Laparoscopic reversal of Hartmann's procedure

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Laparoscopic reversal of Hartmann's procedure

Authors

M Simone, J Marescaux

Keywords

sigmoïdite perforée, Hartmann, rétablissement de la continuité colorectale, Hartmann's procedure, complicated acute diverticulitis

Media type

Surgical video

Duration

06'40''

Publication

2006-04

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E-publication

WeBSurg.com, Apr 2006;6(04).
URL: http://www.websurg.com/doi-vd01en1742.htm

Laparoscopic reversal of Hartmann's procedure

1. Patient history 00'12''

We present the case of a 73-year-old female patient previously operated for perforated diverticulitis 3 months ago. A laparoscopic resection of the sigmoid colon was done at that time. The procedure was in standard Hartmann’s fashion with exteriorization of the afferent colon to the left flank and the closure of the rectal pouch. We insufflate the pneumoperitoneum utilizing Palmer’s technique

2. Pneumoperitoneum 00'31''

with a Veress needle in the left subcostal region to avoid the area of previous surgery and adhesions. For the same reason, the 1st port was introduced with open technique. Preoperatively, the colostomy was covered with a gauze and sterile wrap.

3. Trocar placement 00'54''

Four 10mm ports were placed as shown. As we had expected, some adhesions were present. They were lyzed with monopolar scissors to provide exposure. We used the Ligasure for the larger vessel-laden adhesions.

4. Start of the procedure 01'20''

We seek to identify the rectal stump in the pelvis. The patient is placed in a Trendelenburg position, and the small bowel is retracted to the right side of the abdomen. The remainder of the adhesions in our surgical field are divided for mobilization of the small bowel. Time spent preparing for the exposure of the procedure will aid in the efficiency of the procedure later on. These time savings will be had with the operative field being stagnant and without interruption of re-exposure maneuvers during the procedure. In this case, we can see that the inflammatory response is completely resolved and permits easier dissection than of attempting a reversal a few weeks after the resection. The distal sigmoid and the rectal stump can be mobilized easily as seen here. As there is some redundant sigmoid left in place we will plan to resect this 15cm segment.

5. Mobilization of rectosigmoid stump 02'22''

Preoperatively, the barium enema did reveal a few diverticula in this segment. We begin to dissect the mesentery and surrounding fat with coagulation scissors and Ligasure. Some surgeons will leave a thick Prolene stitch to identify the stump more easily during reversal. We don’t routinely perform this as with the visualization obtained from the laparoscope in the pelvis is better than the open technique. Take note the operative field and the ease of the procedure. As stated earlier, we have a total of 4 port sites in place. A suprapubic port is utilized for retraction, the 2 operative ports from the right mid-clavicular line, and the optic port is above the umbilicus. Henri Albert Hartmann, a French surgeon described this procedure in 1921 at a French Congress of Surgery. In 1934 in his rectal surgery proclamation he describes his successful experience of 34 patients treated with this philosophy. Today, this is the gold standard treatment of sigmoid perforations due to benign disease. He arrived at the appropriate level to perform the anastomosis. The Endo-GIA stapler is utilized for this resection and the specimen segment is removed and placed in a retrieval bag.

6. Preparation of rectal stump 04'03''

Since this was a small colonic specimen that will be removed from the current “ostomy” site later. Having the rectal stump prepared for the anastomosis, we now begin mobilization of the proximal end of the colon. The proximal small bowel is retracted to the right side of the abdomen. We will require the afferent colon to reach up to the rectum just as in a standard left colectomy. As some of the mobilization was done 3 months ago, we must ascertain the reperitonealization along the left colon and note our anatomical landmarks as the postoperative anatomy can be distorted allowing for the unassuming surgeon to dissect onto a tissue plane incorrectly and coagulate. Lateral attachments are released and the anatomy adjacent to Toldt’s fascia is identified including the left ureter and iliac vessels. The Ligasure device and scissors were used to further dissection. The splenic flexure was mobilized and good approximation of both ends was achieved before proceeding to the anastomosis. The colostomy was dissected free from the skin. Once liberated, this end was prepared extracorporeally for the anastomosis for the placement of the anvil and the purse-string device. The beforementioned distal sigmoid specimen is also removed from the abdomen at this time. The colon is then reintroduced into the abdominal cavity and the pneumoperitoneum is reinsufflated after suturing the fascia of the “ostomy” site.

7. Dissection of the colostomy 05'45''

As well, the surgical team changes gloves to maintain sterile conditions. The trocar of the EEA device is advanced through the rectal stump and the anvil is then advanced without tension to the stapler, and the orientation is checked to make sure there is no torsion on the left colon. This is our standard procedure.

8. Anastomosis 06'00''

We insufflate the rectum trans-anally to confirm no air leak. This completes the procedure. The patient was initiated on a diet the 1st postoperative day, was ambulating without assistance, and required minimal narcotic analgesics postoperatively. We feel the adaptation of the Hartmann’s philosophy with a laparoscopic approach is another advance in the surgical treatment of perforated diverticular disease.