Laparoscopic Hartmann reversal after multiple open surgeries: surgical technique

Hartmann's reversal following prior multiple laparotomies represents on of the most technically challenging procedures in colorectal surgery. Dense adhesions, altered anatomy, and impaired tissue planes increase the risks of enterotomies, anastomotic complications, and conversion to open surgery. Although minimally invasive techniques offer improved postoperative recovery, their role in complex reoperative settings remains limited, prefering an open approach. This article presents a structured laparoscopic approach to enhance safety and reproducibility. A standardized laparoscopic Hartmann reversal was performed in a patient with a history of multiple open abdominal surgeries. The standardization proposed in this article is based on the systematic application of the following operative steps. Peritoneal access was obtained through the colostomy site using an Alexis^® retractor to ensure controlled entry and stable pneumoperitoneum. Adhesiolysis was conducted using a cold-blade technique to minimize thermal injury. Following mobilization of the rectal stump and proximal colon, a Knight-Griffen stapled colorectal anastomosis was performed. Indocyanine green (ICG) fluorescence angiography was employed to assess bowel perfusion. Anastomotic integrity was evaluated using an air-leak test, a selective reinforcement using barbed sutures when then performed. Postoperative care followed the enhanced recovery after surgery (ERAS) protocol. The procedure was completed laparoscopically without conversion. No diverting stoma was required. The postoperative course was uneventful, and the patient was discharged on postoperative day three. This approach may reduce morbidity and facilitate early recovery, supporting the adoption of minimally invasive techniques even in challenging Hartmann reversals. As experience accumulates and technologies such as ICG become integrated into routine practice, minimally invasive reversal surgery is likely to become increasingly standardized, safe and feasible even in highly complex reoperative settings.