Patient Education and Consent
Patient instructions
When a patient is evaluated for laparoscopic Hartmann procedure reversal (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. LHPR carries a lower frequency of morbidity than open reversal does (12.2% vs 20.3%). [5]
Elements of informed consent
A patient’s decision is often expressed via their signing of an “informed consent” form that states the details of the surgery and outlines 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 form of either a living will or durable power of attorney for health care.
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:
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Agreement with physician recommendations for optimal care
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Right to refuse interventions
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Choice among alternatives
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Shared decision making
Specific information to discuss with LHPR candidates includes the following:
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Specific characteristics of the procedure
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Expected outcomes and potential complications
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Alternatives to LHPR and associated risks and benefits [26]
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Changes in the operation caused by unanticipated findings; possibility of conversion to conventional or open Hartmann procedure reversal [27, 28]
Equipment
Insufflation devices allow distention of the abdomen through the establishment of a pneumoperitoneum with gases such as CO2 (the most commonly used gas in this setting), O2, and nitrous oxide, among others. [29] 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 the 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 accurate transmission of anatomic structures within the abdominal cavity to the video monitor. [29]
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. [29]
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. [29]
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. [29]
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. [29]
Trocars provide access to the abdomen while maintaining continuous pneumoperitoneum. They range from 3 to 12 mm in diameter. LHPR requires port sizes in the range of 10-12 mm to accommodate larger equipment. [29]
Circular end-to-end anastomosis (CEEA) staplers range from 21 to 34 mm in diameter.
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. [29]
Patient Preparation
The remaining rectal stump is examined via endoscopy, contrast enema, or both in order to ensure sufficient mobilization. [30]
The patient undergoes a rectal enema on the day of surgery. [30]
Alvimopan, a peripherally acting mu opioid receptor antagonist, is administered to accelerate upper and lower gastrointestinal (GI) tract recovery in patients undergoing colorectal resection. [31]
Prophylactic antimicrobial agents are administered as recommended by the Committee on Perioperative Care of the American College of Surgeons (ACS) and by the Hospital Infection Control Practice Advisory Committee of the Centers for Disease Control and Prevention (CDC). [32, 33]
General anesthesia is used. The patient is placed into the modified lithotomy position. [13, 16]
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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.
