Laparoscopic Reversal of Hartmann’s Procedure
KEY STEPS
1. Peristomal incision for stoma mobilization; 0 polypropylene purse-string suture and insertion of a circular stapler anvil into the distal end of the colon.
2. Insertion of ports: 12-mm open technique through stoma site after mobilization of stoma; 10-mm at umbilicus for camera; 5-mm right iliac fossa; 5-mm right upper quadrant; 5-mm left upper quadrant if necessary.
3. Patient is placed in the Trendelenburg position (slight rotation to right may be required to aid visualization of sacral promontory).
4. Laparoscopic lysis of adhesions, followed by assessment, and the small bowel and omentum moved toward the right upper quadrant. Further adhesiolysis is needed to identify rectal stump.
5. Lateral mobilization of the left colon and splenic flexure to allow tension-free reach of the colon to the rectum. Left ureter identified.
6. Medial-to-lateral mobilization of the descending colon off Gerota’s fascia.
7. Rectal mobilization, and revision of stump if required (only necessary if the distal sigmoid is still present or stapler cannot be advanced transanally).
8. Dissection in the presacral plane to free proximal rectum with preservation of hypogastric nerves (no violation of fascia propria of rectum).
9. Circular stapled anastomosis completed and leak test performed.
10. Closure of all trocar sites >5 mm.
ADDITIONAL ADVICE
1. Make the peristomal incision as close to the bowel as possible to enter the correct dissection plane. Once free circumferentially in the abdomen, trim the colostomy, insert the anvil, and use figure-of-eight sutures to close the fascia, permitting a port to be inserted between two stitches.
2. Gradually and carefully lyse adhesion adequate to complete the procedure. Additional ports are inserted under direct vision. Nontraditional port placements may be required.
3. Rectal dissection is only required to a level where advancement of the circular stapler to the end of the rectum is possible. The level of transection must be distal to the true rectosigmoid junction.
PATIENT POSITIONING
The patient is placed supine on the operating table on a bean bag. After induction of general anesthesia and insertion of an orogastric tube and a Foley catheter, the patient’s legs are placed in yellow fin stirrups. The arms are tucked at the patient’s side and the bean bag is aspirated. The abdomen is prepared with antiseptic solution and draped routinely (Chapter 2).
INSTRUMENT POSITIONING
The primary monitor is placed on the left side of the patient at approximately the level of the hip. The secondary monitor is placed on the right side of the patient at the same level and is primarily for the assistant during the early phase of the operation and port insertion (Fig. 27.1). The operating nurse’s instrument table is placed between the patient’s legs. There should be sufficient space to allow the operator to move from either side of the patient to between the patient’s legs if necessary. The primary operating surgeon stands on the right side of the patient with the assistant standing on the patient’s left, and moving to the right side, caudad to the surgeon once ports have been inserted. A 0-degree camera lens is used.
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