Laparoscopic Hartmann Procedure Technique

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. A single-port approach has been described. ^[14]

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, two or three more port sites are established in the right upper quadrant (RUQ), the right lower quadrant (RLQ), and (optionally) the suprapubic region. The ports placed in the RUQ and RLQ 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. ^[15]

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. ^[16]

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.

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).

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. ^[10]  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%. ^[10]  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. ^{[17, 18]}