Approach Considerations
To ensure optimal patient outcomes, laparoscopic Hartmann procedure reversal (LHPR) should be performed instead of the conventional open equivalent, when circumstances permit. [34, 35] LHPR can be performed via a multiport approach or by means of single-incision laparoscopic surgery (SILS). [36]
A single-center retrospective study by Yamamoto et al described standardization of the technique of LHPR in 10 patients who underwent the Hartmann procedure followed by laparoscopic reversal of the same. [37] The stoma was mobilized with a circular incision, and the glove technique was used to create pneumoperitoneum. Intraoperative colonoscopy was performed to identify the rectal stump whenever needed. The median operating time was 265 minutes (range, 160-435), and the median blood loss was 100 mL (range, 10-700). There were no major perioperative morbidities.
Extreme adhesions surrounding the colostomy site and remaining rectal stump may necessitate conversion from the laparoscopic approach to the open approach. This possibility is addressed 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). [16]
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 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. [13, 38, 39]
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. [36] 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 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 of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
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. [30, 15, 40]
-
Positioning and room setup.
-
Trocar configuration. Abbreviations: LLQ, left lower quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.
-
Descending colon with the anvil. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
-
Placement of the single port trocar at the ostomy site. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
-
Connecting anvil with the rectal stump. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
-
Stapled colorectal anastomosis. Courtesy of Prof. Dr. Thomas Carus, Hospital Bremen-East, Germany.
