Laparoscopic Hartmann Reversal
The Hartmann procedure is a standard life-saving operation for acute left colonic complications. It is usually performed as a temporary procedure with the intent to reverse it later on. This reversal is associated with considerable morbidity and mortality by the open method. The laparoscopic reestablishment of intestinal continuity after the Hartmann procedure has shown better results in terms of a decrease in morbidity and mortality. There are several laparoscopic techniques of the reversal of the Hartmann procedure. The principle common to all techniques is a tension-free intracorporeal stapler anastomosis. The introduction of a circular stapler in the rectal stump helps in the identification and mobilization of the rectal stump. Others have mobilized the colostomy first and have used the colostomy site as a first port or used a standard umbilical port. It is technically challenging and requires an experienced laparoscopic surgeon but offers clear advantages to patients. The main reasons reported for conversion to open were dense abdominal-pelvic adhesions secondary to diffuse peritonitis at the primary operation, a short delay before the reconstruction, difficulty in finding the rectal stump, and rectal scarring. Leaving long nonabsorbable suture ends at the rectal stump or suturing it to the anterior abdominal wall helps in its localization. Other relative limitation factors could be a large incisional hernia from the previous laparotomy and contraindications to general anesthesia and laparoscopy.
Patient Position
The patient is placed supine on the operating table, on a beanbag. After induction of general anesthesia and insertion of an orogastric tube and Foley catheter, the legs are placed in a lithotomy stirrup position. The arms are tucked at the patient's side and the beanbag is aspirated. The abdomen is prepared with an antiseptic solution and draped routinely.
Position of Surgical Team
The primary monitor is placed on the left side of the patient at approximately the level of the hip. The secondary monitor is placed on the right side of the patient at the same level and is primarily for the assistant during the early phase of the surgery and port insertion. The operating nurse's instrument table is placed between the patient's legs. There should be sufficient space to allow the surgeon to move from either side of the patient to between the patient's legs, if necessary. The primary operating surgeon stands on the right side of the patient with the assistant standing on the patient's left and moving to the right side, caudad to the surgeon once ports have been inserted. A 30-degree camera lens is better to be used. The colostomy is mobilized and all adhesions dissected through the fascial opening until an adequate segment of bowel has been freed from the surrounding tissues. The bowel is trimmed as necessary and a purse-string suture is positioned before insertion of the anvil of a curved EEA stapling device. The bowel is returned to the abdomen, the fascia is closed with a monofilament suture, but before tying the suture a 12 mm port is inserted at this site, and the abdomen is insufflated.
The laparoscope is inserted into the abdomen through the stoma port to assess adhesions and allow direct visualization for subsequent port insertion and an initial laparoscopy is performed, carefully evaluating the liver, small bowel, and peritoneal surfaces. A 10 mm port is inserted in the umbilicus for camera location. A 5 mm right lower quadrant trocar is placed approximately 2 to 3 cm medial to the anterior superior iliac spine. This is carefully inserted lateral to the inferior epigastric vessels, paying attention to keep the tract of the port going as perpendicular as possible through the abdominal wall. A 5 mm port is then inserted in the right upper quadrant at least a hand's breadth superior to the lower quadrant port. A left upper quadrant 5 mm port is inserted. Again all of these remaining ports are kept lateral to the epigastric vessels. This may be ensured by diligence to anatomic port site selection and using the laparoscope to transilluminate the abdominal wall before making the port site incision to identify any obvious superficial vessels. The assistant now moves to the patient's right side, standing caudad to the surgeon. The patient is rotated with the left side up and right side down, to approximately 15 to 20 degrees tilt, and often as far as the table can go. This helps to move the small bowel over to the right side of the abdomen. The patient is then placed in the Trendelenburg position. This again helps gravitational migration of the small bowel away from the operative field. The surgeon then inserts two atraumatic bowel clamps through the two right-sided abdominal ports. The greater omentum is reflected over the transverse colon so that it comes to lie on the stomach. If there is no space in the upper part of the abdomen, one must confirm that the orogastric tube is adequately decompressing the stomach. The small bowel is moved to the patient's right side allowing visualization of the proximal rectum. Variable degrees of adhesiolysis may be required. This may necessitate the use of the assistant's 5 mm atraumatic bowel clamp through the stoma trocar or left upper quadrant.
Left Colon Mobilization
An atraumatic bowel clamp is placed on the descending colon to take down the inflammatory and native attachments to free it laterally. The omentum is dissected off the transverse colon and the lesser sac is entered. The splenic flexure is released to allow a tension-free reach to the proximal rectum. The colonic mesentery should be mobilized off the Gerota's fascia. The left ureter is identified at the pelvic brim and freed from the proximal rectum to avoid injury. The ureter should be just deep to the parietal peritoneum, and just medial and posterior to the gonadal vessels. Care must be taken not to dissect too deep or caudad, leading to injury of the iliac vessels.
Mobilization of Rectum
An atraumatic bowel clamp inserted through the left lower quadrant port is used to elevate the proximal rectum out of the pelvis and away from the retroperitoneum and sacral promontory, to enable entry into the presacral space. The posterior aspect of the mesorectum can be identified and the mesorectal plane dissected with diathermy, preserving the hypogastric nerves as they pass down into the pelvis anterior to the sacrum. Dissection needs to progress only to allow the advancement of the circular stapler to the end of the rectum and assure that all the sigmoid has been resected. If residual sigmoid is present, the linear endoscopic stapler should be used to divide the bowel at the level of the proximal rectum. A site for rectal division should be chosen in proximal, peritonealized rectum, which assures that the anastomosis will be distal to the sacral promontory. The rectum is divided laparoscopically with a linear endoscopic stapler through the right lower quadrant trocar. One or two firings of the stapler may be required to divide the rectum. The mesorectum is divided using monopolar and bipolar cautery at this level.
Specimen Extraction and Anastomosis
If residual sigmoid is required, the specimen is extracted through the stoma site port. Pneumoperitoneum is recreated, and the circular stapled anastomosis is formed under laparoscopic guidance. The anastomosis can be leak-tested by filling the pelvis with saline and inflating the neorectum using a proctoscope or bulb syringe and the orientation and lack of tension confirmed. The fascia of all the 10 mm or above port is closed and skin dressing is applied by the usual manner.
Conclusion
The reversal of the Hartmann procedure can be a difficult due tendency of the Hartmann segment to become densely adherent deep in the pelvis. The laparoscopic reversal has made this major operation easier, safe, and practical. As a majority of these patients is in the elderly age group, it has the advantage of early mobilization, less pain, short hospital stay, and return to normal life.
The Hartmann procedure is a standard life-saving operation for acute left colonic complications. It is usually performed as a temporary procedure with the intent to reverse it later on. This reversal is associated with considerable morbidity and mortality by the open method. The laparoscopic reestablishment of intestinal continuity after the Hartmann procedure has shown better results in terms of a decrease in morbidity and mortality. There are several laparoscopic techniques of the reversal of the Hartmann procedure. The principle common to all techniques is a tension-free intracorporeal stapler anastomosis. The introduction of a circular stapler in the rectal stump helps in the identification and mobilization of the rectal stump. Others have mobilized the colostomy first and have used the colostomy site as a first port or used a standard umbilical port. It is technically challenging and requires an experienced laparoscopic surgeon but offers clear advantages to patients. The main reasons reported for conversion to open were dense abdominal-pelvic adhesions secondary to diffuse peritonitis at the primary operation, a short delay before the reconstruction, difficulty in finding the rectal stump, and rectal scarring. Leaving long nonabsorbable suture ends at the rectal stump or suturing it to the anterior abdominal wall helps in its localization. Other relative limitation factors could be a large incisional hernia from the previous laparotomy and contraindications to general anesthesia and laparoscopy.
Patient Position
The patient is placed supine on the operating table, on a beanbag. After induction of general anesthesia and insertion of an orogastric tube and Foley catheter, the legs are placed in a lithotomy stirrup position. The arms are tucked at the patient's side and the beanbag is aspirated. The abdomen is prepared with an antiseptic solution and draped routinely.
Position of Surgical Team
The primary monitor is placed on the left side of the patient at approximately the level of the hip. The secondary monitor is placed on the right side of the patient at the same level and is primarily for the assistant during the early phase of the surgery and port insertion. The operating nurse's instrument table is placed between the patient's legs. There should be sufficient space to allow the surgeon to move from either side of the patient to between the patient's legs, if necessary. The primary operating surgeon stands on the right side of the patient with the assistant standing on the patient's left and moving to the right side, caudad to the surgeon once ports have been inserted. A 30-degree camera lens is better to be used. The colostomy is mobilized and all adhesions dissected through the fascial opening until an adequate segment of bowel has been freed from the surrounding tissues. The bowel is trimmed as necessary and a purse-string suture is positioned before insertion of the anvil of a curved EEA stapling device. The bowel is returned to the abdomen, the fascia is closed with a monofilament suture, but before tying the suture a 12 mm port is inserted at this site, and the abdomen is insufflated.
The laparoscope is inserted into the abdomen through the stoma port to assess adhesions and allow direct visualization for subsequent port insertion and an initial laparoscopy is performed, carefully evaluating the liver, small bowel, and peritoneal surfaces. A 10 mm port is inserted in the umbilicus for camera location. A 5 mm right lower quadrant trocar is placed approximately 2 to 3 cm medial to the anterior superior iliac spine. This is carefully inserted lateral to the inferior epigastric vessels, paying attention to keep the tract of the port going as perpendicular as possible through the abdominal wall. A 5 mm port is then inserted in the right upper quadrant at least a hand's breadth superior to the lower quadrant port. A left upper quadrant 5 mm port is inserted. Again all of these remaining ports are kept lateral to the epigastric vessels. This may be ensured by diligence to anatomic port site selection and using the laparoscope to transilluminate the abdominal wall before making the port site incision to identify any obvious superficial vessels. The assistant now moves to the patient's right side, standing caudad to the surgeon. The patient is rotated with the left side up and right side down, to approximately 15 to 20 degrees tilt, and often as far as the table can go. This helps to move the small bowel over to the right side of the abdomen. The patient is then placed in the Trendelenburg position. This again helps gravitational migration of the small bowel away from the operative field. The surgeon then inserts two atraumatic bowel clamps through the two right-sided abdominal ports. The greater omentum is reflected over the transverse colon so that it comes to lie on the stomach. If there is no space in the upper part of the abdomen, one must confirm that the orogastric tube is adequately decompressing the stomach. The small bowel is moved to the patient's right side allowing visualization of the proximal rectum. Variable degrees of adhesiolysis may be required. This may necessitate the use of the assistant's 5 mm atraumatic bowel clamp through the stoma trocar or left upper quadrant.
Left Colon Mobilization
An atraumatic bowel clamp is placed on the descending colon to take down the inflammatory and native attachments to free it laterally. The omentum is dissected off the transverse colon and the lesser sac is entered. The splenic flexure is released to allow a tension-free reach to the proximal rectum. The colonic mesentery should be mobilized off the Gerota's fascia. The left ureter is identified at the pelvic brim and freed from the proximal rectum to avoid injury. The ureter should be just deep to the parietal peritoneum, and just medial and posterior to the gonadal vessels. Care must be taken not to dissect too deep or caudad, leading to injury of the iliac vessels.
Mobilization of Rectum
An atraumatic bowel clamp inserted through the left lower quadrant port is used to elevate the proximal rectum out of the pelvis and away from the retroperitoneum and sacral promontory, to enable entry into the presacral space. The posterior aspect of the mesorectum can be identified and the mesorectal plane dissected with diathermy, preserving the hypogastric nerves as they pass down into the pelvis anterior to the sacrum. Dissection needs to progress only to allow the advancement of the circular stapler to the end of the rectum and assure that all the sigmoid has been resected. If residual sigmoid is present, the linear endoscopic stapler should be used to divide the bowel at the level of the proximal rectum. A site for rectal division should be chosen in proximal, peritonealized rectum, which assures that the anastomosis will be distal to the sacral promontory. The rectum is divided laparoscopically with a linear endoscopic stapler through the right lower quadrant trocar. One or two firings of the stapler may be required to divide the rectum. The mesorectum is divided using monopolar and bipolar cautery at this level.
Specimen Extraction and Anastomosis
If residual sigmoid is required, the specimen is extracted through the stoma site port. Pneumoperitoneum is recreated, and the circular stapled anastomosis is formed under laparoscopic guidance. The anastomosis can be leak-tested by filling the pelvis with saline and inflating the neorectum using a proctoscope or bulb syringe and the orientation and lack of tension confirmed. The fascia of all the 10 mm or above port is closed and skin dressing is applied by the usual manner.
Conclusion
The reversal of the Hartmann procedure can be a difficult due tendency of the Hartmann segment to become densely adherent deep in the pelvis. The laparoscopic reversal has made this major operation easier, safe, and practical. As a majority of these patients is in the elderly age group, it has the advantage of early mobilization, less pain, short hospital stay, and return to normal life.
