Laparoscopic Colostomy Reversal

Floriano Marchetti

Abdullah Al Haddad

In 1923, Henry Hartmann introduced the concept of colonic resection and diversion for the treatment of cancers of the distal colon (1). Since that time, this operation has been employed to treat a variety of conditions, mainly of the left colon such as complicated diverticulitis with peritonitis, trauma, obstructing or perforated neoplasms of the left colon or rectum, as well as volvulus or ischemia.

While this procedure has proven effective in reducing mortality in such conditions, the reversal of the end colostomy remains a major surgical procedure associated with significant surgical morbidity up to 50–60%, and mortality as high as 5–10% (2,3,4,5).

Furthermore, this operation is burdened by a usually lengthy hospital stay and prolonged convalescence with significant socioeconomical cost.

Once laparoscopy was introduced to colon and rectal surgery, it was only natural to try to use a minimally invasive approach also for this operation with the goal of reducing morbidity, mortality, and especially hospital stay and convalescence.

In fact, early results were encouraging. In one of the earliest reports of laparoscopic colostomy reversal, Sosa et al. found that laparoscopic-assisted Hartmann’s reversal results in comparable morbidity, but may be associated with shorter hospital stay when compared to laparotomy (6).

Since then, laparoscopic colostomy reversal has been evaluated in many studies, which have indicated this approach to be safe and have shown results not only comparable to the open technique, but also, in some cases, superior, particularly in terms of time to recovery (7). Rosen et al. in 2006 reported the advantage of laparoscopic Hartmann’s reversal in the way of a shorter hospitalization and shorter time to bowel function (4).

Many authors have reported the advantages of laparoscopic colostomy reversal in terms of lower morbidity. A recent meta-analysis of 12 studies (8) comparing open (OHR) versus laparoscopic Hartmann reversal (LHR) found the following in the LHR group:

Overall morbidity was lower (mean 12.2% LHR vs. 20.3% OHR). Complications included, wound infection (10.8% vs. 14.2%), anastomotic leakage (1.2% vs. 5.1%), and cardiopulmonary complications (3.6% vs. 6.9%).
Length of hospital was shorter (mean 6.9, range 3–11 vs. 10.7 days, range 3–18 days).
Rate of reoperation was lower (3.6% vs. 6.9%).

However, it should be noted that to date, the available studies are all retrospective series with small numbers of patients (7–71 patients). Therefore, the impact of selection
bias in these results remains to be determined. Furthermore, the statistical power of such studies is objectively limited.

On the other hand, LHR is a technically demanding operation with a steep learning curve and conversion rates are as high as 22% (8). Khaikin et al. reported that laparoscopic colostomy reversal was technically challenging, and required more operative time than did open technique (9).

However, despite these limitations, in the hands of experienced laparoscopic surgeons, laparoscopic HR appears safe and associated with a reasonably low conversion rate. Furthermore, it is possible that newer prospective studies will confirm the relatively low morbidity rate, shorter hospital stay, and earlier return to bowel function. In fact, with the expansion and further development of minimally invasive surgery, morbidity and conversion rates may be reduced further. The advantage of smaller incisions, decreased postoperative pain, shorter recovery time, and early return to normal activity have been well described (10,11,12,13,14).

Indications/Contraindications

Depending on the original surgical indication for the stoma and if the disease process has been resolved, the stoma can be reversed.

Indications

All Hartmann’s resections conducted on the left colon are amenable to a laparoscopic reversal attempt. Complicated diverticulitis remains the most frequent indication to a Hartmann procedure, followed by obstructed or perforated left-sided colon cancer. Trauma, volvulus, and ischemia are less frequent indications.

A laparoscopic approach may also be attempted for patients with long Hartmann’s pouches such as after segmental transverse colectomies or right colectomies with end ileostomies.

It is possible to speculate that patients who have undergone Hartmann operations performed laparoscopically are the ideal candidates for subsequent laparoscopic HR. However, most colorectal surgeons will have to manage patients who underwent open resections and were possibly operated in emergency by other surgeons. If the patient was operated elsewhere or by another surgeon, the operative note should be reviewed.

Use of adhesion barriers: it is possible that such patients will present with less adhesions and, therefore, be better candidates for laparoscopic reversal. Although the real advantages remain controversial the use of such materials has been shown to be beneficial in decreasing postoperative adhesion formation.
The presence of markers on the stapled end of the rectum: the identification of the rectal stump can be challenging. The presence of nonabsorbable suture near the staple line aids in the identification of the rectum. In several series, the inability to identify the rectal stump was one of the most frequent reasons for conversion (4,6,9,15,16). In one series, this was the reason for seven of the eight conversions (7).
The length of rectum or recto-sigmoid stump: a longer stump is usually more promptly identified both at laparoscopy and at laparotomy.
The presence of an intact superior rectal artery may help to prevent the recoil of the rectum in the pelvis.
The presence of the uterus in female patients: the rectum may retract behind the uterus and form with it dense adhesions, which will render the dissection more complicated.

Contraindications

Contraindications of stoma reversal include the following:

Patient preference
Unresolved disease process such as carcinomatosis, persistent inflammation, or ischemia
Incontinence or expectation of incontinence
Distal obstruction
The presence of medical conditions and comorbidities, which may also be contraindications to open surgery.

Contraindications to Laparoscopic Hartmann’s Reversal

Technically unfeasible cases such as abdomens with extensive adhesions, or in presence of extensive radiation changes.
Hostile anatomy: the rectal stump or the ureter is not identified with certainty.

Preoperative Planning

Since most of these patients underwent emergency surgery without any preoperative screening, most surgeons prefer to evaluate the colon prior to the colostomy reversal by either colonoscopy or barium enema. In our practice, if a patient is 50 or older, or if he/she has increased risk factors for colorectal cancer, the preferred option is a colonoscopy through the stoma and a flexible sigmoidoscopy of the rectal stump. We also obtain a contrast study with water-soluble contrast to assess two important parameters such as the length and the shape of the rectal stump and the level of the splenic flexure. Younger patients without risk factors for colorectal cancer may undergo only the contrast study with hydro-soluble contrast.

If the index procedure was done for cancer, a complete staging workup should be done to assess recurrent or metastatic cancer. Computed tomography as well as a carcinoembryonic antigen (CEA) would serve well for this. PET/CT scan should be reserved when CT scan findings are unclear.

Patients are instructed to fast for the night prior to surgery. The issue of mechanical bowel preparation remains controversial. Multiple reports have now questioned the benefits of such practice. A recent Cochrane database review of 13 randomized studies involving 4,777 patients concluded that there is no statistically significant evidence to prove that patients benefit from bowel preparation (17). However, our preference is to perform a mechanical bowel preparation the day before surgery and two phosphate enemas on the morning of surgery. The rationale is to allow an easier manipulation of the bowel during the laparoscopic handling of the colon, which could be rendered quite difficult in the presence of varying amounts of hard stool. In addition, the presence of stool in the rectal stump would be a problem when an end-to-end or a side-to-end colorectal anastomosis is performed with the circular stapler or the anvil advanced through the rectum. Therefore, two phosphate enemas of the rectal stump should be given to the patient prior to surgery, particularly if no endoscopic examination of the stump has been performed prior to surgery. Furthermore, all our patients undergoing a colorectal anastomosis with a circular stapler introduced per rectum also undergo a rectal lavage at the time of surgery, using a large bore Pezzer drain, saline, and Betadine.

Intravenous antibiotics should be given within 1 hour of the incision and oral antibiotics preparation is not often used. However, all our patients receive oral Metronidazole and Neomycin the day prior to the surgery.

Surgery