Laparoscopically assisted reversal of Hartmann’s procedure

Background Restoration of bowel continuity after Hartmann’s procedure is a major surgical procedure associated with substantial morbidity and occasional mortality. The authors review their experience with laparoscopically assisted reversal of Hartmann’s procedure (LARH) to assess difficulties and potential advantages associated with this procedure. Methods A retrospective chart review of a prospectively entered database was performed to identify patients who underwent LARH over a period of 7 years. Data regarding demographic and clinical characteristics, surgical details, and postoperative course were reviewed. Specifically, age, gender, diagnosis at initial operation, American Society of Anesthesiology (ASA) score, comorbidities, operative time, conversion, surgical team, complications, postoperative bowel movements, and hospital stay were assessed. All surgeries were performed by six experienced laparoscopic surgeons. Results A total of 27 patients, 17 men and 10 women, with mean ages of 58.1 and 62.9 years, respectively, underwent LARH. The procedure was laparoscopically completed for 23 patients. Conversion to laparotomy was required for four patients (14.8%) because of dense adhesions after the initial Hartmann’s procedure in three patients and rectal perforation in one patient. The median operative time was 226 min, and the median hospital stay was 6 days. The overall morbidity rate was 33% (9 patients), attributable to colostomy site infection in 5 of the 9 patients. One patient required reoperation because of intraabdominal bleeding. No anastomotic leaks or intraabdominal abscesses were recorded. There was no operative mortality. Conclusions Laparoscopically assisted reversal of Hartmann’s procedure is technically challenging and time consuming. However, in the hands of experienced laparoscopic surgeons, it is safe and associated with a reasonably low conversion rate. Furthermore, the relatively low morbidity rate, short hospital stay, and earlier return of bowel function may be beneficial to patients. Poster presentation at the 12th International Congress of the European Association for Endoscopic Surgery (EAES), Barcelona, Spain, 9–12 June 2004     

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Reversal of Hartmann’s procedure through the stomal side: a new even more minimal invasive technique

Background  Several minimal invasive, mainly laparoscopic-assisted, techniques for reversal of Hartmann’s procedure (HP) have been published. The purpose of this pilot study was to assess a minimal invasive procedure through the stomal site that may compare favorably with open or laparoscopic-assisted procedures in terms of operative time, hospital stay and postoperative complications. Methods  HP reversal through the stomal side was attempted in 13 consecutive patients. Lysis of intra-abdominal adhesions was done manually through an incision at the formal stoma side, without direct vision between thumb and index finger. The rectal stump was identified intra-abdominally using a transanal rigid club. A manually controlled stapled end-to-end colorectal anastomosis was created. Results  Mean duration of operation was 81 min (range 58–109 min); mean hospital stay was 4.2 days (range 2–7 days). In two patients the procedure was converted because of strong adhesions in the lower pelvic cavity around the rectal stump that could not be lysed manually safely. No complications occurred in the patients in whom reversal was completely done through the stomal site. Conclusions  In our opinion, restoration of intestinal continuity through the stomal side after HP is a feasible operation, without need for additional incisions. In the hands of a specialist gastrointestinal surgeon this technique can be attempted in all patients, as conversion to a laparoscopic-assisted or an open procedure can be performed when necessary.     

Laparoscopic Hartmann’s procedure: a viable option for treatment of acutely perforated diverticultis

Background  A laparoscopic technique for acutely perforated diverticulitis (i.e., laparoscopic Hartmann’s procedure) has not been described. The authors present their technique for laparoscopic sigmoid resection, end colostomy, and subsequent laparoscopic takedown of colostomy. Methods  A retrospective review of patients with Hinchey III/IV diverticulitis who underwent a laparoscopic Hartmann’s procedure was performed in this study. Laparoscopic takedown of sigmoid colostomy was performed 2 to 3 months later. Data from these procedures including estimated blood loss (EBL), length of the operative procedure, patient outcomes, and demographics were evaluated. Results  Seven patients with a mean age of 49.7 years underwent laparoscopic sigmoid colectomy with end colostomy. None of these patients had a history of diverticulitis. Their mean EBL was 138 ml, and their mean operative time was 154 min. None of the procedures required conversion to use of a hand port or conversion to open procedure. The average time to return of bowel function was 3.7 days, with one patient experiencing a postoperative ileus. The mean postoperative hospital stay was 6.6 days. There were no complications. Laparoscopic Hartmann’s takedown was performed for all the patients approximately 2 to 3 months later. The mean EBL was 107 ml, and the average operative time was 189 min. One patient had intraoperative anastomotic leak, which was successfully repaired and retested. Again, none of the procedures required the use of a hand port or a laparotomy. The average time to return of bowel function was 3.4 days. The average length of hospital stay was 5.3 days, with one patient experiencing a fat necrosis. Conclusions  Laparoscopic Hartmann’s procedure and laparoscopic takedown are technically feasible procedures with reasonable outcomes.     

Laparoscopic versus open colostomy reversal: A comparative analysis

Open colostomy reversal carries significant rates of wound infection, anastomotic leak, and incisional hernia which often limit its acceptance. We hypothesized that the laparoscopic approach to the restoration of intestinal continuity may result in lower perioperative morbidity and faster postoperative recovery. Twenty-two cases of laparoscopic colostomy reversals performed at a single institution were identified and compared to 22 randomly selected open colostomy closures performed during the same time period. Patients were compared based on demographics, previous indications for colostomy procedures, and perioperative outcomes. A total of 152 patients underwent reversal of left-sided colostomies during the study period. The laparoscopic approach was successful in 20 of 22 cases; there were 2 conversions to open (9%) secondary to inability to adequately mobilize the rectal stump. The laparoscopic and open groups were comparable based on mean age (54 years versus 49 years; P=0.23), BMI (26 kg/m² versus 27 kg/m²; P=0.66), gender (9% males versus 13% males; P=0.23), ASA Class (2.6 versus 2.3; P=0.07), and history of previous intra-abdominal sepsis (17 versus 16 cases). Operative times were similar (158 versus 189 minutes; P=0.16), and estimated blood loss was significantly less in the laparoscopic group (113 versus 270 ml; P=0.01). No intraoperative complications occurred in the laparoscopic group and two enterotomies occurred in the open group. The laparoscopic group had earlier passage of flatus (3.5 versus 5.0 days; P=0.001) and shorter hospitalization (4.2 versus 7.3 days; P=0.001). Perioperative complications occurred in 3 (14%) laparoscopic and 13 (59%) open cases (P=0.01). There was no mortality in this series. The laparoscopic approach can be safely used in the restoration of intestinal continuity. It results in a decreased perioperative morbidity and faster recovery, and it offers distinct advantages over the open approach to colostomy reversal.     

A retrospective case note review of laparoscopic versus open reversal of Hartmann’s procedure

Introduction

First described in 1921, Hartmann’s procedure is the gold standard treatment for complicated sigmoid diverticular disease. It is also used commonly for other causes of perforation of the large bowel. However, the reversal rate in the UK is much lower than in comparable countries, at only 18–22%. Furthermore, laparoscopic reversal (LRH) is used far less frequently than open reversal (ORH) despite evidence that a laparoscopic technique reduces patient morbidity and decreases patient recovery time.

Methods

This retrospective case note review undertook an analysis of all the patients who had undergone Hartmann’s procedure at two centres in Leeds Teaching Hospitals NHS Trust between February 2007 and February 2012. Out of 305 patients, 235 were identified and included in the analysis. Comparisons were then drawn between LRH and ORH groups.

Results

The reversal rate was 21%. Three-quarters (76%) were performed using an open technique, 20% were laparoscopic and 5% were converted to an open procedure. The mean hospital stay was longer for the ORH group (9.82 days, standard deviation [SD]: 5.85 days, 95% confidence interval [CI]: 2.99 days) than for the LRH group (7.29 days, SD: 4.65 days, 95% CI: 11.58 days) p=0.006). Seven ORH patients (21%) were reoperated but only one LRH patient (13%) had a reoperation at six months. Five factors were found to have a significant effect on the likelihood of reversal of Hartmann’s procedure.

Conclusions

The overall reversal rate for Hartmann’s procedure remains low. Shorter hospital stays, lower 6-month reoperation rates and reduced 30-day complication rates are associated with LRH when compared with ORH.     

How Can We Control Intraoperative Bacterial Contamination and Surgical-Site Infection During an Anterior Resection or Hartmann’s/Miles’ Operation?

Purpose  Intraoperative bacterial contamination (IBC) is a major cause of surgical-site infection (SSI). Therefore, we investigated whether the ingenuity of surgical procedures could reduce the incidence of IBC/SSI. Methods  Sixty patients who were surgically treated for recto-sigmoid cancer were investigated. Among these patients, the colon was transected during the early perioperative period (ET) in 29 patients and during the late period (LT) in 31 patients. Three samples for IBC were obtained from the irrigation fluid before abdominal closure (LAVAGE), the remaining cut sutures after peritoneal closure (SUTURE), and a subcutaneous swab of the wound (SUBCUT). Results  The overall SSI and IBC rates were 25% and 55.2%, respectively. Patients who developed SSI had an extremely high IBC rate (85%), and IBC patients also had a high SSI rate (68%). IBC was highest in the LAVAGE (26%) followed by the SUBCUT (26%), and the SUTURE (12%). The incidence of IBC in the LT was significantly lower than that in the ET (19% vs. 55%, p < 0.01), although the incidence of SSI was similar in both IBC groups. Conclusion  Shortening the exposure of the colonic mucosa decreased the incidence of IBC/SSI; thus, careful operations to minimize IBC are recommended.     

Technical aspects and outcome of a standardized full laparoscopic approach to the reversal of Hartmann’s procedure in a teaching centre

Aim Laparoscopic reversal of Hartmann’s procedure is technically demanding. We evaluated the technical aspects and outcome of a standardized approach in a single centre and examined the feasibility of including this into training curricula. Method The procedure entails a laparoscopy for adhesiolysis and identification and mobilization of the rectal stump. Mobilization of the splenic flexure is performed if necessary, and a colorectal anastomosis is fashioned after introduction of the stapler anvil via the colostomy with intra‐abdominal positioning and delivery into the proximal colonic segment to be anastomosed. The stoma is excised as the last step in the operation. Results Forty‐two patients underwent the procedure over an 8‐year period with either an expert (n=21) or trainee under expert mentorship (n=21) as first operator. Intra‐operative data and postoperative outcomes were evaluated by retrospective review of clinical charts and theatre records. There was a 9.5% conversion rate and 0% mortality. One patient suffered a ureteric injury, while postoperative surgical complications occurred in 7 patients (including one clinical anastomotic leakage). The mean operative time was 117 min. There was no significant difference in intra operative technical parameters or postoperative clinical consequences between procedures performed by a trained surgeon or by a trainee under mentorship. Conclusion Adherence to a standardized operative protocol and expert mentorship allows this technically demanding operation to be associated with low conversion and complication rates. The absence of any difference between procedures performed by a trainee or trained surgeon suggests that the operation can be included in training programmes for laparoscopic surgery.