Laparoscopic Hartmann Procedure Reversal 

Updated: Jul 12, 2019
Author: Juan L Poggio, MD, MS, FACS, FASCRS; Chief Editor: Vikram Kate, MBBS, MS, PhD, FRCS, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS 

Overview

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]

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][2] ) and mortality, reduced duration of postoperative hospitalization, shorter operating time, and more rapid achievement of normal bowel function.[3, 4, 5]  A combined transanal-laparoscopic approach to LHPR has also been described, but further study will be required to determine its utility.[6, 7]

In addition, LHPR is performed in patients experiencing complications of colostomy.

Indications

When evaluating 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.[3]

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.[3]

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[3, 8, 9] :

  • ASA class III or higher
  • Preoperative sepsis
  • Poor functional health status
  • Preoperative albumin levels below 3.5 U/L
  • High body mass index (BMI)
  • Disseminated malignancy
  • Dyspnea
  • Thickness of subcutaneous fat (ratio of fat thickness to total thickness ≥0.42)
  • Smoking

The interval between the primary Hartmann procedure and 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.[10] 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).[11, 9]

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.[12, 13]

Complication prevention

Complication prevention measures include the following:

  • Removal of any remaining sigmoid colon in patients whose pathology stemmed from diverticulitis [13]
  • Stent-facilitated identification of the ureters and subsequent dissection of associated blood vessels [14]
  • Ligation of proximal vasculature via ultrasonic dissection [14]
  • Postoperative intravenous administration of heparin to prevent lower-extremity blood clots

Outcomes

Primary goals of LHPR are as follows:

  • To restore optimal digestive functionality
  • Closure of the ostomy site
  • To establish anatomic uniformity in the gastrointestinal 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.[11, 3, 15]

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.[16]  Length of stay was significantly shorter in the laparoscopic group than in the open surgery group (10.15 ± 2.94 days vs 16 ± 9.5 days). The overall complication rate was also lower in the laparoscopy group.

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).[17]  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.

 

Periprocedural Care

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%).[3]

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.[18]

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:

  • Agreement with physician recommendations for optimal care
  • Right to refuse interventions
  • Choice among alternatives
  • Shared decision making

Specific information to discuss with LHPR candidates includes the following:

  • Specific characteristics of the procedure
  • Expected outcomes and potential complications
  • Alternatives to LHPR and associated risks and benefits [19]
  • The surgeon’s or institution’s individual record of annual case load, outcomes, morbidity, and mortality associated with LHPR as compared with those of other surgeons or institutions [20, 21]
  • Changes in the operation caused by unanticipated findings; possibility of conversion to conventional or open Hartmann procedure reversal [20, 21]

The components of informed consent obtained by the authors' institutions is provided as an example of the aforementioned information to be discussed.[18]

Equipment

Insufflation devices allow distention of the abdomen through the establishment of a pneumoperitoneum with gases such as CO2 (which is the most commonly used), O2, and nitrous oxide, among others.[22] 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.[22]

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.[22]

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.[22]

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.[22]

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.[22]

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.[22]

Circular end-to-end anastomosis (CEEA) staplers range from 23 to 31 mm in diameter.[22]

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.[22]

Patient Preparation

The remaining rectal stump is examined via endoscopy, contrast enema, or both in order to ensure sufficient mobilization.[23]

The patient undergoes a rectal enema on the day of surgery.[23]

Alvimopan, a peripherally acting mu opioid receptor antagonist, is administered to accelerate upper and lower gastrointestinal tract recovery in patients undergoing colorectal resection.[24]

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).[25, 26]

General anesthesia is used. The patient is placed into the modified lithotomy position.[10, 13]

Monitoring & Follow-up

The healthcare team should follow the fast-track protocols in colorectal surgery in order to optimize the perioperative care and recovery of the patient.[25, 26]

 

Technique

Approach Considerations

To ensure optimal patient outcomes, laparoscopic Hartmann procedure reversal (LHPR) should be performed instead of the conventional open equivalent, when circumstances permit.[27, 28] LHPR can be performed via a multiport approach or by means of single-incision laparoscopic surgery (SILS).[29]

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.

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).[13]

Positioning and room setup. Positioning and room setup.

The first port 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 taken to minimize electrical current use and avoid bowel injury. Mobilization of the small bowel is carried out next, 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 leakage. The pelvis is then irrigated with saline solution, and hemostasis is checked. Pneumoperitoneum is discontinued.

All port sites are closed with nonabsorbable sutures, and the ostomy site is dealt with by means of delayed primary closure/packing/secondary intention.[10, 30, 31]

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.[29] 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 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.[23, 12, 32]