Laparoscopic Reversal of the Hartmann Procedure

Chapter 24 Laparoscopic Reversal of the Hartmann Procedure



Linda P. Zhang, Scott Q. Nguyen, Celia M. Divino


The videos associated with this chapter are listed in the Video Contents and can be found on the accompanying DVDs and on Expertconsult.com.image


The Hartmann procedure was first performed by Henri Hartmann in 1921 for rectosigmoid cancer. He reported two patients with obstructing sigmoid carcinoma whom he treated with proximal colostomy, sigmoid resection, and closure of the rectal stump using an abdominal approach. The rationale for this procedure was a 38% mortality rate in patients undergoing an abdominoperineal resection for colorectal cancer during this period. Since that time, the Hartmann procedure has been used to treat various left-sided colonic diseases, such as perforated or obstructed tumors, ischemic colitis, traumatic colonic perforations, volvulus of the sigmoid colon, radiation injury, and complicated diverticular disease—the latter being the most common indication. The Hartmann procedure generally is considered the gold standard of treatment for benign sigmoid perforation. The procedure provides proximal diversion of the fecal stream and resection of the diseased portion of colon, but with no risk for anastomotic leak. It also allows time for the inflammation and intra-abdominal adhesions to improve or resolve before elective restoration of bowel continuity, which typically involves a several month wait.


Minimally invasive approaches have been applied to colostomy closure after a Hartmann procedure (i.e., Hartmann reversal) in an effort to decrease the morbidity and mortality associated with open colostomy closure. Early experiences with laparoscopically assisted Hartmann reversal were reported by Gorey and colleagues in 1993. The technical demands of this procedure have somewhat limited the widespread application of the laparoscopic Hartmann reversal. In addition, there really has not been a consensus on the optimal technique in performing a laparoscopic reversal. In this chapter, we describe our own technique and experience with laparoscopic reversal of the Hartmann procedure.



Operative indications


There are risks associated with reversal of a Hartmann procedure. Morbidity rates for open Hartmann reversal can range from 30% to 40%, with anastomotic leak rates ranging from 0% to 15%. The perioperative mortality rate can be as high as 10%. Technical difficulty with dissection of the rectal stump secondary to dense adhesions, and the occasional need to perform a low anastomosis, can increase the risk for anastomotic failure. The use of various stapling devices since then has facilitated the performance of restorative procedures, particularly in the patient with a short rectal stump.


Studies have shown that patients with stomas score significantly lower on quality-of-life indexes than patients without stomas. Various medical and lifestyle issues associated with a stoma include skin rash, appliance leak, sexual dysfunction, parastomal hernia, and psychological distress. Even so, 40% to 45% of patients with a Hartmann procedure will never undergo reversal, usually because of medical comorbidity or social issues. Compared with open Hartmann reversal, the laparoscopic procedure offers the advantages of a smaller incision, shorter hospital stay, and less blood loss. These advantages may increase the candidate pool for colostomy closure, particularly in those who have multiple comorbidities.


The timing of a Hartmann reversal has been debated. In general, the patient who required a Hartmann procedure was a relatively sick individual whom the surgeon had deemed to have an unacceptable risk for primary anastomosis. It had been advocated to wait for about 6 months to allow patients to recuperate from the initial surgery and also to allow for the local inflammation and adhesions to diminish. More recent studies have suggested that operative difficulty appears to decrease after a waiting period as short as 15 weeks.


The laparoscopic approach can be limited by dense intra-abdominal adhesions, which can increase the difficulty of both abdominal access and mobilization of the rectal stump. This is especially true in the patient who had gross peritonitis from complicated diverticulitis. The open conversion rate for laparoscopic Hartmann reversal has ranged from 9% to 25%. In light of this, some surgeons have advocated hand-assisted laparoscopy for difficult cases to facilitate the dissection. Although there are no strict contraindications to performing laparoscopic Hartmann reversal, it is advisable that this procedure be performed by an experienced laparoscopic surgeon. It should be stressed that open conversion of a difficult laparoscopic Hartmann reversal is an acceptable outcome; such a conversion is not a complication in and of itself.



Preoperative evaluation, testing, and preparation


An evaluation of the patient’s cardiac, pulmonary, and nutritional assessment should be performed. The patient with a poor nutritional status (e.g., preoperative serum albumin level < 3 g/dL) is at an increased risk for postoperative complications, such as anastomotic leak or fascial dehiscence. Because reversal of a Hartmann procedure is an elective operation, the patient with poor nutritional status should have the reversal postponed until the nutritional status can be optimized. Similarly, the patient with unstable cardiopulmonary disease should wait until his or her medical condition improves so that the procedure can be tolerated.


For the patient with diverticular disease, a barium enema can be performed to evaluate for any residual diverticular disease in the rectal stump. A colonoscopy through the stoma is performed to evaluate the proximal colon for any remaining diverticular disease or colon cancer. The patient who had a Hartmann procedure for colon cancer will require the standard preoperative malignancy evaluation, including a colonoscopy and a CT of the chest, abdomen, and pelvis. Neoadjuvant chemotherapy and radiation may be necessary depending on the results of the cancer staging.


It has been debatable whether preoperative mechanical bowel preparation of the remaining colon is necessary. Depending on the surgeon’s preference, an oral cathartic solution or an ostomy enema can be administered to empty the colostomy proximally. Most surgeons have used an enema to evacuate the rectal stump. Patients should receive perioperative intravenous antibiotics, pneumatic sequential compression devices, and a Foley catheter. An orogastric tube may be necessary for better visualization of the upper abdomen and splenic flexure. Depending on the severity of the primary disease process and the degree of difficulty at the index procedure, ureteral stents can be placed to facilitate identification of the ureters.

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Jul 20, 2016 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Laparoscopic Reversal of the Hartmann Procedure

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