After general endotracheal anesthesia is induced and a bladder catheter is placed, the patient will be placed in lithotomy position using Allen stirrups (Allen Medical Systems; Hill-Rom Holdings, Inc., Batesville, IN) ensuring easy access to the anus. (Pitfall: a patient not properly positioned at the edge of the table will preclude access to the anus when introducing the circular stapler for the anastomosis.) Thus, it is crucial that the patient is well secured to the bed, not only for obvious safety reasons but also because the steep Trendelenburg position often necessary for laparoscopic cases may lead to major cephalad shifting of the body. The consequence is that the buttocks may shift over the table, and, therefore, render transanal access with the circular stapler quite difficult.

Both arms should be tucked along the sides of the patient to ensure that adequate padding and protection are provided. In the rare cases that the anesthesiologists require access to one arm, the left arm can be left out given the need for tilting the bed toward the right side when the stoma is on the left side.

Next, as discussed, the patient needs to be secured to the bed, given the extreme positions the bed will assume during the operation (steep Trendelenburg and tilt). This maneuver is usually accomplished with a beanbag or alternatively with multiple strips of 3” cloth adhesive tape to strap the patient to the bed. The skin of the chest and breasts in female patients will have to be protected with towels and pads as necessary. Particular care needs to be taken to pad the arms to try to avoid compression of the radial nerve with subsequent risks of wrist drop. The patient is then prepped and draped in sterile manner. Placement of bilateral ureteric catheters can be very helpful.

For the typical Hartmann reversal, where the colostomy is usually on the left side, the operation is conducted with the surgeon and assistant standing on the right of the patient with the monitor on the left side. The nurse stands in between the legs of the patient or on the right side of the patient as well.

The initial port placement depends on patient factors and surgeon’s preferences. As suggested by Rosen et al., in the presence of a midline scar extending to the epigastrium the first port should be placed at the level of the colostomy, which should therefore first be taken down. Alternatively, a Hasson open technique could be used to place the initial port in the right upper quadrant. In the presence of a lower midline incision, a 5- or 10-mm port could be placed above the upper extent of the midline incision or in the right upper quadrant (Fig. 53-1).

In our practice, the operation starts usually by circumferentially mobilizing the stoma with preservation of the mesentery. The colon is then trimmed to healthy tissue.

A purse string device or a purse string suture is used before the insertion of the anvil of the end-to-end anastomosis (EEA) stapling device in the colon. The purse string is then closed and tied and the colon then dropped back into the abdomen. A 12-mm trocar is inserted through the colostomy site for pneumoperitoneum and secured at the fascia either by running a purse string on the fascia and the rectus muscle or by placing figure-of-eight sutures on the fascia to ensure a good seal around the port.

However, over the past few years, it has become our practice to use at this point the GelSeal cap and the Alexis Wound Retractor (GelPort Laparoscopic System—Applied Medical Corp., Rancho Santa Margarita, CA) through the colostomy site. This device allows for easy access to the abdominal cavity, perfect maintenance of the pneumoperitoneum and placement of additional ports if needed. Finally, the possibility of using it as a hand-assist device provides further advantages. However, use of the GelPort as a hand-assist device will require, as we discuss in section “Hand-assisted Hartmann’s Reversal,” of this chapter, the extension of the incision for at least 7 cm.

Before inserting the remaining ports, the abdominal cavity should be carefully inspected by placing the camera through this port. The pneumoperitoneum helps separate the intra-abdominal structures and place the adhesions under tension allowing for visualization of the right side of the abdomen. If the visualization across the midline of the abdomen is satisfactory, then we proceed to place the other ports in the right upper quadrant and in the right iliac fossa. Obviously, the presence, the extension, and the locations of the adhesions with the anterior abdominal wall will affect the positioning of the other trocars. The camera can be carefully used to take down some of these adhesions to free space for the port insertion. However, in case adequate visualization is obstructed by the adhesions, one
alternative is to place one or more ports on the left side where it is safe, to facilitate the lysis of the adhesions with the anterior abdominal wall. Additional ports can also be placed through the GelSeal cap if the GelPort is used.

This step is followed by the placement of ports on the right side as previously described. If this is not feasible, we place a port using an open technique in the right upper quadrant. The camera can then be moved to this port and a second port placed in the right lower quadrant. It is possible to use 5-mm ports in all cases. The use of bladeless ports is mandatory, particularly in this procedure.

Ideally, the camera port should be placed in the umbilical area to provide a good view of the entire left colon and pelvis. A 5- or a 10-mm camera is used according to the surgeon preference. We normally use a 0-degree camera, although with a rectum buried in the pelvis a 30-degree camera may be helpful.

The patient is then positioned in Trendelenburg position and tilted to the right so that the left side of the patient is up.

Once all ports are in place, the first undertaking is to address the adhesions involving the small bowel, the omentum, and the descending colon. Therefore, methodical careful dissection is initiated.

Once this maneuver has been completed, there is no need to continue to divide any other adhesions as long as they will not interfere with the planned surgery.

At this point, the attention is directed toward the pelvis to identify the rectal stump. This maneuver can be quite difficult, especially if no “identifying” sutures were left on the staple line and/or if the superior rectal vessels were divided. Therefore, if no sutures are found, and the rectum is not clearly identifiable, the insertion of dilators, stapling devices, rigid or flexible sigmoidoscopy, or insufflation of air using a syringe is strongly recommended. In these cases, a 25-mm circular stapler sizer or a similar size Hegar dilator can be used.

However, our preference is to perform a rigid proctoscopy. In fact, particularly if the index surgery was done >6 months before, the rectum becomes more friable and rigid. The natural bends of the rectum might become more acute and fixed because of some pelvic fibrosis and, therefore, more difficult to negotiate blindly with a rigid instrument. Therefore, introducing a sizer or a dilator or even the stapler itself may result in a partial or full-thickness injury to the rectal stump. This problem is especially challenging when the rectal stump is long and includes part of the sigmoid colon.

The rectal stump is then dissected from the surrounding adhesions as needed to straighten its sharp and fixed turns in the pelvis. Particular care is needed to identify and protect the left ureter and the iliac vessels.

A frequent occurrence is the presence of extensive adhesions with the posterior wall of the bladder. It is usually necessary to fill the bladder with 250-300 ml of saline to better visualize the bladder and possibly find a safe plane for dissection. In women, the rectum may be found retracted and contracted in the pelvis behind the uterus. Usually, the introduction of rectal dilators as described will help the visualization.

When the original surgery was done for diverticulitis, any remnant of sigmoid colon found should be dissected and removed using an endoscopic linear cutting stapler, making sure that the anastomosis is to the rectum and not to the remnant sigmoid colon. The 12-mm port at the colostomy site can then be used to introduce the endoscopic GIA to transect the colon at the rectosigmoid junction. Alternatively, the 5-mm port on the right iliac fossa can be switched to a 12-mm port. Passing the endoscopic stapler from the right lower quadrant port may be simpler and straightforward. Therefore, many surgeons prefer to start the case with a 12-mm port in this position. The GelCap can be removed and the specimen is easily extracted through the wound retractor. The GelCap is then repositioned and the pneumoperitoneum reestablished quickly.

At this point, the anvil of the circular stapler is grasped and the descending colon is lowered down to the pelvis. If there is tension or the anvil does not reach the top of the rectal stump, the descending colon has to be mobilized more proximally. The splenic flexure is mobilized only if a tension-free colorectal anastomosis cannot be achieved.

The circular stapler is then very carefully advanced through the rectum. As stated, it may be very difficult to advance the stapler in a rectum that has become more rigid and tortuous and at the same
time more fragile after months of fecal diversion. One should avoid, at all costs, forcing the stapler through this resistance. Although an intraperitoneal tear of the rectum could be repaired, an extraperitoneal injury to the rectum could have disastrous consequences especially if overlooked at the time of surgery.

As stated, it is beneficial to free the rectum of secondary adhesions with the pelvic walls that formed as a consequence of the previous inflammation and surgery. At times, this helps to the point that no further maneuver is required to advance the stapler. More frequently, however, the use of progressive sizers or Hegar dilators is necessary. Once again, we recommend the use of a rigid proctoscope before using any of these tools that will be pushed blindly against the rectal walls. Mobilization of the rectum to ensure a straight stapler insertion to the most proximal rectum is the safest technique.

An end-to-end colorectal anastomosis is then completed under direct vision by deploying the spike of the stapler through the top of the rectal stump. It is very important to deploy the spike completely through the rectum to ensure a watertight closure of the stapler. Furthermore, it is important to ensure that the spike is not accidentally pulled back into the rectum, because this problem could lead to two separate openings on the rectal top, thus increasing the chances of a leak, if one of the openings falls outside the anastomosis area.

The anvil in the descending colon is held using an endoscopic Babcock. (Tip: Some surgeons place the camera in the right iliac fossa port to facilitate the connection of the anvil with the spike.) After securing the anvil to the spike, and before closing the stapler, one should ensure that the colon is not rotated. The stapler is then closed under direct vision ensuring that surrounding structures such as ureter, bladder, gonadal vessels, hypogastric nerves, and, in some cases, the vagina are not accidentally grasped and incorporated into the anastomosis. Indocyanine green fluorescence perfusion assessment can be used before stapler firing.