Reintervention for anastomotic colorectal stenosis after laparoscopic reversal of Hartmann's procedure

The objective of this film is to demonstrate the different steps to resect a stenotic colorectal anastomosis following a Hartmann's reversal procedure and to perform a new anastomosis. The author outlines tips and tricks that allow for pelvic access which is often the seat of abundant adhesions. In addition, prior to undoing the new anastomosis, it is mandatory to check if it is possible to free the rectal stump. The author also shows the principles of a completely laparoscopic technique.

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Reintervention for anastomotic colorectal stenosis after laparoscopic reversal of Hartmann's procedure

Authors

J Leroy, J Marescaux

Abstract

The objective of this film is to demonstrate the different steps to resect a stenotic colorectal anastomosis following a Hartmann's reversal procedure and to perform a new anastomosis.
The author outlines tips and tricks that allow for pelvic access which is often the seat of abundant adhesions. In addition, prior to undoing the new anastomosis, it is mandatory to check if it is possible to free the rectal stump. The author also shows the principles of a completely laparoscopic technique.

Keywords

Reintervention, anastomotic colorectal stenosis, laparoscopic reversal of Hartmann\'s procedure

Media type

Surgical video

Duration

14'49''

Publication

2012-04

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E-publication

WeBSurg.com, Apr 2012;12(04).
URL: http://www.websurg.com/doi-vd01en3030.htm

Reintervention for anastomotic colorectal stenosis after laparoscopic reversal of Hartmann's procedure

1. Introduction 00'20''

The objective of this video is to present the possibilities of laparoscopic treatment for an anastomotic colorectal stenosis after a laparoscopic reversal of Hartmann’s procedure, which was performed for the treatment of a peritonitis with an abdominal resection and cleansing through laparotomy. The difficulty in this type of patient is a fairly high risk of adhesion as can be seen on these images.

2. Approach in abdominal cavity 01'02''

The procedure begins with the patient in a right lateral decubitus position, at the level of the right flank of the abdominal wall. A first port is introduced using a mini-open technique, away from incision sites. Instruments are introduced through the same trocar introduction site, under endoscopic control, using a single port technique. Adhesions around the port are progressively taken down, particularly around the midline, which will allow to secure the scarring area and introduce additional ports which will be located in the right iliac fossa on the midline, at the level of the umbilicus in order to find the classical landmarks used in laparoscopic pelvic and splenic flexure surgery. Adhesions are intimate between the omentum and the abdominal wall, and around the small bowel in some areas. Scissors are mainly used, but the monopolar electrode may also be used in combination with scissors, as a combination of both instruments allows for an easy division of adhesions, which in this case are fairly loose, and not very inflammatory, as they are located at a considerable distance from the surgical area. Adhesions are taken down towards the pelvic cavity, the left flank, and in some cases towards the left hypochondrium, in order to identify the colon. The colon has been lowered, which allows the operator to carry out a colorectal anastomosis as soon as sigmoidectomy has been performed. Adhesions are freed very cautiously; proper traction and counter-traction are exerted here, and as a result, adhesions are mostly divided using cold scissors, or merely by using traction in the adequate adhesion plane, in order not to damage the digestive tract’s wall, the mesocolon, and the mesentery. All of these adhesions can progressively be observed here, towards the left flank, towards the left iliac fossa, and then towards the pelvis. These adhesions will be freed in order to find the anastomotic area between the colon and the rectum. The operator gradually progresses towards the pelvis, using a left lateral approach, as can be seen on these images. An incision is made, making sure not to use monopolar or even ultrasonic devices, in order to prevent any hyperthermia-related burns. The procedure continues steadily, using as much space as possible around the pelvis. Parietal adhesions are freed, as can be seen here in the suprapubic area, by means of cold scissors. The advantage of using roticulating mini-shears is that the scissors’ tip can be angulated, which allows for a perfectly suitable angle for manipulation. Adhesion areas are put under tension by the operator’s left hand, and the small bowel, which is fixed into the pelvis, is freed in a stepwise fashion.

3. Dissection of pelvic space 05'56''

At this point, the root of the lowered sigmoid colon, which is in fact the descending colon, can be observed. It is facing the left iliac vessels and not far from the promontory and beating iliac vessels. The left mesocolon, which has been lowered, can be observed here, and looks quite thick. This rules out the origin of ischemia at the level of the anastomosis, and could well account for an ischemic stenosis, the probable cause being a partial separation with some fibrosis which caused a mechanical embedding of the end-to-end colorectal anastomosis. The pelvis can be observed here, it is slightly hemorrhagic, but that is not very surprising. It is necessary to localize the rectal stump; for this purpose, the use of the Ligasure™ device or of ultrasonic scissors for those who are used to using this instrument, is very useful, as tissues in this area are very hard and inflammatory. One should be very cautious when approaching the left and right pelvic walls, as there is a risk for the plexus, the ureter, and for vascular structures. Entrance is progressively made into the pelvis, which was not dissected as a sigmoid resection had been performed, and a search for the presacral plane is carried out. The head of a circular stapler is introduced and used as a bougie, which will allow to identify the rectum’s position. Work on the retrorectal presacral fibrosis is begun in order to find the plane posterior to the mesorectum, in the same fashion as one would perform a rectal resection for cancer. The objective is to find a non-fibrotic plane and to then carry out a minimal resection on the rectal wall. During the dissection, a small opening has been made in the vaginal pouch. As a result, a suture is carried out by means of PDS suture, using extracorporeal knotting. The dissection is carried on, as can be seen here, on the anterior aspect of the sacrum, which will allow for the mobilization of the rectum, as distally as possible, while preserving vascularization, as the mesorectum remains in contact with the rectal stump. Once the posterior aspect of the rectal stump has been freed, the procedure is carried on in a circular motion, around the rectum, here in a right lateral position, and progressively on the anterior aspect, and then on the lateral aspect.

4. Dissection of anastomotic area 10'12''

As a result, the area of anastomosis can clearly be identified, as the distal sigmoid colon has been divided. This anastomotic area is excised, to confirm adequate plane positioning at the level of the rectal wall. This excision allows to find a very large fibrosis, which is probably the result of an ischemia on the anastomosis, and more importantly combined with a partial dehiscence and/or fistula. Now to the rectal resection at the distal end. The rectal stump should now be re-cut in a healthy and compliant area with a flexible wall. A partial closing and a suspension of the rectum will be carried out by means of Ethibond 2/0 suture, with extracorporeal knotting. This will allow to exert an adequate traction and to use a stapler, after completing the rectal stump’s mobilization. The opened rectal ampulla can be observed here; a third stitch will be placed on the middle part, not to close the rectal stump, but to perform a suspension of the stump and apply a stapler underneath the tip of the divided stump. The mesorectum is now prepared. The fibrotic area is incised laterally and posteriorly until contact with the rectal wall is made, taking care not to damage it. The emaciated aspect of this rectal wall can clearly be observed here, and contact with the rectal wall will have to be maintained, because cutting off fibrotic tissue around this area with a mere stapler will be impossible.

5. New anastomosis 13'09''

The usefulness of suture to close the rectal stump can be observed here, as it allows for good traction, while a stapler is being used on the sutured area of the rectum. A second staple firing can be observed here, by means of an Endo-GIA™ linear stapler loaded with a 45mm long blue cartridge. After checking the rectal stump by means of an air test and a betadine test, the anvil of a PCEEA 28mm circular stapler is introduced into the proximal colon, exteriorized by means of a suprapubic mini-incision, and re-cut once the descending colon has been mobilized. The rectal stump is transfixed by means of the Endo-GIA™ linear stapler. The colon and the anvil are then connected to the tip of the Endo-GIA™ linear stapler. The anastomosis is then performed. It will be controlled by means of an air test and control of the doughnuts.