and Robotic Hartmann’s Reversal: Strategies to Avoid Complications

Fig. 21.1

Fecal peritonitis

The morbidity associated with a traditional open Hartmann’s reversal has led many surgeons to explore minimally invasive options. However, there are significant inherent challenges to this approach, generally related to the fact that the initial surgery may have been performed via an open approach. These patients may present with significant intra-abdominal contamination, resulting in dense intra-abdominal adhesions. Patients’ comorbid conditions may also make a minimally invasive approach challenging. However, in well-selected patients, a minimally invasive approach can be performed safely with low perioperative morbidity and may help increase stoma reversal rates.

In this chapter, we will discuss indications and contraindications of minimally invasive Hartmann’s reversal and key aspects of preoperative evaluation and describe general steps of a minimally invasive technique.

Indications and Contraindications

A minimally invasive Hartmann’s reversal may be considered in any patient undergoing the procedure. Ideal candidates are those whose initial operation was performed through either a limited laparotomy incision (i.e., a lower midline below the umbilicus) (Fig. 21.2) or a hybrid laparoscopic/open resection (i.e., laparoscopic hand-assisted via Pfannenstiel incision), although any patient considered suitable for laparoscopy may be a candidate [6].

../images/465809_1_En_21_Chapter/465809_1_En_21_Fig2_HTML.jpg — Fig. 21.2

Straightforward abdominal access

While there are no absolute contraindications to minimally invasive Hartmann’s reversal, two factors that are most likely to limit the successful completion of a minimally invasive approach are intra-abdominal adhesions and patient comorbidity . Obesity has been identified as an independent risk factor for complications in patients undergoing Hartmann’s reversal [7]. Patients with a BMI ≥ 30 kg/m² are at increased risk of morbidity, surgical site infection, and need for diverting ileostomy creation. While minimally invasive surgery may help ameliorate some of these risks, the technical challenges faced in obese patients can still make minimally invasive Hartmann’s reversal difficult. Surgeons often recommend obese patients to lose weight prior to elective surgery. However, many patients find this difficult. Consultation with a dietician, weight loss specialist, or bariatric surgery program should be considered preoperatively.

Patients who suffered medial sigmoid perforations resulting in a large amount of purulent or feculent peritonitis at the index operation are more likely to have extensive lower abdominal or pelvic adhesions, making a minimally invasive approach challenging. Similarly, patients with long midline laparotomy incisions extending well above and below the umbilicus may have limited domain for safe laparoscopic entry into the abdomen (Fig. 21.3). Patients who have had multiple open surgeries in the past may experience difficulties with safe laparoscopic abdominal entry.

../images/465809_1_En_21_Chapter/465809_1_En_21_Fig3_HTML.jpg — Fig. 21.3

Difficult abdominal access

Laparoscopic Hartmann’s reversal can require extended periods of time in steep Trendelenburg position, particularly if extensive pelvic dissection is required. Patients with significant congestive heart failure, chronic obstructive pulmonary disease, and morbid obesity may not be able to tolerate this positioning, precluding a minimally invasive approach.

Principles and Quality Benchmarks

The key steps to a successful minimally invasive Hartmann’s reversal include the following:

1.

Safe laparoscopic lysis of intra-abdominal adhesions
2.

Takedown of the colostomy without injuring the colon
3.

Sufficient mobilization of the splenic flexure and descending colon (often needed)
4.

Identification, mobilization, and preparation of the rectal stump for creation of the anastomosis
5.

Performance of a tension-free colorectal anastomosis.

Preoperative Planning, Patient Workup, and Optimization (Box 21.1)

Most Hartmann’s procedures are performed emergently with little or no preoperative planning. In contrast, a Hartmann’s reversal is an elective procedure. Careful and thoughtful preoperative assessment and planning is essential. Often, this is an excellent opportunity to complete aspects of the preoperative workup that ideally would have been performed prior to the original sigmoid colectomy. For example, recent colonoscopy reports should be reviewed. If one was not recently performed, this should be considered. Thorough cardiopulmonary assessments should be performed as part of the preoperative workup.

Box 21.1 Preoperative Checklist Prior to Hartmann’s Reversal

[ ] Review operative report

[ ] Review pathology

[ ] Colonoscopy

[ ] Water-soluble enema of rectal stump

[ ] Physical exam (assess sphincter function)

[ ] Medical/cardiac clearance

[ ] Ureteral stents

Review Operative Report

Whenever possible, the original operative report of the Hartmann’s procedure should be carefully reviewed. Details such as the degree of abdominal contamination, bleeding, and any pre-existing adhesive disease may predict how hostile the abdomen will be during colostomy closure. It is also important to note where the distal margin of resection is and which, in any, major mesenteric vessels were ligated. Additional information such as whether suture tags were left on the end of rectal stump may also be helpful.

Review Pathology Report

The pathology report from the original surgery should be reviewed to ensure that there was no incidental cancer diagnosis or evidence of inflammatory bowel disease at the original operation.

Colonoscopy (Colon and Rectal Stump)

If the patient has not had a recent colonoscopy , this should be performed prior to Hartmann’s closure. This should include evaluation of the remaining colon through the colostomy as well as the rectal stump. If the patient is up to date with colonoscopy (i.e., within the past year), then at a minimum a flexible sigmoidoscopy of the rectal stump should be performed to assess the health of the stump and to ensure that it is not structured or obstructed by inspissated mucus or stool. For patients in whom the indication for Hartmann’s procedure was colorectal cancer, endoscopy should be performed to rule out persistent or recurrent cancer in the rectal stump. The length of the rectal stump is important to know prior to attempt at colostomy closure, as a short stump may impart poorer functional outcomes after closure. Distensibility of the rectum, which may be poor due to a fibrosing pelvic process from sepsis, may also portend poorer functional outcomes.

A water-soluble contrast enema of the rectal stump is also helpful to ensure that the staple line at the top of the stump is intact and that there are no sinus tracts to adjacent organs.

Assessment of Sphincter Function

A detailed history can reveal if the patient had any degree of fecal incontinence prior to them developing perforated diverticulitis. A digital rectal exam should be performed to assess the patient’s sphincter function prior to Hartmann’s reversal. If the patient has poor sphincter function, then he or she should be counseled on the expected functional outcomes of reversal, and the option of keeping a permanent colostomy should be discussed. Anorectal manometry may also be considered, although not necessary, if there are any concerns about sphincter function. Patients with long-standing fecal diversion may have impaired function, and this should be clearly discussed with the patient prior to attempts at reversal.

Cross-Sectional Imaging

Although not essential, review of any available cross-sectional imaging (prior to or after the original sigmoid colectomy) should be performed. This may help define relevant anatomy, as well as identify potential anatomic issues that may arise at the time of colostomy reversal. For example, large uterine fibroids may limit access to the pelvis for rectal dissection and anastomosis. Tracing the course of the ureters may also be possible, allowing for anticipation of potential areas of injury during the surgery. This may also reveal parastomal and/or midline hernias that can be addressed simultaneously with the takedown operation.

Ureteral Stents

Bilateral ureteral stents should be considered to assist with intraoperative identification of the ureters and help ensure that they are protected. Patients with Hinchey III or IV diverticulitis often have dense fibrosis in the lower abdomen and pelvis, making intraoperative identification of the ureters challenging.

Operative Setup

A variety of minimally invasive and hybrid techniques are possible based on equipment availability and surgeon preference. As for all colorectal surgery procedures, straight laparoscopic, single-incision laparoscopic, laparoscopic hand-assisted, and robotic-assisted techniques have all been described. There is no single approach that will work for everyone, so the surgeon should remain adaptable and able to alter the surgical approach based on the intraoperative findings.

Regardless of which minimally invasive technique is chosen, there are a few common themes in preparing for the procedure. The patient should be positioned on the operating table with access to the anus to allow for passage of a transanal stapling device or intraoperative endoscopy. Our preference is supine on a split-leg table, but modified lithotomy position is also acceptable (Figs. 21.4 and 21.5). Both arms should be tucked, if possible, to allow both the surgeon and the first assistant to stand cephalad on either side of the patient facing toward the pelvis. The patient should lie on a nonskid mat (our preference is either a bean bag or foam mat), and a shoulder strap should be utilized to secure the patient to the operating table to prevent sliding with steep positioning.

../images/465809_1_En_21_Chapter/465809_1_En_21_Fig4_HTML.jpg — Fig. 21.4

Lithotomy position

../images/465809_1_En_21_Chapter/465809_1_En_21_Fig5_HTML.jpg — Fig. 21.5

Split-leg position

Robotic-assisted Hartmann’s reversal should be reserved for surgeons both trained and comfortable using currently available robotic platforms. The DaVinci Si® or Xi® platforms (Intuitive Surgical, Sunnyvale, CA, USA) are the most widely available. Port placement strategies in general follow conventions unique for each platform. For the DaVinci Si, placing the cannulae in the right abdomen at least 8 cm apart in a “C” configuration is most helpful. One can take down the end colostomy at the beginning of the procedure, or once it is determined intraoperatively, that safe colostomy reversal is possible. For the DaVinci Xi system, the authors find it helpful to place the cannulae in a nearly straight vertical line along the right abdomen. The arm docked closest to the pelvis should be able to accommodate an endoscopic stapler, should division of the rectal stump be necessary. The Xi platform has the added advantage of intraoperative table motion, which can aid in operating in more than one abdominal quadrant comfortably (Fig. 21.6).

../images/465809_1_En_21_Chapter/465809_1_En_21_Fig6_HTML.jpg — Fig. 21.6

Xi robotic port placement

For both Si and Xi platforms, intra-abdominal adhesions are typically assessed and managed laparoscopically before the robot is docked. Availability of laparoscopic scissors with monopolar energy is helpful during this portion of the procedure and adds minimal additional cost to the case. Once the robotic trocars are safely inserted, the patient is positioned in steep Trendelenburg position with right side down. The small bowel and omentum are lifted out of the pelvis into the right upper quadrant. The authors find it helpful to do this laparoscopically prior to docking the robot. The table is then lowered as low as it can go, and the robot is docked from the patient’s left side. If “targeting” is used on the Xi platform to help align the robotic arms, the authors prefer to target the left pelvic inlet, as this typically allows for comfortable reach from the splenic flexure to the pelvis. If the colon proximal to the splenic flexure requires mobilization, the surgeon should be prepared to undock and re-dock as necessary. This can be easily accomplished with the Xi by simply rotating the boom and retargeting. However, with the Si platform, the patient cart may need to be moved to the patient’s right side. This can be quite burdensome and is often an indication for conversion to a laparoscopic or open approach. The bedside assistant is positioned on the patient’s right side. A sitting stool is provided so that the assistant can comfortably access the ports while staying below the level of the moving robotic arms.

Single-incision laparoscopic surgery (SILS) -assisted Hartmann’s reversal can also be considered, if the surgeon is appropriately trained and comfortable. Those who perform SILS procedures often gain abdominal access by first taking down the end colostomy and placing the SILS port at this location. Proponents advocating for this technique report the advantage of avoiding the adhesions often present in the midline from prior laparotomy. The use of an angled or flexible-tip laparoscope can be very helpful to overcome the difficulty encountered with the use of straight laparoscopic instruments and their close proximity. As the vast majority of surgeons do not perform SILS procedures , there are no reliable data examining SILS Hartmann’s reversal.

Operative Technique: Surgical Steps

There are many nuances of technique that will vary depending on surgeon preference and the minimally invasive approach that is selected. Here, we will describe the general steps of any minimally invasive Hartmann’s resection. These basic steps can be performed using any minimally invasive technique.

The first challenge is to safely gain entry into the peritoneal cavity and establish pneumoperitoneum. This can be quite challenging depending on the degree of intra-abdominal adhesions and is a common reason for early conversion. In general, we allow the patients’ previous incision to guide our site of abdominal entry. We try to avoid entering the abdomen directly through a previous incision, as one is likely to encounter dense adhesions immediately underneath. If the patient has a lower midline or Pfannenstiel scar, then a supraumbilical direct cutdown (“Hasson”) technique is a good option. If their scar extends above and below the umbilicus, then an off-midline entry site may be better suited. For off-midline entry, our preference is to use a Veress needle in the left upper quadrant at Palmer’s point (two fingers below the costal margin at the genu of the rib) (Fig. 21.7). Once pneumoperitoneum has been achieved, a 5 mm laparoscopic camera is advanced through the abdominal wall inside a clear 5 mm trocar so that the surgeon can observe each layer of the abdominal wall as the trocar passes through it until the abdominal cavity is safely entered.