Laparoscopic versus open reversal of a Hartmann procedure: a single-center study

Re-anastomosis after a Hartmann procedure is associated with a higher morbidity and mortality than other elective colorectal operations. The goal of this comparative study was to evaluate whether laparoscopic reversal is a justified operative approach, although the initial operation is most often an emergency laparotomy.

A retrospective analysis was conducted on data collected on all 70 patients who underwent laparoscopic and open reversal of a Hartmann procedure at the Department of Surgery, University of Schleswig-Holstein, Campus Lübeck, between January 1999 and December 2011. Together with general demographic data, the analysis included the indication for the initial Hartmann procedure, time to reversal, intraoperative findings, the choice of operative method, operating time, postoperative pain control, return of normal bowel function, length of hospital stay, and peri- and postoperative morbidity and mortality.

In most patients, the Hartmann procedure was performed after a perforated sigmoid diverticulitis. We were not able to find any statistically significant differences with respect to gender, body mass index (BMI) and American Society of Anesthesiologists classification between the laparoscopic group (LG) (N = 24 patients) and the open group (OG) (N = 46). In the LG, patients were significantly younger (p = 0.019). The median operating time was 210 min (75-245) in the LG, which was significantly longer than in the OG (166 min; 66-230). The statistical analysis of the duration of postoperative analgesic therapy (LG 7 days; OG 12 days), return to normal diet (LG 3 days; OG 4 days), return of normal bowel function (LG 3 days; OG 4 days) and length of hospital stay (LOS) (LG 10 days; OG 15 days) detected significant differences in advantage for the LG. Unplanned return to theatre during index admission was only necessary in the OG (N = 7, 15.2 %). With a median follow-up of 8 months (range 1-20), we observed a comparable number of minor complications in both groups but a significantly higher number of major complications in the OG (N = 27, 58.7%) (p = 0.001). Conversion occurred in three cases (12.5%). There was no mortality in either of the two groups.

This study was able to demonstrate the feasibility of the laparoscopic approach. In terms of postoperative results it should be seen as equivalent to the open procedure. However, the laparoscopic approach requires profound surgical expertise. The indication should be made after a careful risk/benefit analysis for each individual patient.