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

Abstract

Background Several minimal invasive, mainly laparoscopic-assisted, techniques for reversal of Hartmann's procedure (HP) have been published. The purpose of this pilot study was to assess a minimal invasive procedure through the stomal site that may compare favorably with open or laparoscopic-assisted procedures in terms of operative time, hospital stay and postoperative complications. Methods HP reversal through the stomal side was attempted in 13 consecutive patients. Lysis of intraabdominal adhesions was done manually through an incision at the formal stoma side, without direct vision between thumb and index finger. The rectal stump was identified intra-abdominally using a transanal rigid club. A manually controlled stapled end-to-end colorectal anastomosis was created. Results Mean duration of operation was 81 min (range 58-109 min); mean hospital stay was 4.2 days (range 2-7 days). In two patients the procedure was converted because of strong adhesions in the lower pelvic cavity around the rectal stump that could not be lysed manually safely. No complications occurred in the patients in whom reversal was completely done through the stomal site. Conclusions In our opinion, restoration of intestinal continuity through the stomal side after HP is a feasible operation, without need for additional incisions. In the hands of a specialist gastrointestinal surgeon this technique can be attempted in all patients, as conversion to a laparoscopic-assisted or an open procedure can be performed when necessary.Restoration of bowel continuity after Hartmann's procedure (HP) is a technically challenging operation, associated with significant morbidity, with reported anastomotic leak rates of 4-16% and a mortality of up to 4% [1]. These rates can be as high as 30% and 14%, respectively, after stoma reversal in patients who had undergone a HP for complicated diverticulitis [2,3]. This is the main reason why approximately 40% of the patients after HP will never undergo restoration of digestive continuity [1]. Besides risk factors such as the patients characteristic's [4,5] and disease etiology [1,2] that cannot be altered, the most important risk factor for morbidity is the technique used for restoration of bowel continuity [6][7][8].Although many technical variations are described for reversal of HP, the optimal technique is still a matter of debate. Minimal invasive techniques (laparoscopic or endoscopic assisted), although lasting longer and technically challenging, seem to have advantages regarding less postoperative pain and disability, shorter hospital stay, and better cosmetics [8][9][10][11]. However, also in laparoscopic HP reversal all adhesions in the midline and pelvis need to be loosened. This may increase morbidity, i.e., postoperative paralytic ileus and small bowel lacerations.This study describes a new even less invasive technique for reversal of HP through the stomal site, without the need

Reversal of Hartmann’s Procedure after Perforated Diverticulitis through the Stomal Side without Additional Incisions: The SIR Procedure

“…A similar technique like SIR, but laparoscopically-assisted, has been published before [11,16]. In contrast with other laparoscopic HP reversal procedures, SIR was found to have a shorter operation time compared to HP reversal by laparotomy.…”

“…The only exclusion criterion for SIR was an accompanying symptomatic abdominal wall hernia that needed (open) correction. A brief description of the surgical procedure of SIR is stated below [11]. …”

“…Secondary endpoints were the incidence of postoperative complications and the time period between the primary procedure and HP reversal. Some data of 8 patients who underwent SIR has been used in a feasibility study before [11]. Data are represented as median (range) unless indicated otherwise.…”

“…Previously, we described a new minimally invasive method of Hartmann’s reversal performed through the stomal side [11]. As no additional incisions have to be made besides the one at the stomal side, we have called this procedure ‘stomal incision reversal’ (SIR).…”

Reduced Port Laparoscopic Reversal of Hartmann’s Procedure Using the Colostomy Site

“…Recently, utilization of the colostomy site for laparoscopic reversal of Hartmann' s procedure was introduced, and several studies have shown the feasibility of the procedure. [1][2][3][4][5] It allows for the colostomy site as an access port for the operation. However, single port surgery is technically more challenging than multiport surgery due to instrument interference and inaccessible angles from a single site.…”