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19 Robotic Left-Sided Colon Resections: Unique Considerations andOptimal Setup
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and robotic colectomies using a large National Database: outcomes and trends related to surgery center volume. Dis Colon Rectum. 2016;59:535–42.
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Key Steps During Hartmann’s
Procedures toFacilitate Minimally
20
Invasive Hartmann’s Reversal
AlanE.Harzman andSyedHusain
Introduction andRationale
Hartmann’s creation (colectomy with closed rectosigmoid stump and end colostomy) is a commonly performed surgical procedure in emergency colorectal surgical practice. The most common indication for this procedure is perforation or
obstruction of the distal colon or rectum, typically secondary to diverticulitis or a
neoplastic process. Other indications include uncontrolled inammatory bowel disease involving the rectum and anal canal or dehiscence of a previously performed
colorectal anastomosis. Irrespective of the underlying etiology, the overwhelming
majority of Hartmann’s procedures are usually performed in an urgent or semiurgent setting. Given the emergent nature of these operations, surgeons are typically
focused on addressing the acute situation at hand, and measures to facilitate
Hartmann’s closure are often ignored.
Hartmann’s closure has been historically associated with a high complication
rate attributable to the technical complexity of this operation [1]. For this reason,
many patients with Hartmann’s pouches are never offered a reversal [2]. While
there is a plethora of evidence indicating that a laparoscopic approach ameliorates
The authors would like thank the members of the SAGES Colorectal Surgery Masters Program
Collaboration Facebook Group for their recommendations regarding this chapter.
A. E. Harzman (*) ∙ S. Husain
The Ohio State University, Department of Surgery, Columbus, OH, USA
Ohio State University Wexner Medical Center, Division of Colon and Rectal Surgery,
Columbus, OH, USA
e-mail: Alan.Harzman@osumc.edu; Syed.Husain@osumc.edu
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020
P. Sylla et al. (eds.), The SAGES Manual of Colorectal Surgery,
https://doi.org/10.1007/978-3-030-24812-3_20
307
308
many complications associated with Hartmann’s closure [3, 4], there has been
underutilization of this technique, and the adoption of minimally invasive techniques for Hartmann’s closure has lagged behind that observed for other colorectal procedures [5].
In this chapter, we discuss the measures that can be undertaken at the time of
Hartmann’s creation to potentially rectify common difculties experienced during
closure. We believe that adaption of these techniques can lead to improved stoma
reversal rates and facilitate utilization of laparoscopic technique for Hartmann’s
reversal.
A. E. Harzman and S. Husain
Indications andContraindications
There are no absolute contraindications to the operative maneuvers discussed below.
Hemodynamic instability can be considered a relative contraindication as most of
these measures can lead to prolongation of operative time. Operating surgeons
should use their judgment to determine the appropriateness of the measures in an
unstable patient where an expeditious laparotomy may prove more benecial than
maneuvers to facilitate a future operation. Given that many patients will never have
the colostomy closed, it is also unwise to focus strictly on facilitating colostomy
closure. The ideal is creating a good colostomy that the patient could keep forever
while setting up for a future closure if possible.
Principles andQuality Benchmarks
Timing ofHartmann’s Reversal
The need to resist patient’s demands for an expeditious stoma reversal cannot be
overstated. Stoma reversal is almost never an urgent operation, and it is important to
permit a sufcient interval between the index operation and stoma reversal to allow
time for the thick vascularized adhesive bands to evolve into avascular, lmy adhesions. We recommend an interval of at least 6 months between Hartmann’s creation
and reversal, both to minimize trouble with adhesions at the second operation and to
allow the patient to return to an otherwise normal physiologic state.
Impact ofLaparoscopic Hartmann’s Procedure
In the authors’ opinion, the most important maneuver to minimize complications
and ensure successful Hartmann’s reversal is to perform Hartmann’s operation laparoscopically. Laparoscopy has been proven to be associated with less adhesion formation than an open approach in a variety of surgical settings [6]. With the
emergence of literature favoring “straight” laparoscopy, hand-assisted laparoscopic
colectomy has been largely supplanted by straight laparoscopy. Despite its
20 Key Steps During Hartmann’s Procedures toFacilitate Minimally Invasive…
309
shortcomings hand assistance may be particularly useful during emergency
Hartmann’s creation for acute, complicated diverticulitis, where presence of inammation and abscess formation may preclude successful completion of the case using
a straight laparoscopic technique. This is particularly true when most of the case can
be accomplished laparoscopically, but one portion of the case, such as dissection of
a phlegmon tightly adherent to the left pelvic side wall or retroperitoneum or takedown of a colovesical stula, can be performed more safely and expeditiously using
direct hand palpation, dissection, and retraction. When needed, conversion from
laparoscopic to hand assist or to open should be done prior to creating a signicant
injury or greatly prolonging operative time.
In cases where a laparoscopic approach is abandoned due to hemodynamic instability or colonic dilation precluding safe visualization of operative eld, use of an
adhesion barrier should be considered. While adhesion barriers have never been
tested in this particular clinical setting, there is plenty of evidence that they result in
signicant reduction in adhesions in a variety of surgical settings comparable to
Hartmann’s [7, 8] creation. Another step that can minimize adhesions is the restora-
tion of peritoneal lining by careful peritoneal approximation during midline incision
closure. Finally, placing omentum under the midline laparotomy incision can minimize adhesions between the anterior abdominal wall and underlying small bowel
loops which can present a challenge during Hartmann’s closure.
Operative Technique: Surgical Steps
The following are techniques to aid later laparoscopic stoma closure, broken down
by the steps of the original Hartmann’s operation.
• Opening
– Perform a laparoscopic Hartmann’s procedure when possible.
• Resection
– Proximal extent: Resect only what is required, and do not mobilize the splenic
exure unless absolutely required to form the colostomy. This will allow it to
be newly mobilized at the stoma closure and maximum length obtained.
– Distal extent: For inammatory disease such as diverticulitis, dividing
just distal to the inammation leaves sigmoid colon and therefore
decreases the chance that the rectosigmoid will retract into the pelvis.
However, the remaining sigmoid will then need to be resected at the time
of stoma closure. Therefore, the authors would divide at the rectosigmoid
junction (where the tinea splay out) at the rst operation. Do not, though,
divide lower than that unless absolutely necessary. Certainly do not divide
at or distal to the anterior peritoneal reection if the goal is to close the
stoma later. Doing so makes the rectal stump exceptionally difcult to
identify and dissect from the vagina and bladder.
– Do not divide the IMA or the superior hemorrhoidal vessels, and do not vio-
late the mesorectal plane. Save the holy plane to use to nd the rectum later.
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A. E. Harzman and S. Husain
– Avoid topical procoagulants as a means of hemostasis, especially on the rectal
stump staple line. These can cause a great deal of inammation and scarring.
• Stoma creation
– As above, avoid mobilizing the splenic exure unless required to create a
good stoma.
– Remember that for many patients the stoma will be permanent.
– Making a large trephine in the fascia may increase the risk of parastomal her-
nia. However, it may also allow the patient to regain bowel function more
quickly than a tight stoma. A large parastomal hernia can make stoma closure
difcult, although a small hernia can make it easier to dissect the stoma from
the abdominal wall.
– Wrap an adhesion barrier around the stoma before closing when feasible.
– For more details regarding optimizing stoma formation, please refer to Chap.
36 on best practices in planned and unplanned stoma creation.
• Dealing with the rectal stump and pelvis
– Place dyed, nonabsorbable sutures on the staple line on the rectal stump.
These can be placed through the corners of the staple line or through the peritoneum immediately adjacent to them (Fig.20.1a, b).
– Some surgeons use those sutures to tack the rectal stump to the anterior
abdominal wall. The authors prefer to tack them to the peritoneum along the
sacral promontory, medial to the ureters. This does not require a particularly
long stump and does not create any space that could create an internal
hernia.
– Cut the sutures 3–5cm long to make them easier to nd at the time of stoma
closure.
• Closing
– Thoroughly explore and irrigate the abdomen.
a
Fig. 20.1 (a, b) Intraoperative identication of the suture marking the rectal stump during laparo-
scopic Hartmann’s reversal. (a) The suture can be identied, but the rectal stump is tightly adherent
to a loop of small bowel that is partially covering it. (b) Following dissection of the small bowel
loop, the rectal stump is exposed. (Both: Courtesy of Dan Popowich, MD)
b
20 Key Steps During Hartmann’s Procedures toFacilitate Minimally Invasive…
– Leave a drain in the pelvis to prevent accumulation of contaminated uid and
subsequent abscess formation in the pelvis.
– Bring the omentum down to underlie the incision. If possible, place the tip in
the pelvis to prevent the small bowel from adhering to the pelvis or rectal
stump.
– If the operation is done open, use an adhesion barrier under the midline wound
and in the pelvis.
– Close the peritoneum as part of the fascial closure. The goal of this is to mini-
mize the raw surface area for abdominal wall adhesions to form.
– Leave the skin open to lower the rate of wound infection and therefore the rate
of hernia formation and/or dehiscence.
• Postoperative course
– Ensure that the patient has fully recovered from the rst operation. This
includes returning to work and all normal activities.
– Wait at least 6months before attempting stoma reversal. Stoma reversal may
be possible at 3months, but adhesions will continue to transition from inammatory to imsy between 3 and 6months. A failed attempt at stoma closure
will make any further attempt exponentially harder, so it is better to wait the
full 6months.
– Some patients are told after Hartmann’s procedure that their stoma is not
reversible. When this is true, it is imperative to clearly dictate the reasons and
explain them to the patient. It is incumbent on the surgeon closing a stoma
created by someone else to understand what was done at the rst operation
and to know which if any of the above maneuvers were performed.
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Pitfalls andTroubleshooting
It is imperative to discuss the reasons why even experienced laparoscopic surgeons
often opt to perform Hartmann’s reversal using an open technique. The technical
challenges deterring laparoscopic Hartmann’s closure or prompting conversion to
open technique include the following issues discussed below.
Adhesions
Since many Hartmann’s operations are performed to treat distal colonic or rectal
perforations, these procedures are often complicated by signicant peritoneal contamination leading to peritonitis and abscess formation which in turn result in signicant adhesion formation (Fig.20.2). The fear of hostile adhesions often represents
the major deterrent to laparoscopic closure of a colostomy. Thus it is imperative to
suction out any residual blood, purulence or fecal material from the peritoneal cavity at time of Hartmann’s creation. Furthermore, copious peritoneal irrigation with
warm saline should be undertaken to decrease the burden of peritoneal
contamination.
312
Fig. 20.2 Adhesions of
small bowel loops to
Hartmann’s pouch require
careful lysis of adhesions.
Identication of the rectal
stump is facilitated by
visualization of the
marking suture that was
placed at the original
operation. (Courtesy of
Dan Popowich, MD)
A. E. Harzman and S. Husain
Presence ofaLarge Ventral Wall Hernia
Given the contaminated nature of these cases, many Hartmann’s creations are
associated with incisional complications ultimately leading to incisional hernias
[9]. A large ventral or parastomal hernia can present a daunting task especially if
laparoscopic reversal is planned. Utilization of a laparoscopic approach at the
time of initial stoma creation obviates the need for a large abdominal incision.
Whether this reduction in incision length translates into a lower incidence of incisional hernia remains a topic of debate. It is quite plausible, however, that the
incisional hernias occurring at a laparoscopic extraction site are much smaller and
easier to manage than those occurring after a generous midline laparotomy. In
addition, the skin of the midline wound should be left open at the time of
Hartmann’s operation if there is signicant contamination. Wound infection, even
those that can be managed by “popping out a few staples,” can lead to incisional
hernia formation. Certainly efforts to avoid wound dehiscence and evisceration
will also contribute to reduced incisional hernias. Avoiding a large abdominal
wall fenestration for stoma exteriorization can also minimize the risk of parastomal hernia. On the other hand, prophylactic mesh placement to avoid parastomal
hernia is not indicated unless one is certain that the stoma will not be closed later.
For additional details, please refer to Chap. 37 on prophylactic mesh placement
during laparoscopic stoma creation.
Difficult Rectal Stump Dissection
Identication and dissection of the rectal stump represents another component of
Hartmann’s reversal that can prove to be quite challenging. The rectal stump often
tends to adhere to the lateral pelvic wall in close proximity to ureters and major
pelvic vessels. In other cases, the rectal stump forms dense adhesions to the bladder
or female genital organs leading to a quite tedious dissection at time of reversal.
Copious pelvic irrigation with removal of purulent/fecal material can minimize
20 Key Steps During Hartmann’s Procedures toFacilitate Minimally Invasive…
these adhesions. Furthermore, interposition of omentum between the rectal stump
and pelvic organs can also facilitate rectal stump dissection at time of closure.
Finally, it is very important to preserve as much rectum as possible at the time of
Hartmann’s creation. A long rectal stump lends itself to easy identication at time
of reversal. Barring malignant cases where it is important to achieve a distal resection margin, rectal division should be carried out as close to the pathology as possible. Every attempt should be made to avoid violation of mesorectal planes as this
can lead to dense posterior adhesions which make identication and dissection of
rectal stump very difcult at time of closure.
313
Rectal Stump Retraction
In addition to forming adhesions to the surrounding structures, the divided rectum
often retracts into the pelvic cavity leading to “bunching up” of the rectal stump. A
retracted rectal stump frequently folds upon itself creating sharp angles which can
be very difcult to negotiate with the rigid EEA stapler. This inability to advance the
EEA stapler to the end of the rectal stump can lead to the creation of an inadvertent
end-to-side rather than end-to-end colorectal anastomosis. While most of the endto- side anastomoses have excellent functional results, the rectal blind pouch can
sometimes lead to bacterial stasis with its attendant issues. Worse yet, adhesions of
the vagina or bladder to the retracted stump can lead to inadvertently incorporating
them into the anastomosis. Retraction of the rectal stump into the pelvic cavity can
be prevented by leaving a long rectal stump and tacking the stapled end to the anterior abdominal wall or retroperitoneum with the help of an anchoring stitch.
Inability toAccomplish aTension-Free Anastomosis
Inadequate proximal colonic length often prompts surgeons to convert to an open
technique to be able to accomplish tension-free anastomosis. Often, this situation is
due to extensive mobilization of left colon and splenic exure at the index operation. We advocate limiting left colonic mobilization to the bare minimum required
for exteriorization of the colonic end for stoma creation. Splenic exure dissection
is typically discouraged unless absolutely necessary for exteriorization.
Outcomes
There are no outcome data for the specic techniques described above. Chapter 21
covers the procedure of minimally invasive Hartmann’s reversal, for which there are
data that are cited there and in the references below. However, the authors of those
studies do not specically identify what steps they or other surgeons took in the
initial operation.
314
A. E. Harzman and S. Husain
Conclusion
There are multiple strategies during stoma creation that can maximize the possibility of a minimally invasive stoma closure. Most of these are also relevant to open
stoma closure as well. However, the surgeon must also remember that many stomas
will never be closed, so making stoma closure easier should not come at the cost of
a good initial stoma. Nor should it signicantly prolong the rst operation and delay
getting a sick patient out of the operating room safely.
References
1. Roig JV, Cantos M, Balciscueta Z, Uribe N, Espinosa J, Rosello V, etal. Hartmann’s operation:
how often is it reversed and at what cost? A multicentre study. Color Dis. 2011;13(12):e396–402.
2. Hallam S, Mothe BS, Tirumulaju R.Hartmann’s procedure, reversal and rate of stoma-free
survival. Ann R Coll Surg Engl. 2018;100(4):301–7.
3. Brathwaite S, Kuhrt M, Yu L, Arnold M, Husain S, Harzman AE.Retrospective evaluation of
laparoscopic versus open Hartmann’s reversal: a single-institution experience. Surg Laparosc
Endosc Percutan Tech. 2015;25(5):e156–8.
4. Arkenbosch J, Miyagaki H, Kumara HM, Yan X, Cekic V, Whelan RL.Efcacy of laparoscopic-
assisted approach for reversal of Hartmann’s procedure: results from the American College
of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Surg
Endosc. 2015;29(8):2109–14.
5. Brathwaite S, Latchana N, Esemuede I, Harzman A, Husain S.Risk factors for surgical site
infection in open and laparoscopic Hartmann closure: a multivariate analysis. Surg Laparosc
Endosc Percutan Tech. 2017;27(1):51–3.
6. Mais V.Peritoneal adhesions after laparoscopic gastrointestinal surgery. World J Gastroenterol.
2014;20(17):4917–25.
7. Kumar S, Wong PF, Leaper DJ.Intra-peritoneal prophylactic agents for preventing adhesions
and adhesive intestinal obstruction after non-gynaecological abdominal surgery. Cochrane
Database Syst Rev. 2009;1:CD005080.
8. Metwally M, Watson A, Lilford R, Vandekerckhove P. Fluid and pharmacological agents
for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev.
2006;2:CD001298.
9. Timmermans L, Deerenberg EB, Lamme B, Jeekel J, Lange JF. Parastomal hernia is an
independent risk factor for incisional hernia in patients with end colostomy. Surgery.
2014;155(1):178–83.
Laparoscopic andRobotic Hartmann’s
Reversal: Strategies toAvoid
21
Complications
DavidA.Kleiman andStevenA.Lee-Kong
Introduction andRationale
Approximately 65% of the population over age 65 develop sigmoid diverticulosis
[1]. Of those, approximately 20% will develop diverticulitis during their lifetime,
requiring some type of medical or surgical intervention [2]. The management of
diverticulitis accounts for nearly $2.7 billion in healthcare-related costs within the
United States annually and is a common indication for emergency surgery [3].
Current clinical practice guidelines recommend emergent surgery for acute
diverticulitis in patients with peritonitis or for those in whom non-operative management of diverticulitis has failed [2]. A Hartmann’s procedure, which involves
segmental sigmoid colectomy with creation of an end colostomy and a blind-ending distal rectal stump, was initially described for the management of acute malignant large bowel obstructions in 1923 [4]. It has since become the widely accepted
standard surgical treatment of sigmoid diverticulitis in the emergent setting, particularly for Hinchey III and IV disease (Fig.21.1). It remains an attractive option
to many surgeons because by not creating a colorectal anastomosis, operative times
are shorter, there is usually no need to perform a splenic exure mobilization, and
there is no risk of anastomotic complications (leakage or bleeding). However, the
real morbidity of a Hartmann’s procedure is often associated with the subsequent
reversal operation. Since Hartmann’s reversal can require a reoperative laparotomy, there can be signicant associated risks, including surgical site infections,
D. A. Kleiman
Division of Colon and Rectal Surgery, Lahey Hospital and Medical Center,
Burlington, MA, USA
Tufts University School of Medicine, Boston, MA, USA
e-mail: David.kleiman@lahey.org
S. A. Lee-Kong (
New York Presbyterian Hospital, Columbia University, New York, NY, USA
e-mail: Sal116@cumc.columbia.edu
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020
P. Sylla et al. (eds.), The SAGES Manual of Colorectal Surgery,
https://doi.org/10.1007/978-3-030-24812-3_21
*)
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