Reversal of Hartmann's procedure through the stomal side: a new even more minimal invasive technique

A comparative study between open versus laparoscopic Hartmann reversal: A single-center experience and analysis

As one of the most challenging procedures in colorectal surgery, Hartmann reversal (HR) carries a burden of morbidity and mortality. We report our experience and compare open and laparoscopic HR.Between December 2012 and January 2020, 30 patients who underwent Hartmann reversal were reviewed. All patients either received laparoscopic or open reversal.Of the 87 patients who underwent Hartmann operation (HO), 30 patients received HR (Laparoscopic Hartmann Reversal, [LHR], n = 20; Open Hartmann Reversal, Open Hartmann Reversal [OHR], n = 10). There were 15 males and 15 female patients. The mean operation time was 223.8 minutes (range 115-350 minutes) with mean blood loss of 252.5 mL (range 0-700 mL). There was no conversion from LHR to OHR, and there was no ileostomy formation. Mean time to flatus was 5.0 days (range 2-13 days). There were 15 early postoperative complications and 5 late postoperative complications, but only 1 case of grade 3A. No anastomosis leakage was reported.HR is an operation that can be performed safely in well-selected patients. Minimally invasive techniques, such as LHR, is an attractive option resulting in shorter operation time, less blood loss, less pain, and shorter hospital stay.

Trans-stomal single-port laparoscopic Hartmann's reversal is an efficacious and efficient procedure: a case-controlled study

BACKGROUND

Hartman's reversal remains challenging and is associated with a widely variable success rate. In a previous study, we reported that laparoscopy may lower the mortality and morbidity rates of the procedure. The aim of the current study was to assess the operative results of single-port laparoscopic Hartmann's reversal (SP-HR) as compared to the more standard, multi-port laparoscopic variant (MP-HR).

METHODS

We performed a retrospective, non-randomized, case-controlled study of 44 consecutive patients who had SP-HR (Group A) compared to 44 patients who had MP-HR (Group B). The study was conducted in a high-volume colorectal unit in a 1200-bed university affiliated hospital, The Poissy-Saint Germain Medical Complex, France.

RESULTS

Preoperative patients' characteristics (sex, body mass index, American Society of Anesthesiologists status, prior surgery, comorbidities, colonic disease) were comparable in both groups. The conversion rate was 13.6% and 4.5% in Group A and in Group B, respectively (p = 0.084) and consisted of placement of any additional ports. Conversion to open surgery did not occur in any patient in either group (p = 1). Mean operative time was shorter in Group A than in in Group B, (105 vs. 155 min; p = 0.0133). The mortality rate was 2.2% in Group A and 0% in Group B (p = 0.3145). The overall morbidity rate was 11.4% in Group A and 18.2% in Group B (p = 0.5344). The median length of hospital stay was significantly shorter in Group than in Group B (4.8 vs. 6.8 days; p = 0.0102).

CONCLUSIONS

The SP-HR technique was found to be safe and efficient. It compares favorably with MP-HR. Moreover, indirect cost savings could be induced by the reduction in the length of hospital stay.

Considerations in Stoma Reversal

Temporary stomas are frequently used in the management of diverticulitis, colorectal cancer, and inflammatory bowel disease. These temporary stomas are used to try to mitigate septic complications from anastomotic leaks and to avoid the need for reoperation. Once acute medical conditions have improved and after the anastomosis has been proven to be healed, stomas can be reversed. Contrast enemas, digital rectal examination, and endoscopic evaluation are used to evaluate the anastomosis prior to reversal. Stoma reversal is associated with complications including anastomotic leak, postoperative ileus, bowel obstruction, enterocutaneous fistula, and, most commonly, surgical site infection. Furthermore, many stomas, which were intended to be temporary, may not be reversed due to postoperative complications, adjuvant therapy, or prohibitive comorbidities.

Reversal of Hartmann's procedure utilizing single-port laparoscopy: an attractive alternative to laparotomy

BACKGROUND

Complications after restoration of intestinal continuity (RIC) following Hartmann's procedure occur frequently and are often serious. These complications result in a reported morbidity of 4-30 % and a reported mortality of 10-14 %. Reducing the amount of surgical trauma accompanying abdominal access seems an attractive tool to reduce perioperative morbidity. This possibility is offered by single-port Hartmann's reversal (SPHR) through the colostomy site.

METHODS

The purpose of the present prospective study was to compare outcome of SPHR to a retrospectively collected historical control group of conventional open Hartmann's reversal (OHR). All patients undergoing RIC between January 1, 2009, and January 1, 2014, were included in the present study. Operation time, morbidity and hospital stay were assessed. Postoperative surgical results of SPHR and OHR were the main outcome of the study.

RESULTS

During the study period, 41 patients (M/F = 23:18; median age 58 (26-85) years) were included in the present study. Sixteen patients underwent OHR; 25 patients underwent SPHR. No mortality was observed in the present series. Median operation time was similar between groups [184 (29-377) vs. 153.5 (73-332) min]. Hospital stay was significantly shorter in the SPHR group [16 (4-74) vs. 4 (1-34) days, p < 0.05]. The number of complications was significantly lower in the SPHR group (33 vs. 10, p < 0.05); furthermore, significantly less patients had severe complications (Clavien-Dindo III or higher) in the SPHR group (7/33 vs. 1/10). Less wound-related complications occurred in the SPHR group (12 vs. 5, p < 0.05).

CONCLUSION

This study confirms recent findings in the literature regarding the safety and feasibility of SPHR. SPHR seems to be an attractive alternative to OHR.

Surgical outcome in patients undergoing reversal of Hartmann's procedures: a multicentre study

AIM

Recent evidence has suggested that a laparoscopic rather than an open approach to reversal of Hartmann's procedure (ROH) may be associated with fewer complications. Much of the data for comparison are historical or based on small case series. The aims of this study were to determine the morbidity and mortality of ROH in 10 hospitals in the modern era and to identify risk factors for complications.

METHOD

A multicentre study of patients undergoing ROH (2007-2013) was performed. Data were collected retrospectively from perioperative health databases and casenotes where appropriate on patient demographics, laboratory investigations and operative details. Complications were classified as minor (I-II) or major (III-IV) based on the Clavien-Dindo criteria. Risk factors for complications were assessed by multivariate analysis with calculation of OR with 95% CI.

RESULTS

Ten hospitals in Scotland provided data on 252 patients undergoing ROH. Most operations were open (85%) with 15% started laparoscopically (conversion rate 64%). In the postoperative period, 35 (14%) patients had a major complication, including anastomotic leakage in 10 (4%) and postoperative death in one (0.4%). Patients with a complication stayed significantly longer in hospital (12 days vs 7 days, P < 0.001). On multivariate analysis, a wound complication after the original Hartmann's procedure (OR = 3.85, 95% CI: 1.08-13.75, P = 0.038) was associated with any complication after ROH, but only American Society of Anesthesiologists (ASA) grade (OR = 3.35, 95% CI: 1.38-8.09, P = 0.007) was independently associated with the development of a major complication.

CONCLUSION

ROH has a low postoperative mortality but significant morbidity. Most operations are still performed by open surgery, and in those attempted laparoscopically, the conversion rate is high.

Incision-less reversal of Hartmann's procedure

After taking down the colostomy in a patient who has previously undergone a Hartmann's operation, it is possible to restore bowel continuity using the single-port technique via the colostomy site itself. This study presents our experience of this approach using the glove port and standard laparoscopic instrumentation. Between October 2010 and October 2013, 14 patients [median age 62 years (range 42-83 years); median body mass index 25.2 kg/m(2) (range 22.7-34.9) kg/m(2)] underwent attempted single-port (via colostomy site) reversal of Hartmann's. All but one patient had had a laparotomy for their primary surgery. The glove port was used with a camera and two working ports. Additional remote access was needed in 3 (21 %) patients [1 × 5 mm port (two patients); 2 × 5-mm ports ; 2 × 5-mm ports and Pfannenstiel]. Median operative time was 150 min (range 75-270 min). Mortality was nil. One patient required reoperation and a stoma. Median hospital stay was 5 days (range 2-36 days). Glove port reversal of Hartmann's is technically possible, though challenging if extensive adhesions are present. Outcomes are variable. Further studies will be needed to assess whether this is a safe technique.

Comparison between open and laparoscopic reversal of Hartmann’s procedure for diverticulitis

AIM: To compare the open and laparoscopic Hartmann’s reversal in patients first treated for complicated diverticulitis.

METHODS: Forty-six consecutive patients with diverticular disease were included in this retrospective, single-center study of a prospectively maintained colorectal surgery database. All patients underwent conventional Hartmann’s procedures for acute complicated diverticulitis. Other indications for Hartmann’s procedures were excluded. Patients underwent open (OHR) or laparoscopic Hartmann’s reversal (LHR) between 2000 and 2010, and received the same pre- and post-operative protocols of cares. Operative variables, length of stay, short- (at 1 mo) and long-term (at 1 and 3 years) post-operative complications, and surgery-related costs were compared between groups.

RESULTS: The OHR group consisted of 18 patients (13 males, mean age ± SD, 61.4 ± 12.8 years), and the LHR group comprised 28 patients (16 males, mean age 54.9 ± 14.4 years). The mean operative time and the estimated blood loss were higher in the OHR group (235.8 ± 43.6 min vs 171.1 ± 27.4 min; and 301.1 ± 54.6 mL vs 225 ± 38.6 mL respectively, P = 0.001). Bowel function returned in an average of 4.3 ± 1.7 d in the OHR group, and 3 ± 1.3 d in the LHR group (P = 0.01). The length of hospital stay was significantly longer in the OHR group (11.2 ± 5.3 d vs 6.7 ± 1.9 d, P < 0.001). The 1 mo complication rate was 33.3% in the OHR (6 wound infections) and 3.6% in the LHR group (1 hemorrhage) (P = 0.004). At 12 mo, the complication rate remained significantly higher in the OHR group (27.8% vs 10.7%, P = 0.03). The anastomotic leak and mortality rates were nil. At 3 years, no patient required re-intervention for surgical complications. The OHR procedure had significantly higher costs (+56%) compared to the LHR procedure, when combining the surgery-related costs and the length of hospital stay.

CONCLUSION: LHR appears to be a safe and feasible procedure that is associated with reduced hospitality stays, complication rates, and costs compared to OHR.

Should laparoscopic reversal of Hartmann's procedure be the first line approach in all patients?

BACKGROUND/AIMS

To assess if the laparoscopic reversal of Hartmann's can be attempted in all patients, without detriment to short or long-term outcomes if the patient is subsequently converted to open.

METHODS

Retrospective review of a prospectively collected database of all reversals under 8 surgeons at a single unit over 105 months, two surgeons attempting laparoscopic reversal in all patients, two pre-selecting for the laparoscopic approach and four utilising the open approach. Long-term follow-up data for re-admissions, re-operations and incisional hernia rate obtained from a postal questionnaire.

RESULTS

45 laparoscopic and 50 primary open reversals were identified. There was no difference in the mean age or previous peritonitis rate in either group. Laparoscopic conversion rate was 29% (13 patients). On intention to treat analysis, a significant difference was identified in the overall 30-day post-operative surgical morbidity (8.9% Laparoscopic-attempted vs 26.0% Open, p = 0.030). There was no difference in operating times (mean 164 vs 172 min, p = 0.896) despite the 13 patients converted to an open procedure. Mean length of stay was significantly lower in the laparoscopic-attempted group at 6.8 days (5.2-8.4) vs 14.9 days (6.4-23.7) in the open group (p = 0.001). Anastomotic leak rates were not statistically different. The median follow up was 27 months (range 6-105); 60% of patients completed a postal follow-up questionnaire. There was no difference in short-term or long-term re-admission or reoperation rates.

CONCLUSIONS

Laparoscopic reversal of Hartamann's is associated with shorter hospital stay and lower morbidity even in unselected patients. Long-term outcomes are similar.

Laparoscopic restoration of intestinal continuity (the LapRICon procedure): a safe and feasible technique for restoration of transanal defecation

BACKGROUND

The restoration of intestinal continuity after open abdominal surgery can be technically challenging. The authors describe their experience with the laparoscopic approach to attempted reversal for patients with an exteriorized intestine.

METHODS

A consecutive series of patients under the care of a single surgeon (D.B.) underwent laparoscopic restoration of intestinal continuity (LapRICon). All the patients first underwent exclusion of intraabdominal sepsis with computed tomography (CT) scanning and then preoperative localization of proximal and distal bowel ends via water-soluble contrast studies. Stomal sites were used for initial access, establishment of capnoperitoneum, and formation of anastomoses extracorporeally. All adhesiolysis and mobilization of bowel ends were performed intracorporeally. Pre-, intra-, and postoperative data were collected for all the patients. Return of intestinal function, overall hospital length of stay, and postoperative complications were collected. Nonparametric statistics were used to analyze the data.

RESULTS

A total of 13 patients (6 women) were followed up for 9 months (interquartile range [IQR], 5-16 months). The median age of the patients was 39 years (IQR, 28-64 years). Nine patients were categorized as American Society of Anesthesiology (ASA) class 1. One patient was ASA 2, and the remaining patients were ASA 3. The median colorectal physiologic and operative severity scores for the enumeration of mortality and morbidity (CR-POSSUM) were 0.68 (IQR, 0.68-1.72). The intraoperative blood loss was minimal (median 30 ml; IQR, 20-125 ml). The median operative duration was 240 min (IQR, 180-240 min), and a median of 4 ports (IQR, 3-5 ports) were used. Enterocolonic anastomoses were fashioned in six patients, enterorectal anastomoses in two patients, and enteroentero anastomoses in three patients. A single patient had multiple anastomoses. The median time to return of intestinal function was 5 days (IQR, 3-13 days), and the overall hospital stay was 8 days (IQR, 5-24 days). Four complications (25%) (2 recurrent fistulas, 1 anastomotic leak, and 1 open conversion) occurred in this series of patients.

CONCLUSIONS

The LapRICon procedure is a feasible technique with acceptable morbidity. Several principles and techniques are described to aid the surgeon who wishes to embark on use of such a technique.

Technical aspects and outcome of a standardized full laparoscopic approach to the reversal of Hartmann's procedure in a teaching centre

AIM

Laparoscopic reversal of Hartmann's procedure is technically demanding. We evaluated the technical aspects and outcome of a standardized approach in a single centre and examined the feasibility of including this into training curricula.

METHOD

The procedure entails a laparoscopy for adhesiolysis and identification and mobilization of the rectal stump. Mobilization of the splenic flexure is performed if necessary, and a colorectal anastomosis is fashioned after introduction of the stapler anvil via the colostomy with intra-abdominal positioning and delivery into the proximal colonic segment to be anastomosed. The stoma is excised as the last step in the operation.

RESULTS

Forty-two patients underwent the procedure over an 8-year period with either an expert (n=21) or trainee under expert mentorship (n=21) as first operator. Intra-operative data and postoperative outcomes were evaluated by retrospective review of clinical charts and theatre records. There was a 9.5% conversion rate and 0% mortality. One patient suffered a ureteric injury, while postoperative surgical complications occurred in 7 patients (including one clinical anastomotic leakage). The mean operative time was 117 min. There was no significant difference in intra operative technical parameters or postoperative clinical consequences between procedures performed by a trained surgeon or by a trainee under mentorship.

CONCLUSION

Adherence to a standardized operative protocol and expert mentorship allows this technically demanding operation to be associated with low conversion and complication rates. The absence of any difference between procedures performed by a trainee or trained surgeon suggests that the operation can be included in training programmes for laparoscopic surgery.

Reversal of the Hartmann Procedure Through Only a Stomal Orifice

We performed reversal of the Hartmann procedure only through the stoma site and we did not use either any other incision nor laparoscopic assistance. A total of 8 patients (7 males), ages between 23 and 80 years, were treated by means of a defined technique. The indications of the Hartmann procedure were sigmoid volvulus (4), sigmoid cancer obstruction (2), rectal trauma (1), and Fournier gangrene (one). The duration from the first procedure was a mean of 5 months (range, 2 to 8 months). The length of the rectal stump was at least 5 cm over the pelvic peritoneum and the body mass indices of all patients were less than 30 kg/m2. The diameter of the stoma opening was a mean of 50 mm (range, 40 to 55 mm). Incision extensions from the stomal orifice (accepted as conversion) were needed for two cases as a result of injury on the intestine and inability to identify the distal bowel stump (25%). The mean operative blood loss and duration of operation were 50 mL (range, 30 to 100 mL) and 65 minutes (range, 45 to 80 minutes), respectively. Fecal discharge of all patients was weighed before hospital discharge and the length of postoperative hospital stay was a mean of 5.5 days (range, 4 to 9 days). Neither anastomosis leakage nor surgical site infections were observed in any of the patients and all had an uneventful postoperative course. The described technique can be the least invasive one than the previously described techniques for the reversal of the Hartmann procedure by only using the stoma site, particularly for nonobese patients with a long distal rectal stump.