Surg Endosc (2009) 23:496–502 DOI 10.1007/s00464-008-0052-4 Laparoscopic and open reversal of Hartmann’s procedure—a comparative retrospective analysis Haggi Mazeh Æ Alexander J. Greenstein Æ Kristin Swedish Æ Scott Q. Nguyen Æ Aaron Lipskar Æ Kaare J. Weber Æ Edward H. Chin Æ Celia M. Divino Received: 10 July 2007 / Accepted: 18 June 2008 / Published online: 17 July 2008 Ó Springer Science+Business Media, LLC 2008 Abstract and open groups were 193 versus 209 min, respectively Background Restoration of intestinal continuity after (p = 0.33). The laparoscopic group had a significantly Hartmann’s procedure has traditionally required laparot- lower estimated blood loss of 166 versus 326 mL omy. This study compares our experience with (p \ 0.0005), shorter time to bowel function return (4.1 laparoscopic and open reversal of Hartmann’s procedure. versus 5.2 days, p \ 0.05), and a shorter hospital stay (6.4 Study design All laparoscopic and open Hartmann’s versus 8.0 days, p \ 0.05). The major complication rate reversal procedures performed between January 1998 and was also significantly lower in the laparoscopic group than June 2006 were reviewed. Patients with laparoscopic in the open group (4.8% versus 12.1%, p \ 0.05). reversal were retrospectively matched by age, body mass Conclusions Laparoscopic reversal of Hartmann’s pro- index (BMI), and indication to controls with open reversal. cedure is a safe and practical alternative to open reversal. It Demographic data, perioperative course, and postoperative can be performed with similar operative time, fewer complications were documented. complications, and a faster recovery time. Conversion Results We identified 41 patients who underwent lapa- during the reversal procedure was significantly impacted roscopic reversal of Hartmann’s procedure and these were by severity of adhesions and marking of the rectal stump. matched to 41 patients with open reversal. The groups had similar average age and BMI. The predominant indication Key words Hartmann’s procedure Á Reversal Á for surgery in both groups was diverticular disease. Con- Laparoscopy Á Colostomy closure version to laparotomy occurred in eight patients (19.5%), and was due to dense adhesions or difficulty in identifica- Abbreviations tion of the rectal stump. Adhesions were significantly BMI body mass index greater in the conversion group (p \0.05), and the rectal LAHR laparoscopic-assisted Hartmann’s reversal stump was not marked in any of these cases. The most OHR open Hartmann’s reversal common short-term complications were ileus and surgical PCA patient-controlled analgesia site infection. There were no anastomotic leaks and no SICU surgical intensive care unit mortalities. The mean operative times in the laparoscopic H. Mazeh In 1923, a French surgeon named Henri Albert Hartmann Department of General Surgery, Hadassah-Hebrew University described an end colostomy procedure for the treatment of Medical Center, Jerusalem, Israel e-mail: [email protected] proximal rectal cancer [1]. Although originally indicated for carcinomas of the lower sigmoid and upper rectum, the A. J. Greenstein Á K. Swedish Á S. Q. Nguyen Á A. Lipskar Á procedure is used today for a variety of indications, mainly & K. J. Weber Á E. H. Chin Á C. M. Divino ( ) perforated diverticulitis, ischemic colitis, and colonic Department of Surgery, Mount Sinai School of Medicine, 5 East 98th Street, 1259, New York, NY 10029, USA obstruction. Other indications include traumatic perfora- e-mail: [email protected] tions, volvulus, inflammatory colitis, and anastomotic leaks 123 Surg Endosc (2009) 23:496–502 497 [2]. After recovery from the initial surgery, colostomy Details of the initial Hartmann’s procedure were recor- reversal and restoration of bowel continuity is indicated in ded. All procedures performed for diverticulitis were given selected patients. This second-stage procedure requires a a Hinchey class of 1–4. Whether the rectal stump was major abdominal surgery and is associated with a low but marked or not was also noted. Marking consisted of either real mortality rate and a significant morbidity rate ranging suturing the stump to the abdominal wall or placement of from 10 to 50% [3–5]. lengthy, nonabsorbable sutures in the stump. Minimally invasive techniques for colorectal surgery In both the index procedure and at the reversal proce- have evolved since the early 1990 s. Advantages of the dure, the need for splenic mobilization and the use of laparoscopic approach in colectomies such as decreased closed suction drains were recorded. Adhesions at the morbidity, postoperative pain, hospital stay, and faster reversal procedure were graded by the surgeon as none (0), return to normal activity [6–10] have led to the application mild (1), moderate (2), or severe (3). The use of anti- to other procedures such as reversal of Hartmann’s pro- adhesive materials at the index procedure was also cedure. Several small series have reported successful documented. laparoscopic assisted Hartmann’s reversal (LAHR) [11– 13], and a recent systematic review has confirmed that Surgical procedure minimally invasive benefits apply for LAHR [14]. Never- theless, the data comparing laparoscopic and open The interval between the original procedure and the Hart- Hartmann’s reversal is limited. The aim of this study is to mann’s reversal was determined by each attending surgeon present a teaching university hospital’s experience with and the patient. Documented considerations included LAHR and compare short-term outcomes with those of patient’s preference, findings on initial procedure, as well open reversal. as metabolic and overall clinical status. Results of preop- erative evaluation of the colon by colonoscopy or barium enema were recorded. All patients underwent preoperative Patients and methods mechanical bowel preparation and enemas to clear the rectal stump. After the approval of the Institutional Review Board of the Prior to anesthetic induction, pneumatic compression Mount Sinai School of Medicine, we searched the medical boots were placed in all cases, and intravenous antibiotics record database of the Mount Sinai Medical Center for were given approximately 30 min preoperatively. A uri- keywords ‘‘colostomy closure,’’ ‘‘Hartmann’s procedure,’’ nary catheter was routinely inserted and patients were ‘‘reversal of Hartmann’s colostomy,’’ and ‘‘large bowel placed in either split-legged or modified lithotomy position. stoma closure’’ for patients [18 years of age who were Video monitors were placed on the left side of the patient, admitted between January 1998 and June 2006. Charts were with the surgeon and assistant standing on the right. Initial reviewed to identify patients post Hartmann’s procedure port insertion was accomplished by the open Hasson who underwent subsequent closure of colostomy, and all technique in the right lateral abdomen. Two to three patients who underwent reversal of a left or end sigmoid additional ports were used in the upper abdomen and right colostomy were included. Exclusion criteria were: previous lower quadrant as needed. Lysis of adhesions was done to nonresectional end colostomy, reversal of loop or transverse allow mobilization of the colostomy and identification of colostomies, the presence of concomitant procedures, and the rectal stump. This was carried out using scissors, resection of more than 10 cm of proximal sigmoid or colon at monopolar diathermy, or ultrasonic activated devices the time of closure. To maintain an intent-to-treat analysis all according to surgeon’s preference. When necessary to patients who began with laparoscopy were included in the identify the rectal stump, a dilator, stapling device or sig- laparoscopic group, even if converted. moidoscope was inserted into the rectum. The colostomy After identifying the laparoscopic group, the open cases was freed from the abdominal wall and the anvil of a cir- were carefully reviewed. From the open group, an equiv- cular stapling device was inserted into the lumen. The alent number of controls were selected after matching by colostomy was then delivered into the abdomen, and either age group (within 5 years), body mass index (BMI), and a 12-mm trocar placed at this site or fascial closure per- indication for the initial Hartmann’s procedure. Data col- formed. Mobilization of the left colon, splenic flexure, and lected for both groups included demographics, indication resection of proximal sigmoid or left colon were done as for initial surgery, comorbidities (cardiovascular, diabetes, needed. A transanal, end-to-end anastomosis was per- renal or pulmonary disease, and other carcinoma), opera- formed using a circular stapling device. Anastomotic tive events including conversions, and postoperative integrity was confirmed by using insufflations of air and course. All complications, reoperations, and readmissions colored saline. Hand-assisted technique was not used in up to 30 days after were recorded. any case. The open technique has been described in detail 123 498 Surg Endosc (2009) 23:496–502 previously [15, 16], and included mobilization of the Results colostomy, laparotomy through the previous abdominal midline incision, and a similar transanal, stapled anasto- A total of 295 patients were initially identified by the mosis as the laparoscopic approach. database search. From this group, 41 cases met the study Postoperatively, all patients were encouraged to ambu- inclusion criteria for laparoscopic-assisted Hartmann’s late on postoperative day 1. Pain management included