Laparoscopic restoration of intestinal continuity after Hartmann procedure

The description of the laparoscopic restoration of intestinal continuity after Hartmann procedure covers all aspects of the surgical procedure used for the restoration of intestinal continuity. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: abdominal exploration, adhesiolysis, rectal stump, mobilization of left colon, freeing of the colostomy, colorectal anastomosis, anastomosis. Consequently, this operating technique is well standardized for the management of this condition.

Browse the WORLD
Virtual University
English ▼

Laparoscopic   restoration   of   intestinal   continuity   after   Hartmann   procedure

Authors
J Leroy, J Milsom, J Okuda
Abstract
The description of the laparoscopic restoration of intestinal continuity after Hartmann procedure covers all aspects of the surgical procedure used for the restoration of intestinal continuity.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: abdominal exploration, adhesiolysis, rectal stump, mobilization of left colon, freeing of the colostomy, colorectal anastomosis, anastomosis.
Consequently, this operating technique is well standardized for the management of this condition.
Media type
Publication
2001-06
Popular
Favorites
Favorites Media
Audio
en fr jp tw pt


E-publication
WeBSurg.com, Jun 2001;1(06).
URL: http://www.websurg.com/doi-ot02en163.htm

Laparoscopic   restoration   of   intestinal   continuity   after   Hartmann   procedure

1. Introduction
Hartmann's surgical procedure includes distal colonic resection in association with maturation of the proximal colon as an end colostomy and closure of the residual rectal stump. Described initially in 1923 by Henry Hartmann as a primary treatment for obstructing cancers of the distal sigmoid colon and colorectal junction, this procedure has since been widely applied to a variety of benign and malignant diseases of the large intestine (Desai et al., 1998; Shein and Decker, 1988). Latterly however, it has been mostly employed as an emergency procedure in co-morbid patients and so it remains associated with a high rate of morbidity (22-40%) and mortality (9-37%) (Dumont et al., 2005). Furthermore, although the stoma at the time of construction is often intended to be temporary, the rate of reversal Hartmann's procedure remains highly variable as the elective further operation to restore intestinal continuity is dependent on the patient's health and preference.
The technique of laparoscopic reversal of Hartmann procedure was first described by Gorey et al. (Br J Surg 1993;80:109).
The advantages of minimally invasive surgery should provide benefit to selected patients undergoing the second stage procedure and if proven robustly could help shift the harm:benefit ratio in favour of re-intervention overall. Over the last two decades, several authors have reported different approaches for laparoscopic reversal of Hartmann's procedure (LRHP) in small series of patients (Vacher et al., 2002; Gorey et al., 1993; Costantino and Mukalian, 1992; MacPherson et al. 1996; Rosen et al., 2005;) and indicated the clinical promise of the technique.
Different techniques were developed following surgical strategies: laparoscopic-assisted approaches, hand-assisted technique (Dumont et al., 2005) or a full procedure via the colostomy site (Dumont et al. 2005; Vermeulen et al., 2008). According to Vermeulen, the optimal surgical technique is still up for debate (Vermeulen et al., 2008); likewise, Holland et al. (2002), and Pitmann and Smith (1985) consider that the technique used to restore digestive continuity is the most important risk factor for morbidity.
However, most experts in laparoscopic colorectal surgery still consider this a difficult procedure (Jamali et al., Arch Surg 2008).
The objective of this chapter is to demonstrate one of the surgical techniques available for the reversal of Hartmann's procedure.
2. Preop period
• Assessment of general health
Patients are often in fragile health. Many of them have undergone an emergency Hartmann procedure for diverticulitis with complications. The preoperative evaluation should include a thorough health assessment as well as an assessment of the anatomical and functional status of the remaining colon and rectal stump. Each case must be individualized based on the patient’s medical and surgical history. The procedure is always preceded by a full mechanical bowel preparation to ensure that the digestive tract and rectal stump are completely empty.
In addition to assessing the ASA stage, it is important to understand why the patient is asking to have his or her colostomy removed. The patient must be involved in the decision-making process.
• Analysis of medical history
The patient’s previous surgical history is reviewed to assess the extent of the abdominal and pelvic scarring. This review should cover the pathology, the approach used, the types of drain (if used), and the postoperative complications (fistulas, purulent discharge, abscesses). The estimated time of recovery must be known, especially in cases involving postoperative infectious complications.
• Study of the remaining colon
A colonoscopy via the colostomy is performed to search for residual or associated pathology. In addition, a barium enema, administered through the colostomy, is recommended in order to obtain a clear picture of the remaining colon. It is performed to evaluate the length of the remaining proximal colon and the possible need to mobilize the splenic flexure.
• Examination of rectal stump
The anal sphincter function is generally evaluated clinically (digital rectal examination). Manometry is indicated in cases where sphincter function appears to be compromised. A proctoscopy and a barium enema are performed to exclude any residual pathology.
3. Indications
Following a Hartmann procedure, intestinal continuity can be successfully restored in 70% of cases. The success of the restoration depends primarily on the intra-abdominal inflammatory sequelae as well as the timing of the procedure.

Indications
- theoretically, all patients who have undergone a Hartmann procedure and who wish to have their intestinal continuity restored,
- patients with a normal anal sphincter function.

Contraindications
- contraindication to general anesthesia;
- contraindication to laparoscopy (pulmonary emphysema, heart failure);
- large ventral hernias and/or associated abdominopelvic pathologies;
- incompetent anal sphincter.

Timing of the procedure
A Hartmann procedure can be reversed anytime from 1 to 6 months following the original procedure. The exact timing of the reversal depends largely on the extent of the infectious complications observed during the first procedure.
Reoperations following pelvic or generalized peritonitis are ideally performed after an interval of 3 to 6 months or more. This allows for the inflammatory sequelae to subside or disappear rendering
the procedure less difficult and improving its success rate.
4. Operating room set-up
• Patient
• Dorsal decubitus
The patient’s position must enable both abdominal and perineal access to facilitate the dissection and performance of the anastomosis:
- dorsal decubitus, left buttock and flank raised by a cushion: this position results in the descent of the visceral organs toward the right side of the abdomen;
- both arms alongside the body: this permits the surgeon or the assistant to be positioned on the right or the left side;
- legs spread, knees slightly bent;
- urinary and gastric catheters to ensure an empty bladder and stomach;
- endotracheal intubation.
• Trendelenburg
- 20° to 30° Trendelenburg, 10° to 20° tilt to the right: this causes the visceral organs to slide into the right upper quadrant of the abdominal cavity,
- the patient must be prevented from slipping during the procedure as this can lead to nerve compression (brachial plexus, radial and sciatic nerves) and can hamper the manual anastomosis (transanal approach).
• Team
1. Surgeon: to the right side of the patient;
2. First assistant: to the left of the surgeon and near the patient’s right shoulder: he or she holds the video camera in one hand and a retractor (or grasper) in the other;
3. Second assistant: between the patient’s legs to retract the visceral organs and perform the anastomosis by introducing the circular stapling device into the anus;
4. Scrub nurse: to the right of the surgeon, next to the instrument table.
5. Anesthesiologist
• Equipment
1. Laparoscopic unit (3CCD video camera, 1 or 2 monitors, insufflator, cold light source)
2. Ultrasound generator
3. Operating table: adjustable by remote control for an atraumatic installation
4. Monitor to the patient’s left, next to the left hip;
5. Laparoscopic unit to the patient’s left, along with the electrosurgical unit and ultrasonic dissectors;
6. Instrument table to the right of the patient’s feet.
5. Instruments
• Optical devices
Most authors use laparoscopes with 0° and 30° visual axes and a 70° visual field.
Some authors use a laparoscope with a 45° visual axis.
• Operating devices
1. Grasper; 2. Bipolar; 3. Ultrasonic dissectors; 4. Linear stapler; 5. Scissors; 6. Clip applier; 7. Circular stapler; 8. Plastic-coated drape to protect the incision after freeing the colostomy and provide temporary closure of the abdominal wall during the colorectal anastomosis.
• Retracting devices
1. Flexible retractor
2. Peanut swab
• Others
Efficient suction-irrigation device for lavage and dissection (adhesiolysis)
6. Principles/strategies
The goal of the procedure is to perform an anastomosis between the proximal colon and the rectal stump. The difficulties involved in the surgical act can be attributed to the presence of abdominal and pelvic adhesions, the need for mobilization of the proximal colon, and to the quality and length of the rectal stump.

Principles
The procedure is comprised of the following operative steps:
- sealing/closing the colostomy with an airtight purse string or adhesive drape;
- exploration of the abdominal cavity;
- lysis of the abdominopelvic adhesions;
- preparation for the anastomosis: identification of the rectal stump, mobilization of the left colon, mobilization of the colostomy, performance of the colorectal anastomosis.

Strategies
Two strategies are possible:
- primary mobilization of the left iliac fossa colostomy, followed by the freeing of intra-abdominal adhesions through a peristomal incision. The procedure is then continued under laparoscopic guidance;
- primary exploration of the abdominal cavity followed by lysis of adhesions. The colostomy is then mobilized. We prefer this second strategy, as it allows the surgeon to assess the feasibility of the laparoscopic approach and to free the splenic flexure before any potential soilage can occur.
7. Abdominal exploration
• Exploration
The exploration begins at a distance from the areas of scar tissue to avoid omental and small bowel adhesions. The colostomy is left in place during the entire exploration of the abdominal cavity. The first trocar is introduced using the open technique. Additional trocars are then progressively inserted through the abdominal wall under direct vision.
• First trocar
• Standard placement
The first trocar site(10/12 mm in diameter) is chosen away from previous incision sites.
• In case of a median scar
While a midline trocar can be placed using the open technique, we prefer a right lateral or even right subcostal approach. These areas are usually free of adhesions. In the case of a right subcostal scar, the trocar can be introduced through the right iliac fossa.
• Other trocars
The other trocars are positioned based on the presence of adhesions; nevertheless, the surgeon should keep in mind the principles described for laparoscopic rectosigmoid surgery.
As a general rule, two 5 mm operating trocars are introduced on the right midclavicular line, one (trocar B) at umbilical level and the other (trocar C) 8 to 10 cm below trocar B.
If necessary, a 5 to 10/12 mm suprapubic trocar for retraction may be added to facilitate dissection of the pelvis (trocar E).
A 10/12 mm trocar is rapidly introduced in supraumbilical position to reposition the videoscopic system during dissection of the pelvis.
• Variation
• Midline supraumbilical approach
If the first procedure was performed laparoscopically or using a Pfannenstiel incision, a supraumbilical median approach is possible. This may be done after insufflation of the abdominal cavity with a left subcostal puncture.
• Opening through scar tissue
Most authors advise opening the abdominal cavity through a prior incision scar site. This may be done after extraction of the colostomy, or on the median scar in the supraumbilical region.
• Approach on median scar
A classic open laparoscopy in the supraumbilical region is used to free the adhesions at the potential port site under visual guidance. We do not recommend this technique, because adhesions make dissection very difficult.
• Mobilization of colostomy
This operative step has the advantage of being simple. The colostomy is mobilized from the abdominal wall after closing the lumen with a purse string, and the abdominal cavity is explored through the incision. The adhesions surrounding the colostomy site are dissected under direct vision. A laparoscope is introduced through the incision, which is made airtight. The abdominal cavity is then explored. In our experience, 2 out of 4 procedures performed using this approach required conversion due to difficulties in exposure caused by the adhesions.
• Hand-assisted technique
A mini-laparotomy, performed during mobilization of the colostomy, is used to introduce a hand-assisted device through which the surgeon or first assistant can put their hands (hand-assisted technique).
8. Adhesiolysis
• Principles
Lysis of intra-abdominal adhesions is an essential component of the surgical act. This lysis can be accomplished with relative ease or extreme difficulty depending on the extent, nature and density of the prior adhesions.
• Lysis of abdominal wall adhesions
The lysis is begun under direct vision through the open-laparoscopy incision and is continued under laparoscopic guidance after introducing the additional lateral trocars.
Ultrasonic dissectors are very useful. Monopolar electrocautery should be avoided.
In case of hemorrhage of the small vessels, bipolar cauterization is preferred.
A bloodless plane of dissection can be identified with the help of pneumoperitoneum as well as the traction of the weight of the omentum or small bowel. This bloodless plane is always present, except in cases of incisional hernias or abscess sequelae.
• Freeing of visceral adhesions
Only those visceral adhesions that interfere in the surgical act need be lysed, particularly those that hinder access to the pelvis and the atraumatic mobilization of the left colon. Once the small bowel has been freed, notably in the region surrounding the colostomy site, the entire abdominal cavity should be explored. Adhesions that could lead to future secondary obstructions must be divided.
• Lysis of pelvic adhesions
Exposure of the rectal stump can be a difficult step, especially in case of local infectious complications. In such cases, an endo-rectal bougie can be introduced to facilitate identification of the stump. Hydro-dissection can also be used in separating the planes.
9. Rectal stump
• Preparation
The status of the rectal stump depends on the level of the division (distal part of the sigmoid colon or rectum) during the first procedure and on the postoperative complications that may have occurred (fistulas, abcesses).
It is not necessary to perform a complete dissection of the posterior surface of the rectal stump, which may be closely attached to the sacrum. Such a dissection may result in an injury to the sympathetic nerve plexuses.
• Identifying the rectal stump
The introduction of an endo-rectal bougie facilitates the identification of the rectal stump. The rectal stump is particularly difficult to identify if the rectal resection was wide, and the rectal stump was divided below the peritoneal reflection, particularly in women. The posterior rectouterine pouch (Douglas’ pouch) must be identified and visualized during the dissection and anastomosis.
The anterior surface of the rectal stump is mobilized (but not overly so). The dissection along its posterior surface should be restricted. Exceptions to the guidelines above include a long rectal stump with part of the sigmoid colon still attached or a stenosed rectal stump. In these cases, full circumferential mobilization and division of the rectal stump is required.
• Trimming the rectal stump
This is sometimes necessary in case the rectal stump is too long, or in case of stenosis of the colorectal junction caused by inflammation or scar tissue. The stump is divided with a linear mechanical stapling device.
10. Mobilization/left colon
• Mobilization
The colorectal anastomosis to be performed must be tension-free.
If the left colon was mobilized during the preceding procedure, the anastomosis may be performed without additional mobilization of the splenic flexure (rare but ideal case). More commonly, however, the descending colon and splenic flexure must be mobilized to ensure a tension-free anastomosis.
This operative step may be performed after freeing the colostomy through the parietal opening if the left colon is in good condition and supple enough.
We prefer to mobilize the left colon and splenic flexure under laparoscopic guidance before taking down the colostomy, in order to avoid intra-abdominal spillage.
The mobilization of the left colon may be performed laterally, medially or cephalad to caudad.
• Laterally
The left paracolic gutter, the phrenocolic ligament, and the attachments of the omentum to the transverse colon are opened caudad to cephalad.
• Medially
The left mesocolon is detached from Toldt’s fascia and from the anterior surface of the pancreas from right to left. In this case, it is often necessary to divide the left colic vessels and the inferior mesenteric vein.
• Cephalad to caudad
The left transverse colon is progressively brought down after dividing its attachments to the omentum and the left phrenocolic ligament. The descending colon is mobilized laterally.
11. Freeing/colostomy
• Parietal incision
We perform this step at the end of the procedure, just before the colorectal anastomosis.
Once the colostomy has been freed from the abdominal wall, the peristomal adhesions between the distal colon and the abdominal wall are lysed under direct vision through the parietal incision.
• Freeing of the colostomy
The colostomy opening is sealed with a purse string suture to avoid parietal and abdominal contamination. The colostomy is freed from the various planes (cutaneous, subcutaneous, muscular) taking care to keep the colonic wall intact. The pneumoperitoneum facilitates the exposure of the peritoneal attachment plane. It is mandatory to preserve the mesentery of the colon.
• Lysis of adhesions
Lysis is performed under visual guidance or with a finger. The prior laparoscopic lysis of all abdominal adhesions renders this step very simple.
12. Colorectal anastomosis
• Steps
The anastomosis comprises an extra-abdominal preparatory step and an intra-abdominal step using laparoscopy. The colorectal anastomosis is performed using a mechanical circular stapler. The anvil of the circular stapler is introduced into the lumen of the proximal part of the colon outside the abdominal cavity.
• Positioning the anvil
The anvil is positioned in the descending colon after trimming of the colostomy back to an intact and well-vascularized region. The anvil (at least 28 mm in diameter) is introduced into the lumen of the colon, which is closed by a purse string suture. The left colon with the anvil in place is then pushed into the abdominal cavity.
• Closure of abdominal opening
This step is necessary to allow reestablishment of the pneumoperitoneum and allow the laparoscopic anastomosis. Closure can be performed either by suturing the muscular and peritoneal planes of the parietal opening or preferably by inserting a plastic-coated drape with a ring, which allows for the exteriorization of the colon if needed.
13. Anastomosis
• Intra-abdominal step
The intra-abdominal step involves transfixing the rectal stump and performing the colorectal anastomosis using a mechanical circular stapling device. This step is performed entirely laparoscopically once the abdominal cavity has been reinsufflated.
• Transfixing the rectal stump
After ensuring that the abdominal cavity is airtight, the pneumoperitoneum is reestablished. The circular stapler is introduced into the rectum after gentle manual dilatation of the anus. The rectal stump is then transfixed with the tip of the circular stapler in a supple region of its anterior surface.
In female patients, the posterior vaginal wall must be retracted anteriorly.
• Anastomosis
Once the anvil has been joined to the proximal part of the circular stapler, the surgeon must make sure that the proximal colon has not rotated, potentially causing an obstruction. The stapler is closed after checking that there is no interference from neighboring organs. The stapling procedure is then performed in accordance with the manufacturer’s recommendations. The stapler is loosened and removed from the anus.
• Testing the anastomosis
Verification of the anastomosis is mandatory. This includes checking for the completeness of the circular rectal and colonic donuts, optional air test and, for some authors, endoscopic transanal evaluation of the anastomosis.
14. End of procedure
The procedure ends with the lavage of the peritoneum and optional drainage of the pelvis.
The various trocar sites are carefully closed. 5 mm sites are reapproximated at the skin level only. Trocar sites >= 10 mm are reapproximated using several layers (including one muscular or aponeurotic layer, or both) to prevent incisional hernias.
The colostomy opening is closed layer by layer with parietal drainage.

Certain authors recommend infiltrating the incisions with xylocaine in order to reduce postoperative pain.
15. Postop period
The gastric tube is usually removed as soon as the patient wakes up.
The urinary catheter is also removed on POD1.
If postoperative antibiotic therapy is indicated, it must be a broad spectrum and include coverage of anaerobic bacteria.
As soon as bowel function returns, liquids and then solid food are allowed. Discharge from the hospital is allowed after the return of normal bowel habits and as soon as care and follow-up can be safely performed in an outpatient setting.
17. Conclusions
Laparoscopic Hartmann reversal is not devoid of risks since mortality ranges from 0% to 4% and average morbidity ranges from 25% to 30%.

Our laparoscopic approach at a distance from adhesions along with the late freeing of the colostomy ensures safety and efficacy. The exploration of the abdominal cavity allows for a better evaluation of the risk of adhesions. The freeing of adhesions under visual guidance prevents unnecessary bleeding. The late freeing of the colostomy minimizes contamination and reduces the risk of parietal damage.
18. Reference
Casal Nunez JE, Ruano Poblador A, Garcia Martinez MT, Carracedo Iglesias R, Campo Perez V. Morbidity and Mortality after a Hartmann operation due to peritonitis originating from a sigmoid diverticulum disease (Hinchey grade III-IV). Cir Esp 2008;84:210-4.

Costantino GN, Mukalian JJ. Laparoscopic reversal of Hartmann procedure. J Laparoendosc Surg 1994;4:429-33.

Desai DC, Brennan EJ, Reilly JF, Smink RD. The utility of the Hartmann procedure. Am J Surg 1998;17:152-4.

Dumont F , Vibert E, Duval H, Manaouil D, Sredic A, Alfahel N, Mouvais F, De Fresnoy H, Rudant J, Katsahian S, Riboulot M, Gali C, Verhaeghe P, Dupont H, Regimbeau JM. Morbi-mortality after Hartmann procedure for peritonitis complicating sigmoid diverticulitis. A retrospective analysis of 85 cases. Ann Chir 2005;130:391-9.

Gorey TF, O’Connell PR, Waldron D, Cronin K, Kerin M, Fritzpatrick JM. Laparoscopically assisted reversal of Hartmann’s procedure. Br J Surg 1993;80:109.

Hartmann H. Nouveau procédé d’ablation de cancer de la partie terminal du colon pelvien. Trentième congrès de chirurgie. Strasbourg 1923.411-3.

Holland JC, Winter DC, Richardson V. Laparoscopic assisted reversal of Hartmann procedure revisited. Surg Laparosc Endosc Percutan Tech 2002;12:291-4.

Jamali FR, Soweid AM, Dimassi H,Bailey C, Leroy J, Marescaux J. Evaluating the degree of difficulty of laparoscopic colorectal surgery. Arch Surg 2008;143:762-7.

Khaikin M, Zmora O, Rosin V, Bar-Zakai B, Goldes Y, Shabtai M, Ayalon A, Munz Y. Laparoscopically assisted reversal of Hartmann procedure. Surg Endosc 2006;20:1883-6.

MacPherson SC, Hansel VT, Porteous C. Laparoscopic assisted reversal of Hartmann procedure: a simplified technique and audit of 12 cases. J Laparoendoscopic Surg 1996;5:305-10.

Mazeh H, Greenstein A, Swedish K, Nguyen SQ, Lipskar A, Weber KG, Chin EH, Divino CM. Laparoscopic and open reversal Hartmann’s procedure-a comparative retrospective analysis. Surg Endosc 2009;23:496-502.

Pitmann DM, Smith LE. Complications of colostomy closure. Dis Colon Rectum 1985;28:836-46.

Rao P, Clement D, Davies M, Torkington J. Comment on: Laparoscopically assisted reversal of Hartmann procedure. Letter to the editor Surg Endosc 2007;21:1036.

Roque-Castellano C, Acosta Merida A, Rodriguez Mendez A, Marchena Gomez J, Hemmersbach Miller M. Analysis of the risk factors related to the decision of restoring intestinal continuity after Hartmann’s procedure. Int J Colorect Dis 2007;22:1091-6.

Rosen MJ, Cobb WS, Kercher KW, Sing RF, Heniford T. Laparoscopic restoration of intestinal continuity after Hartmann procedure Am J Surg 2005;189:670-4.

Schmeizer TM, Mostafa G, Norton J, Newcomb WL, Hope WW, Lincourt AE, Kercher KW, Kuwava TS, Gersan KS, Heniford ET. Reversal of Hartmann’s procedure : A high-risk operation? Surgery 2007 142;4:598-607.

Shein M, Decker G. The Hartmann procedure. Extended indications in severe intrabdominal infection. Dis Colon Rectum 1988;31:126-9.

Sosa JL, Sleeman D, Puente I, Mc Kennedy MJ, Hartmann R. Laparoscopic-assisted colostomy closure after Hartmann procedure. Dis Colon Rectum 1994;3:149-52.

Vacher C, Zaghloul R, Bori F, Laporte S, Callafe R, Skawinski P, Leynau G, Domergue J. Laparoscopic re-establishhment of digestive continuity following Hartamnn’s procedure. Retrospective study of the French Society of Endoscopic Surgery. Ann Chir 2002;27:189-92.

Vermeulen J, Vrijlanv W, Mannaerts G. Reversal of Hartmann’s procedure trough the stomal side: a new even more minimal invasive technique. Surg Endosc 2008;22:2319-22.