Laparoscopic Reversal of Hartmann's Procedure Following An Open Emergent Resection

Laparoscopic Reversal of Hartmann’s Procedure Following An Open Emergent Resection

Sergio H Ibarra, MD¹, Alberto Gonzalez-Almada, MD¹, Rodrigo Pedraza, MD², Jean-Paul LeFave, MD², Saeed Shoar, MD³, Eric M Haas, MD². ¹Division of Minimally Invasive Colon and Rectal Surgery, Department of Surgery, University of Texas Medical School, Houston, TX, USA, ²Houston Methodist Hospital, Houston, Texas., ³Colorectal Surgical Associates, Houston, Texas

Introduction: Procedures to restore bowel continuity following a prior emergent Hartmann’s procedure are associated with high morbidity and failure rates. It is estimated that around 20-50% of patients never progress to a restorative procedure. There are few studies that evaluate the feasibility and safety of approaching these complex cases using a minimally invasive platform. We present a single center series evaluating laparoscopic-assisted reversal following an open emergent Hartmann's procedure.

Methods: The data were obtained from an IRB-approved prospectively maintained database. Consecutive patients who presented for closure following a previous emergent open Hartmann’s procedure were evaluated. All patients underwent minimally invasive reversal and were included in our study. The procedures were performed using one of four minimally invasive platforms: multiport laparoscopy (LAP), hand-assisted laparoscopy (HAL), robotic-assisted laparoscopy (RAL) and single-incision laparoscopic surgery (SILS).

Results: 40 patients were evaluated. The majority were performed using LAP technique n=25 (62.5%). The mean age, ASA, and BMI were 58.2, 2, and 27.9, respectively. Nearly half were female (n=18, 45%). The mean operative time and EBL were 207 minutes and 103 mL respectively. In all cases reversal with establishment of bowel continuity was successful, however, 9 patients underwent diverting loop ileostomy to protect the anastomosis. Eight cases (20%) required conversion to open surgery chiefly due to inability to safely expose and mobilize the rectal stump. In all converted cases, the majority of the procedure had already been accomplished using laparoscopic techniques and there were no significant differences in all outcome measures when compared to the non-converted cases. The mean LOS was 4.1 days (range 2-18). There were a total of 5 postoperative complications (12.5%) including 2 deep surgical site infections one of which required readmission. There were no anastomotic leaks.

Conclusion: Reversal of Hartmann’s stump following a prior open and emergent procedure can be successfully achieved using a minimally invasive surgical platform. The outcomes result in a higher success rate and lower rates of complications compared to historical data. The benefits of minimally invasive surgery should be considered as a feasible option when planning the surgical approach for these complex cases.