Page 10 - World Journal of Laparoscopic Surgery

K Kilic, K Ulker

patient, with the second assistant standing on the left. The lower quadrant as needed. Lysis of adhesions was done to
initial port insertion was performed by one of two techniques allow mobilization of the colostomy and identification of
depending upon the surgeons’ preference. The first technique the rectal stump. This was carried out using scissors,
involved mobilization of the colostomy site through a monopolar diathermy, or ultrasonic activated devices
peristomal incision, with the anvil of a circular stapling device
according to surgeon’s preference. When necessary to
inserted into the lumen. For the left colon, the anvil was identify the rectal stump, a dilator, stapling device or
placed into the abdominal cavity, and the colostomy site sigmoidoscope was inserted into the rectum. The colostomy
was used as the port site for the establishment of was freed from the abdominal wall and the anvil of a circular
pneumoperitoneum. The fascia at the colostomy site was stapling device was inserted into the lumen. The colostomy
closed using two continuous 0 Prolene sutures, and the was then delivered into the abdomen, and either a 12 mm
Hasson cannula was placed between these sutures, creating trocar placed at this site or fascial closure performed.
an airtight port site. The second approach involved Mobilization of the left colon, splenic flexure, and resection
placement of a Hasson trocar into the right lateral abdomen, of proximal sigmoid or left colon were done as needed. A
away from the previous incision. This approach allowed transanal, end-to-end anastomosis was performed using a
dissection of adhesions before mobilization of the colostomy circular stapling device. Anastomotic integrity was
from the abdominal wall. Two to three additional ports were confirmed by using insufflations of air and colored saline.
then inserted under direct vision. A 12 mm port was placed Hand-assisted technique was not used in any case.
in the lower right iliac fossa, and a 5 mm port was inserted
RESULTS
into the right upper quadrant. The colostomy site was closed
8
primarily. The skin wound was closed using a skin stapler Kohler et al in their study had 18 patients for laparoscopic
without suturing of the subcutaneous tissues. Intra- reversal of Hartmann’s procedure. They had to convert in
abdominal adhesions were dissected free by sharp dissection. two cases (11%). They found the median operative time of
The descending colon and the splenic flexure were routinely 114 (65 to 180) minutes. Only three patients had immediate
mobilized to ensure a tension-free colorectal anastomosis. postoperative wound infections.Their patients had first
In patients with diverticular disease, any residual distal evacuation 3.3 (3 to 5) days after procedure, and complete
sigmoid colon was resected to the level of the rectosigmoid oral nutrition was started 3.6 (3 to 5) days after operation.
junction using a laparoscopic linear stapler. The steep Hospiatal stay was 7.5 (5 to 12) days. Duration of
Trendelenburg position with a tilt to the right was useful postoperative hospital stay was 7.5 (5 to 12) days. Clinically
significant anastomotic stricture which needed endoscopic
for keeping the small bowel out of the pelvis. Identification
dilatation was seen only in one patient.
of the rectal stump and its mobilization might be facilitated
Holland JC et al 9 published their experience of
by the transanally inserted circular stapler or Hegar dilator.
laparoscopic reversal of Hartmann’s procedure. They had
The transanal end-to-end anastomosis was performed using
succes of reversal in 3 of 4 cases.
a circular stapling device. In this study, all surgeries were 10
Michael J Rosen et al. analysed the results of twenty-
performed by six experienced attending surgeons, each of
two laparoscopic reversal of Hartmann’s procedure (all but
whom had performed more than 20 laparoscopic colorectal
one with left colon colectomies, the reminder right
procedures and extensive noncolorectal laparoscopic
colectomy). They had a sucess rate of 91% (20 cases)
procedures. Hand-assisted laparoscopic surgery was not
with laparoscopic approach. There were 2 conversions to
used for Hartmann’s reversal. open (9%) secondary to dense adhesions around the rectal
7
In the study of H Mazeh et al, they placed pneumatic
stump. The mean time to closure of the colostomy and the
compression boots in all cases, and gave intravenous
mean operative time were 168 days (range 69 to 385 days)
antibiotics approximately 30 minutes preoperatively. A
158 minutes (range 84 to 356 minutes), respectively. Blood
urinary catheter was routinely inserted and patients were
loss was estimated as averaged 114 ml (range 30 to 250
placed in either split-legged or modified lithotomy position. ml). Hospital stay was 4.2 days (range 2 to 6 days). 3.5
Video monitors were placed on the left side of the patient, (range 2 to 5 days) days after the operation bowel function
with the surgeon and assistant standing on the right. Initial returned. Three patients (14%) developed postoperative
port insertion was accomplished by the open Hasson wound infections. Anastomotic leaks and amortality were
technique in the right lateral abdomen. Two to three not seen. A small hernia at a colostomy site was the only
additional ports were used in the upper abdomen and right long-term complication in a mean 14.7 months follow-up.

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