Adhesions

Since many Hartmann’s operations are performed to treat distal colonic or rectal perforations, these procedures are often complicated by significant peritoneal contamination leading to peritonitis and abscess formation which in turn result in significant adhesion formation (Fig. 20.2). The fear of hostile adhesions often represents the major deterrent to laparoscopic closure of a colostomy. Thus it is imperative to suction out any residual blood, purulence or fecal material from the peritoneal cavity at time of Hartmann’s creation. Furthermore, copious peritoneal irrigation with warm saline should be undertaken to decrease the burden of peritoneal contamination.

Presence of a Large Ventral Wall Hernia

Given the contaminated nature of these cases, many Hartmann’s creations are associated with incisional complications ultimately leading to incisional hernias [9]. A large ventral or parastomal hernia can present a daunting task especially if laparoscopic reversal is planned. Utilization of a laparoscopic approach at the time of initial stoma creation obviates the need for a large abdominal incision. Whether this reduction in incision length translates into a lower incidence of incisional hernia remains a topic of debate. It is quite plausible, however, that the incisional hernias occurring at a laparoscopic extraction site are much smaller and easier to manage than those occurring after a generous midline laparotomy. In addition, the skin of the midline wound should be left open at the time of Hartmann’s operation if there is significant contamination. Wound infection, even those that can be managed by “popping out a few staples,” can lead to incisional hernia formation. Certainly efforts to avoid wound dehiscence and evisceration will also contribute to reduced incisional hernias. Avoiding a large abdominal wall fenestration for stoma exteriorization can also minimize the risk of parastomal hernia . On the other hand, prophylactic mesh placement to avoid parastomal hernia is not indicated unless one is certain that the stoma will not be closed later. For additional details, please refer to Chap. 37 on prophylactic mesh placement during laparoscopic stoma creation.

Difficult Rectal Stump Dissection

Identification and dissection of the rectal stump represents another component of Hartmann’s reversal that can prove to be quite challenging. The rectal stump often tends to adhere to the lateral pelvic wall in close proximity to ureters and major pelvic vessels. In other cases, the rectal stump forms dense adhesions to the bladder or female genital organs leading to a quite tedious dissection at time of reversal. Copious pelvic irrigation with removal of purulent/fecal material can minimize these adhesions. Furthermore, interposition of omentum between the rectal stump and pelvic organs can also facilitate rectal stump dissection at time of closure. Finally, it is very important to preserve as much rectum as possible at the time of Hartmann’s creation. A long rectal stump lends itself to easy identification at time of reversal. Barring malignant cases where it is important to achieve a distal resection margin, rectal division should be carried out as close to the pathology as possible. Every attempt should be made to avoid violation of mesorectal planes as this can lead to dense posterior adhesions which make identification and dissection of rectal stump very difficult at time of closure.

Rectal Stump Retraction

In addition to forming adhesions to the surrounding structures, the divided rectum often retracts into the pelvic cavity leading to “bunching up” of the rectal stump. A retracted rectal stump frequently folds upon itself creating sharp angles which can be very difficult to negotiate with the rigid EEA stapler. This inability to advance the EEA stapler to the end of the rectal stump can lead to the creation of an inadvertent end-to-side rather than end-to-end colorectal anastomosis. While most of the end-to-side anastomoses have excellent functional results, the rectal blind pouch can sometimes lead to bacterial stasis with its attendant issues. Worse yet, adhesions of the vagina or bladder to the retracted stump can lead to inadvertently incorporating them into the anastomosis. Retraction of the rectal stump into the pelvic cavity can be prevented by leaving a long rectal stump and tacking the stapled end to the anterior abdominal wall or retroperitoneum with the help of an anchoring stitch.

Inability to Accomplish a Tension-Free Anastomosis

Inadequate proximal colonic length often prompts surgeons to convert to an open technique to be able to accomplish tension-free anastomosis. Often, this situation is due to extensive mobilization of left colon and splenic flexure at the index operation. We advocate limiting left colonic mobilization to the bare minimum required for exteriorization of the colonic end for stoma creation. Splenic flexure dissection is typically discouraged unless absolutely necessary for exteriorization.