Page 11 - World Journal of Laparoscopic Surgery

Laparoscopic Reversal of Hartmann’s Procedure

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M Khaikin et al, studied 27 patients underwent laparos- Results were as follows: A short operative time (69
copic reversal of the Hartmann’s procedure. 17 (63%) of minutes), a conversion rate of 17.9%, wound complications
their patients with a mean age of 58.1(23 to 88) years were in 10.7% and an anastomosic leak in 1 patient (3.6%). On
males and 10 (37%) with a mean age of 62.9 (17 to 80) average the patients were discharged after 8.6 (6 to 17)
years were females. There were 2,13 and 12 patients
postoperative days.
classified for anesthesia risk as ASA 1, 2, 3 respectively. Chouillard E et al 13 compared 44 patients who had
81.5% (22 cases) of the initial surgery was for benign
laparoscopic Hartmann’s reversal with the 44 patients who
indications (19 perforated diverculitis, 1 iatrogenic sigmoid
had open Hartmann’s reversal. Conversion rate in this was
perforation, 1 sigmoidal gun shot wound and 1 colon sigmoid
9.1%. Operative incidents were comparable in both groups.
volvulus) and 18.5% (5 cases) for obstructing sigmoid
carcinoma. Reversal procedures were done 3 to 10 months Operative duration was not significantly shorter in open
after the initial operation. They used the colostomy site as group (195 minute in laparoscopic versus 160 minutes in
the initial port in 21 patients and used Hasson technique in open group). Mortality rate was 2.2 % and 0% in
the 6 remaining cases.Their median operative time and laparoscopic group and open group, respectively. Overall
median follow-up period were 226 (83 to 329) minutes and morbidity rate was 11.4 % and 28.6 % in laparoscopic and
8.5 (2 to 14) months, respectively. Laparoscopical complition open group, respectively (P < 0.05). The mean length of
success rate was 85.2% (23 cases). Extensive adhesions in hospital stay was significantly shorter in laparoscopic group
three patients and rectal perforation during transanal insertion (4.8 days when compared to open group 6.8 days),
of the circular stapler in one patient caused canversion. respectively. An efficiency analysis was performed and
Complications of entorotomy during adhesiolysis and
demonstrated that laparoscopic reversal did not generate a
incomplete stapled anastomosis in two patients were repared
significant additional cost.
succesfully laparoscopically. The median bowel movement 7
Haggi Mazeh et al selected 41 open case of reversal of
and the median hospital stay were 4 (1 to 7) days and
Hartmann’s procedure with the best matched criteria of the
6 (3 to 20) days respectively. In 9 (33%) patients, post-
41 laparoscopic reversal cases to compare the outcomes.
operative complications occured. 5 colostomy-site infection,
Diveticulutis was the most common initial operation
2 acute upper gastrointestinal bleeding, 2 intra-abdominal
indication in both groups. Perforation, volvulus (four
bleeding, 1 pseudomembranous colitis and 1 small bowel
patients), anastomotic leak (three patients), obstructing
obstruction were seen. Three patients had more than one
colorectal carcinoma, ischemic colitis (three patients),
complication. One patient with extensive adhesiolysis
Fournier’s gangrene (two patients), trauma (two patients),
underwent reoperation on postoperative day 2 for intra-
and rectovaginal fistula (one patient) were the other
abdominal bleeding. No anastomotic leaks, ureteral injuries,
indications. Convertion rate was 19.5% (8 patients) in
or intra-abdominal abscesses were recorded,and there was
laparoscopic group due to dense adhesions or failure to
no operative mortality. In one patient late complication of
identify the rectal stump. In three of these cases a stapling
the anastomotic stricture 3 months after surgery,
device that was inserted into the rectum failed to assist in
successfully dilated endoscopically was observed. identification of the rectum. In the other five cases dense
In 2007, Faure JP et al 11 compared the 14 cases of
adhesions were the reason for conversion. There were
laparoscopic reversal of Hartmann’s procedure with 20
significant differences in operative time [193.1 (89 to 460)
cases of open reversal of Hartmann’s procedure. They found
minutes vs 209.2 (57 to 335) minutes], blood loss [166.6
a conversion rate of 14. 28%. Operating time was shorter (50 to 900) ml vs 326.6 (50 to 950) ml], time to bowel
for the laparoscopic group 143 (90 to 240) vs 180 (90 to movement [4.2 (2 to 5) days vs 5.3 (3 to 17) days], time to
350) minutes. Hospital stay length was shorter for the solid diet [4.6 (2 to 9) days vs 5.8 (2 to 10) days] and
laparoscopic group 9.5 (4 to 18) vs 11 (6 to 39) days. Use length of hospital stay [6.5 (3 to 16) days to 8.1 (4 to 22)
of patient-controlled analgesia was not significantly shorter days], in respective to the first values laparoscopic and
in the laparoscopic group 3 (0 to 4) vs 3.5 (0 to 8) times. second values open group. Postoperative morbidity was
Morbidities observed in the laparoscopy group include a 37.8%, most commonly surgical site infection and ileus.
parietal abscess and an anastomotic stenosis without surgical Reoperation for two patients was needed in the open group:
treatment. The open group had 6 complications of 1 One for debridement of a deep surgical site infection, and
anastomotic leak and 5 incisional hernias. another who developed an incarcerated inguinal hernia on
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Carus T Et al in their study succeded to perform 28 of postoperative day 3. Two other patients in this group were
34 reversal of Hartmann’s procedure laparoscopically. admitted to the surgical intensive care unit (SICU) posto-
World Journal of Laparoscopic Surgery, January-April 2010;3(1):7-11 9