Totally laparoscopic reversal of Hartmann's procedure

Authors

Abstract

This video presents a totally laparoscopic reversal of Hartmann’s procedure in a patient with a surgical history of laparotomy for colorectal surgery.

Classification

basic techniques

Keywords

laparoscopy, reversal Hartmann, setting up of PCEEA, circular stapler

Media type

Duration

15'00''

Publication

2008-09

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Audio

Subtitles

E-publication

WeBSurg.com, Sept 2008;8(09).
URL: http://www.websurg.com/doi-vd01en2387.htm

Totally laparoscopic reversal of Hartmann's procedure

1. Clinical case presentation 00'01''

This video demonstrates the standard surgical technique for a totally laparoscopic reversal of Hartmann’s procedure. We will also show you a new approach for a totally laparoscopic colorectal anastomosis that allows to restore intestinal continuity after the Hartmann procedure. This is the case of a male patient who has had a previous sigmoidectomy via laparotomy because of a voluminous adenoma that was non-resectable endoscopically. Intraoperatively, we observed a dehiscence of the colorectal anastomosis. This led us to perform a Hartmann’s procedure. Six months postoperatively, once the preoperative workup was completed, laparoscopic restoration of intestinal continuity was decided upon. During the course of surgery, we accidentally injured the vas deferens and we used a new completely closed, ie, total laparoscopic technique, to restore bowel continuity.

2. Patient and trocar position 00'46''

The patient is placed in a dorsal decubitus with a reverse Trendelenburg position, his legs are apart. The 1st trocar is introduced using an open approach under visual control around 5cm away from the previous laparotomy scar. Careful positioning away from the adhesions induced by the previous surgery helps to avoid any type of bowel injury. This trocar placement also helps us to perform adhesiolysis at midline level and helps to create an adequate operative field. Once we have completed adhesiolysis at the site of the midline laparotomy, we introduce the 1st trocar, a 10mm one, at umbilical level. The other trocars will be placed according to the left colonic resection technique described on WeBSurg.com.

3. Dissection of the rectal stump 01'34''

Freeing of the adhesions should not be a priority since it is suspected that these may be at the origin of postoperative complications. The 1st step of this surgical procedure is to carefully dissect the rectal stump. Its identification is facilitated by the placement of intrarectal bougies. Here we can see the dissection of the peritoneum that covers the rectal stump. To achieve this, we use traction and counter-traction combined with monopolar cautery. Continued dissection aims at obtaining a minimal dissection of the rectal stump and you can now see the vas deferens. As a reminder, minimal dissection has the objective of avoiding another division of the rectal stump. Therefore, we can preserve the functionality of the excluded rectal reservoir. Once dissection is achieved, we have obtained a well-vascularized and sufficiently mobilized rectal stump which will help to create a posterior anastomosis. We will now prepare the proximal segment of the colon. At this point, we will perform the colorectal anastomosis without mobilizing the stomy, which will be mobilized last at the end of the procedure. This allows us to reduce the risk of associated infection and ensure a totally laparoscopic approach without loss of pneumoperitoneum that would impair exposure making the operative field difficult to handle.

4. Distal colon mobilization 03'11''

We mobilize the proximal segment of colon using monopolar cautery and free the adhesions at the level of the stomy in order to achieve total freeing of the adhesions at the left iliac fossa. Mobilization of the descending colon, or proximal segment of colon, is carried out with the aid of monopolar cautery using a lateral approach at the level of the left paracolic space. Median traction is exerted towards the colon and helps to achieve a perfect dissection. Dissection is extended until we obtain an entirely supple proximal colon that will allow for a tension-free anastomosis. Because of this, mobilization of the splenic flexure is not done routinely; in this way we reduce operative time and limit the complications associated with this complex procedure. Lateral dissection is continued until we reach the left Toldt’s fascia. We then free a few colo-colonic adhesions as well as adhesions located at the left iliac fossa. We apply lateral traction on the colon in order to control its suppleness once complete mobilization has been achieved. We divide a few adhesions at the level of the left mesocolon using the Ligasure device. We then select the new site for the colonic division, the mesocolon will be identified and dissected using the Ligasure device.

5. Preparation of the anvil and its abdominal placement 05'41''

Thanks to the external view we can now see the preparation of the anvil’s head of the circular stapler (PCEEA), which will be introduced through the stomy by a forceps. A 20cm suture is placed at the superior extremity and will help to retrieve the device later on as well as its manipulation in the colon. Thus we can precisely observe the first step in the restoration of the colorectal anastomosis. The laparoscopic view enables to control the progress of the anvil’s head during its colonic introduction. It is then advanced beyond the operative site that has already been selected and freed by the Ligasure device. We then perform a partial colonic resection using a 60mm linear stapler-EndoGIA device (blue cartridge) by placing the head of the circular stapler proximally. The suture is then caught in the line of the mechanical staples as you can see here. We perform a colotomy using scissors and retrieve the suture material that will help us to, first, correctly place the head of the anvil of the circular stapler, and then complete the colonic division by a second application of 60mm linear staples (blue cartridge). Once the colonic division has been achieved, we reposition the head of the anvil of the circular stapler and fashion a purse-string. For this we use a Vicryl 2.0 allowing for a good safety margin of tissue after completion of the colorectal anastomosis. We then remove the spike-end of the stapler out of the abdominal cavity using a laparoscopic forceps.

6. Circular stapler insertion and colorectal anastomosis 08'02''

The circular stapler is then introduced trans-anally. Beforehand, dilatation and lavage are performed to ease its introduction and reduce the risk of operative incontinence. We then perforate the rectal stump and assemble the whole system to create the anastomosis. At this moment, we notice that the proximal colon will not twist and the circular stapler is used in order to achieve the colorectal anastomosis.

7. Air test 08'57''

We perform an air test, showing that there is no dehiscence of the anastomosis.

8. Removal of stoma 09'09''

Reconstruction is then completed laparoscopically after reversal of Hartmann’s procedure. We then extract the stomy and close the defect left by the laparotomy using an anterior approach.

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