Patients are positioned on an electric bed in the modified Lloyd-Davies/lithotomy position. A proctosigmoidoscopy is performed to wash out any retained stool or mucus. After the abdomen is prepped with chloraprep or Betadine, a large sheet of antibiotic-impregnated adhesive drape (Ioban) is placed over the entire abdomen with a folded 4 × 4 gauze over the colostomy site. This will allow for minimal cross contamination to other areas of the abdominal wall. Laparoscopic monitors are placed to the right and left side of the patient. Standard bowel graspers, dissectors, sheers, and energy-based devices should be chosen and used as per surgeon preference during laparoscopic procedures.

There are several approaches to a hand-assisted reversal of a Hartman’s procedure. The most common technique involves the use of the colostomy site as the location of the hand-assist port. The colostomy is dissected away from the mucocutaneous junction, with an incision that extends both medially and laterally for several centimeters around the colostomy. Detaching the colon from the subcutaneous tissue is often a fairly unencumbered dissection because of the high incidence of paracolostomy hernia. Entrance into the abdomen and placement of the hand through the hand-assisted device is also aided by this parastomal hernia and fascial separation. Direct visualization into the abdomen can be performed from the incision and local adhesions can be dealt with effectively, particularly those intimate with the previous midline incision from the initial operation. Once the colostomy has been detached from the abdominal wall and the colon resected to a healthy bowel, the distal end is prepared for anastomosis in standard manner with a purse string stitch and the anvil of a circular stapler (Fig. 54-1). This maneuver will allow the colon to be reduced into the abdominal cavity without contamination. The healthy bowel can just be stapled across and prepared for anastomosis after complete dissection. If the underlying abdominal wall is clear of adhesions, the hand-assist port is placed into the colostomy site incision and pneumoperitoneum is achieved (Fig. 54-2). One to three 5-mm trocars are placed in the right lateral abdomen and suprapubic area. An umbilical port can also be placed to provide a more traditional camera angle. Frequently, the camera will need to be introduced through the hand-assist port to survey the abdomen and to perform initial adhesiolysis. The surgeon can approach the operation from a position in between the legs or on the patient’s right side with the right hand through the hand-assisted device and the left hand using a laparoscopic instrument. The assistant will be positioned between the legs or on the patient’s right side. This orientation will allow for complete descending colon and splenic flexure mobilization with the distal end already prepared. The procedure should be performed as if it were open. The ureter is identified in the retroperitoneum, and the rectal stump is dissected and prepared in standard manner. At times, it may be necessary to remove partial or complete remnant sigmoid colon. This step can usually be achieved if the surgeon stands on the patient’s left-hand side and inserts the left hand through the device to grasp the sigmoid
colon or rectal stump. Additional dissection can be undertaken with the right hand with laparoscopic instruments through the trocars on the right side. The specimen is extracted through the hand port. A standard stapled anastomosis is created with a circular stapler.