Laparoscopically assisted reversal of Hartmann procedure

Restoration of intestinal continuity following Hartmann procedure is an operation associated with a lengthy stay in hospital, protracted convalescence, and a high morbidity rate. With the aim of using 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, the laparoscopic modality was employed. The objective of the present study was to investigate the usefulness of laparoscopic restoration of intestinal continuity following Hartmann procedure.

A total of 71 patients who, in the period between 1995 and 2005 within the framework of the prospective multicenter study "Laparoscopic Colorectal Surgery Study Group," underwent a laparoscopically assisted restoration of bowel continuity following Hartmann procedure, were investigated.

In 62 patients (87%), the laparoscopic procedure was completed as planned, whereas 9 cases had to be converted to open surgery-mostly on account of massive intra-abdominal adhesions. The 39 male (55%) and 32 female (45%) patients had an average body mass index of 25 (range, 19 to 38), a height of 168 cm (range, 150 to 190 cm), and a weight of 72 kg (range, 49 to 103 kg). Mean operating time was 164 min (range, 60 to 410 min) and the intraoperative blood loss 196 mL (range, 10 to 1000 mL). Five patients (7%) received packed red cells. In all, 85.9% of the procedures (n=61) were free of complications. The most common intraoperative complications were injuries to the bowel and problems with the anastomosis (dehiscence, difficult stapling), each occurring in 5.6% of the cases (n=4). Intraoperative lesions to the ureters (0%), the bladder (n=1/1.4%), and blood vessels (n=1/1.4%) played a numerically subordinate role. Purely parenteral nutrition was applied up to the third postoperative day (range, 0 to seventh postoperative day). In those patients who were able to take a liquid meal on the third postoperative day (range, first to eighth postoperative day), enteral nutrition was initiated on the fifth postoperative day (range, second to tenth postoperative day). On average, bowel movements were restored on the fourth postoperative day (range, second to ninth postoperative day). Patients in whom a bladder catheter was placed for the operation had it removed on the third postoperative day (range, first to twelfth postoperative day) and had normal urination thereafter. In Hartmann procedure, patients without such a catheter, normal urination was possible from postoperative day 1 onward (range, 0 to second postoperative day). Postoperative complications included hematomas/abscesses (n=3/4.2%), transit disorders (n=2/2.8%), surgery-requiring ileus (n=2/2.8%), cardiopulmonary complications (n=1/1.4%), and surgery-requiring hemorrhage (n=1/1.4%), with other complications accounting for 4.2% (n=3). The median hospital stay was 11 days (range, 5 to 35 d); the mortality rate was 1.4% (n=1).

Reversal of Hartmann procedure employing the laparoscopic modality is compatible with acceptable morbidity and mortality rates. The elevated conversion rate is a reflection of the fact that the operation is technically demanding.