Laparoscopic Hartmann Procedure

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 decades, this technology was slow to advance in the realm of general surgery, not gaining momentum until the burgeoning of laparoscopic biliary surgery.

Advances in fiberoptic 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, lent credibility to the accuracy of this approach and clarity to the complexity involved.

Although progress was initially slow, several technological milestones have been reached that allow clinicians to apply laparoscopy 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, 5, 6]}

Reversal of the procedure is discussed in more detail elsewhere (see Laparoscopic Hartmann Procedure Reversal). ^{[7, 8, 9, 10]}

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. In clinically suitable patients, the laparoscopic Hartmann procedure has advantages over the equivalent open procedure. ^[4]

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. ^{[11, 12]} Accordingly, the combined laparoscopic Hartmann procedure is used in a limited patient population.

Although the laparoscopic Hartmann procedure has not been as frequently performed as the equivalent open procedure, 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 two techniques yielded similar outcomes. ^[13]  However, multiple relative contraindications have been cited.

The surgeon’s proficiency with laparoscopic colorectal surgery is the paramount consideration. ^[14]  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 has been debated. ^{[13, 15]}  Retrospective studies have shown laparoscopic lavage to be 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 a single quadrant of the abdomen poses less of a challenge for laparoscopic lavage than fecal contamination that is disseminated throughout all four 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 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 that the occurrence of three 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. ^{[6, 16]}

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