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, 2]
Surgical approaches to LHPR include conventional open surgery, multiport laparoscopic surgery, and single-incision laparoscopic surgery (SILS). The laparoscopic approach offers significant advantages over the open approach in terms of decreased morbidity (eg, surgical-site infection [SSI] [3] ) and mortality, reduced duration of postoperative hospitalization, shorter operating time, and more rapid achievement of normal bowel function. [1, 4, 5, 6, 7] A combined transanal-laparoscopic approach to LHPR has also been described, but further study will be required to determine its utility. [8, 9]
Advances in medical science have also led to the performance of robotic Hartmann procedures in various centers. Giuliani et al assessed the short-term outcomes of robotic Hartmann reversal in 24 patients. [10] Mean operating time was 240 minutes; none of the robotic procedures were converted to open procedures, and there were no major complications.
In addition, LHPR is performed in patients experiencing complications of colostomy.
Indications
When 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. [5]
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. [5]
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 [5, 11, 12] :
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ASA class III or higher
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Preoperative sepsis
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Poor functional health status
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Preoperative albumin levels below 3.5 U/L
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High body mass index (BMI)
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Disseminated malignancy
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Dyspnea
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Thickness of subcutaneous fat (ratio of fat thickness to total thickness, ≥0.42)
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Smoking
The interval between the primary Hartmann procedure and the 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. [13] Thus, for optimal outcomes, the reversal should be performed at least 6 months after the primary procedure is performed.
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). [14, 12]
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. [15, 16]
Complication prevention
Complication prevention measures include the following:
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Removal of any remaining sigmoid colon in patients whose pathology stemmed from diverticulitis [16]
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Stent-facilitated identification of the ureters and subsequent dissection of associated blood vessels [17]
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Ligation of proximal vasculature via ultrasonic dissection [17]
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Postoperative intravenous (IV) administration of heparin to prevent lower-extremity blood clots
Outcomes
Primary goals of LHPR are as follows:
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To restore optimal digestive functionality
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To close the ostomy site
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To establish anatomic uniformity in the gastrointestinal (GI) 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, SSIs, and hernias. [18, 14, 5, 19]
Park et al retrospectively analyzed the outcomes of Hartmann colostomy reversals in 68 patients at a single center, of whom 29 underwent open reversal, 20 underwent laparoscopic reversal, and 19 underwent an initial laparoscopic reversal that was converted to a laparotomy. [20] Length of stay was significantly shorter in the laparoscopic group than in the open surgery group (10.15 ± 2.94 vs 16 ± 9.5 d). The overall complication rate was also lower in the laparoscopy group.
Panaccio et al, in a case-controlled study that included 34 patients, compared laparoscopic Hartmann reversal (n = 17) with open Hartmann reversal (n = 17). [21] They found that mean operating time and mortality were similar in the two groups, but the laparoscopic group had less intraoperative blood loss, a shorter time to passage of flatus, and a reduced duration of hospitalization.
In a study that included 89 patients who underwent Hartmann reversal after having undergone Hartmann surgery for colorectal cancer, Tan et al evaluated the short-term outcomes of laparoscopic reversal (n = 48) against those of open reversal (n = 41). [22] They found no significant differences between the two approaches with respect to operating time, blood loss, duration of postoperative hospitalization, or postoperative complications; however, they concluded that laparoscopic reversal still had some advantages by virtue of being less invasive.
Thambi et al retrospectively studied SILS Hartmann reversal vs conventional laparoscopic reversal (CL) and open surgical reversal (OS) in 106 patients who underwent reversal for diverticular disease (n = 71), cancer (n = 19), anastomotic leakage (n = 4), or miscellaneous reasons such as trauma (n = 12). [23] Postoperative complication rates were 30.4% for SILS, 43.8% for CL, and 50.0% for OS. Median operating time was 146 minutes (range, 44-389) for SILS, 211 minutes (range, 109-320) for CL, and 211 minutes (range, 85-420) for OS. Median length of stay was 4 days (range, 2-44) for SILS, 6 days (range, 3-34) for CL, and 7 days (range, 4-34) for OS.
D'Alessandro et al, in a case-controlled study of 88 patients, compared single-port Hartmann reversal (SP-HR; n = 44) with multiport Hartmann reversal (MP-HR; n = 44). [24] They found that mean operating time was shorter in the SP-HR group (105 min) than in the MP-HR group (155 min). None of the procedures were converted to open reversal.
A similar study, by Kang et al, reported on the safety and feasibility of SILS Hartmann reversal through the colostomy site in 20 patients. [25] Single-port laparoscopic reversal of Hartmann colostomy was successful in 85% of the patients. The colostomy was mobilized, and the single-port laparoscopic device was installed for carrying out the procedure.
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Positioning and room setup.
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Trocar configuration. Abbreviations: LLQ, left lower quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.
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Descending colon with the anvil. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
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Placement of the single port trocar at the ostomy site. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
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Connecting anvil with the rectal stump. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
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Stapled colorectal anastomosis. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
