Stepwise approach for laparoscopic reversal of Hartmann's procedure

Restoration of intestinal continuity following reversal of Hartmann's procedure is an operation associated with a lengthy hospital stay, protracted convalescence, and a high morbidity rate. The advantages of minimally invasive surgery such as rapid mobilization, less postoperative pain, early restoration of bowel function, and a rapid return to a normal diet, and reduced morbidity are very useful in this procedure. Furthermore, laparoscopic reversal of Hartmann's has a comparable operative time with the open technique when performed by experienced surgeons like in this case. This interesting video shows each step of the procedure clearly. Three ports are used and the colon is divided intra-abdominally.

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Stepwise approach for laparoscopic reversal of Hartmann's procedure

Authors

J Leroy, F Costantino, J Marescaux

Abstract

Restoration of intestinal continuity following reversal of Hartmann's procedure is an operation associated with a lengthy hospital stay, protracted convalescence, and a high morbidity rate. The advantages of minimally invasive surgery such as rapid mobilization, less postoperative pain, early restoration of bowel function, and a rapid return to a normal diet, and reduced morbidity are very useful in this procedure. Furthermore, laparoscopic reversal of Hartmann's has a comparable operative time with the open technique when performed by experienced surgeons like in this case. This interesting video shows each step of the procedure clearly. Three ports are used and the colon is divided intra-abdominally.

Classification

basic techniques

Keywords

Stepwise approach, laparoscopic reversal of Hartmann's procedure

Media type

Surgical video

Duration

09'53''

Publication

2009-04

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E-publication

WeBSurg.com, Apr 2009;9(04).
URL: http://www.websurg.com/doi-vd01en2579.htm

Stepwise approach for laparoscopic reversal of Hartmann's procedure

1. Introduction 00'18''

The objective of this film is to show our technique for restoration of the colorectal continuity after reversal of Hartmann’s procedure. The technique does not begin by the removal of the colostomy and consists in entering the abdominal cavity at a distance from the abdominal scars with a number of ports depending on the intra-abdominal check-up. In this case, three ports are used. They allow to free the adhesions located at the midline and around the peristomal region.

2. Trocars introduction and abdominal cavity exploration 00'47''

Three 12mm ports are placed. The first port is introduced in a right subcostal position using a mini-open technique. After exploration of the abdominal cavity, two other ports are introduced, one in the right iliac fossa, and another one suprapubically. The optical port introduced suprapubically allows to visualize the content of the abdominal cavity from caudad to cephalad, avoiding omental adhesions located at the upper part of the abdomen. Surprisingly enough, there are no major adhesions at the level of the small bowel, which allows to perform a clear exploration of the submesocolic region.

3. Dissection of adhesions 01'42''

Omental adhesions are taken down in a minimal fashion in order to appreciate the mobility of the small bowel and free the descending colon. The freeing of adhesions is carried out thanks to the camera introduced in the suprapubic port, which gives an unusual view from caudad to cephalad, and which helps to visualize the entire lateral portion of the descending colon as well as the splenic flexure. The adhesions of the splenic flexure to the diaphragm are easily taken down using the 10mm Ligasure Atlas device combined with traction exerted by a forceps introduced in the right subcostal port.

4. Splenic flexure dissection 02'20''

Freeing of the omentum helps to take down the splenic flexure, but as it is not sufficient, posterior freeing of the splenic flexure and division of colo-omental attachments must also be achieved. Once the omentum and the lateral and posterior attachments of the splenic flexure have been freed, the descending mesocolon is further mobilized on its posterior aspect using a lateral approach. Lowering maneuvers are tried.

5. Pelvic dissection 03'40''

The next operative step is to dissect the pelvis with the objective of identifying the rectal stump. Here loose adhesions of the small bowel at pelvic level can be seen. These adhesions are gradually taken down using the electrode of monopolar scissors ensuring a minimal coagulation. It is mainly traction placed on these adhesions that contributes to free the planes. After freeing of the pelvis, the next step is to identify the rectal stump.

6. Identification and dissection of rectal stump 04'16''

Placement of an endorectal bougie facilitates this identification. Adhesions, which fix the rectal stump on the anterior aspect of the sacrum and perisacral region are taken down. The fibrotic tissues must be excised. No anastomosis can be done at this level as there may be sequels of fistula. Once the stump has been fully dissected, an Endo-GIA linear stapler, blue cartridge is applied. We control that the closure has been performed adequately. We observe here that there has been a malfunctioning in the stapling process at the level of the stapled extremity where staples have not been closed properly. A B-shaped closure of the staples means that staples have been closed perfectly. Interrupted Ethibond 2/0 stitches performed extracorporeally are used to close the gap in the stapling line. Another control of patency is being made through the anus with a Betadine solution. Only a small defect persists between 2 stitches. The next operative step is to prepare the anastomosis. We chose to divide the colon intra-abdominally close to the colostomy site. Therefore we avoid to free the colostomy.

7. Anvil introduction 06'21''

As can be seen in the picture, we prefer to introduce the anvil of a DST PCEEA circular stapler into the proximal colon through the colostomy.

8. Colon division 06'35''

Then the colon is divided as proximal to the colostomy area as possible. The anvil has to be identified through a small incision close to the stapled area thanks to a suture thread placed on the tip of the anvil. Once the anvil has been positioned, closure is complete thanks to the realization of a purse-string.

9. Colorectal anastomosis 07'51''

Then the colorectal anastomosis is achieved into the abdominal cavity, which has not been opened yet. The anastomosis is created by joining the 2 parts of the circular stapler. Once the fragile area has been perforated, we check that there is no twist as is the case here. A twist would induce an ischemia. We also check that there is no tension at the anastomotic area, which is the case here, and the freeing of mesocolic adhesions is completed. The donuts are controlled for patency.

10. Test of anastomosis 09'18''

An air test is also carried out to make sure that there is no fistula at the anastomotic area by injection of high-pressured air through the anus and by placing a clamp at the level of the proximal colon.

11. Excision of the colostomy 09'31''

The colostomy is excised.

12. Closure of parietal defect 09'36''

The different aponeurotic planes are re-approximated carefully in order to prevent the risk of late incisional hernia. No drainage is necessary. In this case, there is no mesocolic defect to close.