Laparoscopic-assisted reversal of Hartmann's procedure

Is laparoscopy a reliable alternative to laparotomy in Hartmann's reversal? An updated meta-analysis

BACKGROUND

The aim of this study was to perform a systematic review of the literature on and updated meta-analysis of surgical postoperative complications after laparoscopic Hartmann's reversal (LHR) and open Hartmann's reversal (OHR).

METHODS

Studies comparing LHR versus OHR published from inception until June 2020 were selected and submitted to a systematic review and meta-analysis. Articles were searched in the MEDLINE and Cochrane Trials Register databases. Meta-analysis was performed with Review Manager 5.0.

RESULTS

Twenty-three retrospective comparative studies (including 5 case-controlled studies) with a total of 3139 patients with LHR and a total of 10,325 patients with OHR were included. Meta-analysis showed that LHR was significantly associated with a decreased rate of revision surgery (OR = 0.73, 95% CI = 0.60-0.89, p < 0.001), anastomotic leakage (OR = 0.61, 95% CI = 0.49-0.75, p < 0.00001), postoperative morbidity (OR = 0.53, 95% CI = 0.47-0.58, p < 0.00001), intra-abdominal abscess (OR = 0.67 [0.52-0.87], 95% CI = , p = 0.003), wound abscess (OR = 0.53 [0.46-0.61], 95% CI = , p < 0.00001), and postoperative ileus (OR = 0.46, 95% CI = 0.29-0.72, p = 0.0008), respectively. Conversely, mortality was comparable between LHR and OHR.

CONCLUSIONS

These results suggest that LHR significantly improved surgical postoperative outcomes. However, considering the low level of evidence, further randomized trials are required to validate these findings.

A comparative study between open versus laparoscopic Hartmann reversal: A single-center experience and analysis

As one of the most challenging procedures in colorectal surgery, Hartmann reversal (HR) carries a burden of morbidity and mortality. We report our experience and compare open and laparoscopic HR.Between December 2012 and January 2020, 30 patients who underwent Hartmann reversal were reviewed. All patients either received laparoscopic or open reversal.Of the 87 patients who underwent Hartmann operation (HO), 30 patients received HR (Laparoscopic Hartmann Reversal, [LHR], n = 20; Open Hartmann Reversal, Open Hartmann Reversal [OHR], n = 10). There were 15 males and 15 female patients. The mean operation time was 223.8 minutes (range 115-350 minutes) with mean blood loss of 252.5 mL (range 0-700 mL). There was no conversion from LHR to OHR, and there was no ileostomy formation. Mean time to flatus was 5.0 days (range 2-13 days). There were 15 early postoperative complications and 5 late postoperative complications, but only 1 case of grade 3A. No anastomosis leakage was reported.HR is an operation that can be performed safely in well-selected patients. Minimally invasive techniques, such as LHR, is an attractive option resulting in shorter operation time, less blood loss, less pain, and shorter hospital stay.

Conventional Versus Minimally Invasive Hartmann Takedown: A Meta-analysis of the Literature

Although end colostomy closure following Hartmann's procedure is a major surgery that is traditionally performed by conventional celiotomy, over the last decade there has been a growing interest toward the application of different minimally invasive techniques. We aimed at evaluating the relative outcomes of conventional surgery versus minimally invasive surgery by meta-analyzing the available data from the medical literature. The PubMed/MEDLINE, Cochrane Library and EMBASE electronic databases were searched through August 2018. Inclusion criteria considered eligible all comparative studies evaluating open versus minimally invasive procedures. Conventional laparoscopy, robotic and single-port laparoscopy were considered as minimally invasive techniques. Overall morbidity, rate of anastomotic failure, rate of wound complications and mortality were evaluated as primary outcomes. Perioperative details and surgical outcomes were also assessed. The data of a total of 13,740 patients from 26 studies were eventually included in the analysis. There were no significant differences on baseline characteristics such as age, BMI and proportion of high-risk patients between the two groups of patients. As compared to the conventional technique, minimally invasive surgery proved significantly superior in terms of postoperative morbidity, length of hospital stay and rate of incisional hernia. The current literature suggests that minimally invasive surgery should be considered in performing Hartmann's reversal, if technically viable. However, due to the low level of the available evidence it is impossible to draw definitive conclusions.

Case Selection for Laparoscopic Reversal of Hartmann's Procedure

BACKGROUND

Laparoscopic reversal of Hartmann's procedure offers reduced morbidity compared with open surgery while improving reversal rates. However, it is one of the most technically challenging operations in minimally invasive colorectal surgery, with further < 20% of the reversal procedures being attempted laparoscopically. Complications related to late conversion to open surgery may suggest a selective use of the laparoscopic approach for Hartmann's reversal in a subgroup of patients: The aim of this study is to systematically investigate the literature to identify the ideal case for a laparoscopic approach.

MATERIALS AND METHODS

Data were extracted from a systematic review of the literature of Medline, Scopus, Web of Science, Embase, and the Cochrane Central Register of controlled trials. Subgroup analysis to identify suitable patients for laparoscopic surgery included age at surgery, body mass index, American Society of Anesthesiologists status, indication for the index Hartmann's procedure (HP), interval time to reversal from the index HP, conversion to open surgery, and temporary ileostomy rate.

RESULTS

A total of 862 patients were included, with 403 cases performed laparoscopically. Conversion to open surgery occurred in 65 patients (mean 16.1%). The indication for the HP showed a trend toward more benign patients included in the laparoscopic group, and the interval time between the index Hartmann's procedure and its reversal was significantly shorter in the laparoscopic group with a trend toward a higher rate of temporary ileostomy in patients undergoing an open procedure.

CONCLUSIONS

Patients' selection can explain these differences, with more complex disease operated via an open approach. Nevertheless, future studies are needed to demonstrate an increasing number of reversals attempted laparoscopically in high-volume centers.

Laparoscopic versus open Hartmann's reversal: a systematic review and meta-analysis

BACKGROUND

Hartmann's reversal is a major surgical procedure with consistent morbidity and mortality rates. Laparoscopy has been extensively applied to colorectal surgery providing significant benefits on short- and long-term outcomes. We performed a meta-analysis of the current evidence comparing the short-term outcomes of laparoscopic Hartmann's reversal (LHR) to open Hartmann's reversal (OHR).

METHODS

A systematic search of Medline, Scopus, Web of Science, Embase, and the Cochrane database was performed. Comparative studies reporting short-term outcomes of LHR versus OHR with an intention-to-treat analysis were considered for eligibility. Primary outcome was 30-day morbidity. Secondary outcomes were 30-day mortality, 30-day reoperations, length of hospital stay (LOS), operating time, and estimated blood loss.

RESULTS

Thirteen studies comparing 862 patients (403 LHR vs 459 OHR) were included. There was no difference in mortality, while LHR was associated with a reduced overall postoperative 30-day morbidity (OR, 0.24; 95 % CI, 0.16 to 0.34). Wound infections (OR, 0.54; 95 % CI, 0.35 to 0.85) and ileus (OR, 0.47; 95 % CI, 0.25 to 0.87) were more common after OHR. LOS was shorter in the laparoscopic group as it was the time to flatus. Meta-regression analysis showed that the results were independent from potential effect modifiers.

CONCLUSIONS

LHR has less short-term complications than OHR in terms of overall morbidity, wound infection, and postoperative ileus. LOS is shorter in the LHR group, while no significant difference exists in the operating time. Randomized controlled trials are needed to confirm these findings on unbiased populations.

Laparoscopic versus open reversal of Hartmann's procedure: a retrospective review

BACKGROUND

Restoration of bowel continuity following Hartmann's procedure may be performed using a laparoscopic or open technique. This study is the first of its kind comparing laparoscopic with open reversal of Hartmann's procedure in Australasia.

METHODS

This is a retrospective review of 107 patients who underwent either a laparoscopic (n = 43) or open (n = 64) reversal of Hartmann's procedure between 2001 and 2012. Outcome measures were perioperative clinical outcomes and post-operative complications.

RESULTS

Patients in the two groups were comparable in age, body mass index, American Society of Anesthesiologists score and number of previous operations. The most common indication for the original Hartmann's operation in both groups was diverticular disease. Total theatre time was longer for the laparoscopic group (276.4 versus 242.0 min; P = 0.02). Three patients in the laparoscopic group required conversion to laparotomy (7%). Laparoscopic reversal of Hartmann's procedure was associated with shorter time to passage of flatus (2.8 versus 4.0 days; P < 0.001) and faeces (4.2 versus 5.6 days; P = 0.002), and shorter overall length of hospital stay (6.7 versus 10.8 days; P < 0.001). There were fewer patients in the laparoscopic group who had post-operative complications (14% versus 31%; P = 0.04), including fewer cases of post-operative ileus (2% versus 17%; P = 0.02). There were no cases of anastomotic leak or in-hospital mortality in either group.

CONCLUSION

Laparoscopic reversal of Hartmann's procedure is a safe and feasible alternative to open Hartmann's reversal and may be associated with significantly faster recovery time and fewer post-operative complications.

Should laparoscopic reversal of Hartmann's procedure be the first line approach in all patients?

BACKGROUND/AIMS

To assess if the laparoscopic reversal of Hartmann's can be attempted in all patients, without detriment to short or long-term outcomes if the patient is subsequently converted to open.

METHODS

Retrospective review of a prospectively collected database of all reversals under 8 surgeons at a single unit over 105 months, two surgeons attempting laparoscopic reversal in all patients, two pre-selecting for the laparoscopic approach and four utilising the open approach. Long-term follow-up data for re-admissions, re-operations and incisional hernia rate obtained from a postal questionnaire.

RESULTS

45 laparoscopic and 50 primary open reversals were identified. There was no difference in the mean age or previous peritonitis rate in either group. Laparoscopic conversion rate was 29% (13 patients). On intention to treat analysis, a significant difference was identified in the overall 30-day post-operative surgical morbidity (8.9% Laparoscopic-attempted vs 26.0% Open, p = 0.030). There was no difference in operating times (mean 164 vs 172 min, p = 0.896) despite the 13 patients converted to an open procedure. Mean length of stay was significantly lower in the laparoscopic-attempted group at 6.8 days (5.2-8.4) vs 14.9 days (6.4-23.7) in the open group (p = 0.001). Anastomotic leak rates were not statistically different. The median follow up was 27 months (range 6-105); 60% of patients completed a postal follow-up questionnaire. There was no difference in short-term or long-term re-admission or reoperation rates.

CONCLUSIONS

Laparoscopic reversal of Hartamann's is associated with shorter hospital stay and lower morbidity even in unselected patients. Long-term outcomes are similar.

Single-port access laparoscopic reversal of Hartmann operation

BACKGROUND

Single-port access offers cosmetic advantages in addition to the well-recognized benefits of standard multiport laparoscopic surgery, and can be performed with the use of standard straight instruments. We describe a technique of single-port access reversal of Hartmann colostomy by use of the colostomy site for access.

METHODS

After routine skin preparation and laparoscopic setup, the colostomy is mobilized from its mucocutaneous border, and the anvil of a circular stapler is secured to the distal lumen. By the use of a GelPoint system with 3 or 4 trocars, the intra-abdominal adhesions are divided and the splenic flexure is mobilized to achieve sufficient access to the abdominal and pelvic cavities and proximal colonic mobility. The rectal stump is mobilized to the mid rectum, starting from the posterior mesorectal fascia around to the anterior rectal wall. A tension-free colorectal anastomosis is secured with a standard circular stapling device inserted transanally, and leak tested. The colostomy wound is closed in standard fashion.

RESULTS

Five patients underwent single-port access reversal of Hartmann resection (4 diverticular perforations and 1 pT3N0 colon cancer), with a mean operating time of 155 (range, 137-187) minutes and a median length of stay of 3 (range, 2-11) days. There were no conversions, major surgical morbidity, or deaths.

CONCLUSION

Single-port access reversal of Hartmann colostomy through the stoma site is safe, and it offers additional cosmetic advantages with no apparent additional morbidity in comparison with standard multiport surgery.