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Laparoscopic reversal of Hartmann's procedure

This video demonstrates a laparoscopic closure of a Hartmann's 6 months after it was done for a perforated diverticular disease. The surgeon gains access to the peritoneal cavity through a port placed under direct vision in the right upper quadrant. The adhesions to the midline scar are taken down. The rectal stump is identified and mobilized proximally. The colostomy is then taken down and an end to end anastomosis is made with the rectum using an EEA stapler.

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Laparoscopic reversal of Hartmann's procedure

作者群

J Leroy, D Fölscher

摘要

This video demonstrates a laparoscopic closure of a Hartmann's 6 months after it was done for a perforated diverticular disease. The surgeon gains access to the peritoneal cavity through a port placed under direct vision in the right upper quadrant. The adhesions to the midline scar are taken down. The rectal stump is identified and mobilized proximally. The colostomy is then taken down and an end to end anastomosis is made with the rectum using an EEA stapler.

分類

routine cases

關鍵字

operation, Hartmann closure, perforated diverticulitis, laparoscopic

媒體類型

手術影片

期間

06'00''

刊物

2004-11

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Nov 2004;4(11).
URL: http://www.websurg.com/doi-vd01en1367e.htm

Laparoscopic reversal of Hartmann's procedure

1. Case presentation 00'10''

This 50-year-old woman had a Hartmann’s procedure performed 6 months ago for perforated diverticular disease. In this patient, one can expect multiple adhesions not only to the surgical scar but all around the peritoneal cavity and in the pelvis. It is therefore prudent to use a lateral approach to the peritoneal cavity both for creating the pneumoperitoneum in the left upper quadrant in this case but also placing the 1st port in the right upper quadrant away from the scar. This is done under direct vision allowing one to see any underlying adhesions and preventing damage on the lying bowel.

2. Exploration of abdominal cavity 00'55''

Once the primary optical port has been inserted carefully, one can do a full inspection of the abdominal wall from this vantage position and as we expected in this case, there are multiple adhesions laterally, to the surgical scar, and also between organs.

3. Introduction of 2nd trocar and adhesiolysis 01'31''

A 2nd working port can now be placed under direct vision from the inside in an area free of adhesions. This would be used to divide these attachments using a combination of sharp dissection and blunt stripping away of tissues. As one can see, there is very little bleeding and diathermy should be used with caution. In this case, with dense midline adhesions to the scar, diathermy is needed to control bleeding. One can clearly see that any attempts to put the primary port in this position would have resulted in significant damage to bowel and to bleeding. Using diathermy near the bowel can cause latent damage, which will only cause perforation later on when the patient is already home. This is in the site of the colostomy. That should not be taken down at this stage. As in this case where the bowel is adjacent to the peritoneum, no diathermy is used but only sharp dissection. Once all adhesions are taken down, the rest of the ports can now be inserted and one can transfer the optical port to the more usual midline position, which allows a good view of not only the colostomy but also of the pelvis. Not all adhesions need to be taken down; only those that will interfere with mobilization of the colon and with the eventual anastomosis. These are left intact. As one can expect after perforated diverticular disease, there are numerous adhesions in the pelvis and in the left lower quadrant. These are stripped easily away in this case as they are only omental adhesions. One needs to mobilize fully around the colostomy and in the pelvis to find the rectal stump. Once again, diathermy is used with circumspection only to stop definite bleeding. In the pelvis, dissection can often be difficult and one needs to find the perfect surgical plane and strip adhesions in this case between the uterus and the small bowel but often in the male there are thin small bowel adhesions in the pelvis, which need to be taken down. Hydrodissection is another useful tool for finding the correct plane and locating the rectal stump.

4. Mobilization of colostomy and anastomosis 04'23''

After exploration of the pelvis and identification of the rectal stump, the small bowel is inspected not to take down all adhesions but only to find those that will predispose the patient to later band obstruction. A band like this is clearly dangerous and will need to be divided. The adhesions of small bowel to the colostomy are also taken down to ensure adequate mobilization of the left colon. Hereafter, the colostomy is mobilized in a normal manner and the anvil is fitted. Both the colon and the anvil is now returned to the peritoneal cavity and the colostomy is closed. In this case, the rectal stump is quite long and the end of the stapler could be inserted through the end of the stump. However, sometimes one struggles with the short rectal stump or dense adhesions and in those cases, the anterior wall of the rectum can also be used for the anastomosis. Always one should check that there is no tension on the left colon and that the anastomosis lies comfortably without a twist. All stapling is performed under direct vision ensuring a perfect result and very little extra scarring on the abdomen.