) stapler is then inserted transanally and manipulated to the top of the rectal stump. The intra-abdominal colostomy is dissected and the bowel mobilized.

The proximal colon and splenic flexure are then dissected. Splenic flexure mobilization is completed as needed to ensure a tension-free anastomosis. The anvil of the stapler is then purse-stringed to the distal end of the proximal bowel and deployed. Once the anastomosis has been successfully created, the stapler should be carefully removed to avoid further bowel disruption. The anastomosis is immersed in saline solution, and air is introduced transanally to check for possible anastomotic air leakage. The pelvis is then irrigated with saline solution, and hemostasis is checked. Pneumoperitoneum is discontinued.

All ports are closed with nonabsorbable sutures, and the ostomy site is dealt with by means of delayed primary closure/packing/secondary intention.[4, 23, 24]

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Single-Incision Hartmann Procedure Reversal

The SILS approach to Hartmann procedure reversal uses the existing colostomy site as an entry point, thereby eliminating the need for additional entry points in the peritoneal cavity.[22] Use of a single port access decreases access trauma and possible postoperative morbidities (eg, surgical site infection).

After the patient has been placed in the modified lithotomy position, the stoma is excised, and the mobilized bowel is removed from the abdomen via the open stomal orifice. A purse-string clamp is placed 1-2 cm from the bowel, and the anvil of the CEEA stapler is fixed with purse-string sutures.

The SILS port is introduced at the stomal site and fixed to the opening with sutures to prevent port displacement (see the image below).

Placement of the single port trocar at the ostomy Placement of the single port trocar at the ostomy site. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.

Pneumoperitoneum is established, and a diagnostic laparoscopy is performed. Two 5-mm working trocars at the SILS port are used for the dissector and the ultrasonic scissors. Any adhesions are dissected to ensure rectal stump mobility. At this point, the proximal colon and splenic flexure are dissected. Splenic flexure mobilization is completed as needed to ensure a tension-free anastomosis.

The CEEA stapler is introduced transanally and pushed to the top of the rectal stump. Next, the anvil is connected to the stapler, which is then deployed, thus creating an end-to-end anastomosis (see the images below). After the anastomosis is successfully established, the stapler should be carefully removed.

Connecting anvil with the rectal stump. Courtesy o Connecting anvil with the rectal stump. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
Stapled colorectal anastomosis. Courtesy of Prof. Stapled colorectal anastomosis. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.

The anastomosis is immersed in saline solution, and air is introduced transanally to facilitate identification of any potential anastomotic air leakage. Then, the pelvis is irrigated with saline solution and hemostasis is checked. Pneumoperitoneum is discontinued.

The SILS port is removed and the fascia closed with nonabsorbable sutures. The ostomy site is dealt with by means of delayed primary closure/packing/secondary intention.[16, 6, 25]

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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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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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