Laparoscopic Reversal of Hartmann’s Rectosigmoidectomy
When intestinal continuity may be considered unwise (operating on complicated diverticulitis and colorectal cancer), rectosigmoidectomy (resection of the disease process and close of the top of the rectum) with end colostomy has stood the test of time.
Restoration of bowel continuity however, continues to be a major undertaking with a reported mortality >5% and an anastomotic leak rate of around 15%. As a result, fewer than 60% of patients elect to have their colostomy reversed.
Timing of reversal is crucial with no mortality or anastomotic disruption when patients had their second stage performed after six months.
Open reversal (see below) necessitates a long midline incision (often longer than the original incision), variable division of adhesions and considerable bowel handling.
Self retaining retractors are used to keep the abdominal wall open, the bowel is packed in swabs. Further retractors are used to display the bowel sufficient to allow the two ends of the bowel to be joined together (see below).
The latter frequently leads to an ileus or bowel paralysis. This can then lead to abdominal distension and the need for a nasogastric tube. Most patients will remain in hospital for between 7 and 10 days.
Laparoscopic Hartmann’s reversal is thus a very attractive proposition. Bristol Laparoscopic Associates have one of the largest published experiences of laparoscopic Hartmann’s reversal.
The essential steps of the operation comprise inserting a laparoscope into the abdominal cavity; usually 2 or 3 cms from the midline on the right hand side, approximately 8cm below the rib cage. Two additional 5mm holes are then made for the operating instruments. The adhesions are divided and the small bowel is then mobilized from out of the pelvis. The top of the rectum is then identified. After mobilizing the colon internally, the colostomy is mobilized from the abdominal wall and the stoma site closed. This is then followed by joining the colon (colostomy) to the rectum using a staple gun. Recovery is quick and relatively painless. Most patients are allowed home after 1-3 days.
Laparoscopic restoration of bowel continuity post Hartmann’s procedure (LRH) was attempted in 30 patients (11 males). All had left sided colostomies. Indications for Hartmann’s were complicated diverticulitis (21), cancer (6) and anastomotic dehiscence (3). Their median age was 65 years (range 32-89), median weight 76 kg and median BMI 26 (range 21-39). Laparoscopic surgery was completed in 28 cases (94%). There was one late conversion (lap assisted) to allow safe mobilization of a small bowel loop adherent in the pelvis. LRH was abandoned after 4 hours in a further patient when the rectum split following insertion of the staple gun.
The median operative time of the 28 completed LRHs was 75 minutes (range 40-195 minutes). The median time to resumption of light diet was 10 hrs (range 3-72hrs). There were no other intraoperative complications. Two patients died from non surgical causes. There were no anastomotic leaks. The median postoperative stay was 3 days (range 1-7). Three patients were readmitted, two with wound infections at their colostomy sites and one with abdominal pain. All responded to conservative measures.