Comparison between open and laparoscopic reversal of Hartmann’s procedure for diverticulitis

Surgical trends and outcomes of open, laparoscopic, and robotic colostomy reversal for benign disease

BACKGROUND

Despite the increasing use of minimally invasive surgeries, the outcome benefits of adopting minimally invasive surgery for colostomy reversal remain unclear. We aimed to analyze nationwide trends in the use of minimally invasive surgery for colostomy reversal and compare patient outcomes between different surgical approaches.

METHODS

The National Inpatient Sample was queried for patients who underwent colostomy reversal for benign disease from 2015 to 2021. National trends in the use of minimally invasive surgery for colostomy reversal were analyzed by Cochran-Armitage tests. Multivariable linear and logistic regressions accounting for hospital sample weights were developed to examine the association between operative approach (open, laparoscopic, and robotic) and patient outcomes, including hospital complications, length of stay, and hospital charges.

RESULTS

A total of 23,260 patients underwent colostomy reversal: 18,880 (81.2%) open, 3,245 (14.0%) laparoscopic, and 1,135 (4.9%) robotic surgery. From 2015 to 2021, the proportion of robotic approaches increased >5-fold (range 2.1-12.5%; Ptrend < .001), whereas the increase in laparoscopic approaches was not significant (range 11.5-16.2%; Ptrend = .34). Multivariable analysis showed that the laparoscopic approach was associated with a lower incidence of pulmonary complications (adjusted odds ratio, 0.49; 95% confidence interval, 0.28-0.87), surgical-site infection (odds ratio, 0.37; 95% CI, 0.19-0.72), peritonitis/abdominal abscess (odds ratio, 0.45; 95% confidence interval, 0.26-0.78), and paralytic ileus (odds ratio, 0.67; 95% confidence interval, 0.48-0.92). The robotic approach was associated with a lower incidence of paralytic ileus (odds ratio, 0.58; 95% confidence interval, 0.33-0.99). Laparoscopic and robotic approaches were associated with 22.9% and 29.9% shorter length of stay, respectively. The robotic approach was associated with 33.0% greater hospital charge.

CONCLUSIONS

This study observed a significant trend toward the increased use of robotics in colostomy reversal and potential clinical benefits with minimally invasive surgery. Robotic colostomy reversal, along with laparoscopic approach, may provide better postoperative recovery compared with the open approach; however, the utility of robotic surgeries needs to be reevaluated in the future, given the limited clinical benefits despite greater hospital charges.

Hartmann’s Reversal: Controversies of a Challenging Operation

Purpose. Hartmann’s reversal is a complex operation with a high morbidity rate. Minimally invasive surgery has been used to reduce the impact of surgery on fragile patients. The aim of this comparative study is to look at the results of Hartmann’s reversal procedures with different approaches. Methods. All the patients who underwent Hartmann’s reversal were collected retrospectively (124 cases). Sixty-four patients (50.4%) had an open operation, 6 cases (5%) were treated with a conventional laparoscopic approach, 34 patients (28.1%) underwent single incision laparoscopic surgery (SILS), and 20 (16.5%) required other additional trocars. Results. SILS operations were slightly longer than the open procedures (175 min vs 150 min), with the same rate of postoperative complications and reoperations (p = 0.83 and p = 0.42), but with a shorter hospital stay (5 days p = 0.007). Age (p = 0.03), long operative time (p = 0.01), and ASA score (p = 0.05) were identified as independent factors affecting postoperative morbidity. The grade of adhesions caused a longer operative time (p = 0.001) and a higher risk of conversion $\left(p<0.001\right)$ , and short rectal stump increased the risk of protective loop ileostomy (p = 0.008). Patients with grade 2-3 of adhesions had a longer length of stay (p = 0.05). Conclusions. Minimally invasive procedures had a shorter hospital stay and did not show any increase in morbidity rate when compared with open cases. Age, longer operative time, and ASA score increased the risk of postoperative complications. Furthermore, patients with a short rectal stump had a higher chance of having a defunctioning ileostomy.

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.

[Results of reconstructive surgery with formation of low colorectal anastomoses after previous Hartmann's procedure]

OBJECTIVE

To evaluate the efficacy and safety of original access to short rectal stump compared to traditional direct one.

MATERIAL AND METHODS

A retrospective-prospective cohort comparative study was conducted between 2012 and 2018. Inclusion criterion was previous Hartmann's procedure with formation of a short rectal stump. Short stump was determined by its length from anal-skin line to the cupola <7 cm. There were 93 patients who were divided into 2 groups: the main group - new approach (n=38), the control group - traditional direct approach (n=55). We analyzed surgery time, blood loss, intraoperative, early and late postoperative morbidity.

RESULTS

Surgery time and blood loss were similar in both groups (299.9 vs. 288.3 min, p=0.82; 204.5 vs. 112.4 ml, p=0.94, respectively). Intraoperative complications occurred in 7 patients of the control group (0 vs. 12.7% (7/55), p=0.02). Incidence of early postoperative complications was similar (28.9% (11/38) vs. 25.5% (14/55), p=0.71). Adverse events Clavien-Dindo grade I and IIIa were more common in the main group, grade IIIb and IVa - in the control group. Incidence of delayed postoperative complications were similar (10.5% (4/38) vs. 7.3% (4/55), p=0.58). Colorectal anastomosis stricture prevailed in the control group, ureteral stricture - in the main group. Neurophysiological and complex urodynamic examinations revealed no between-group differences.

CONCLUSION

The new method ensures access to the rectal stump and formation of colorectal anastomosis under direct visual control. Postoperative outcomes demonstrated safety and effectiveness of this technique.

Comparison of outcomes between laparoscopic and open Hartmann's reversal: A single-center retrospective study in Japan

INTRODUCTION

Laparoscopic Hartmann's reversal (LHR) has recently been reported to be safer and more feasible than open Hartmann's reversal (OHR); however, there is limited data on the outcomes of LHR compared with those of OHR from Asian countries. Therefore, we aimed to clarify the postoperative outcomes of LHR compared with OHR, and additionally compare the patient outcomes post-LHR according to the previous Hartmann's procedure (HP) approach.

METHODS

Patients who underwent OHR and LHR between January 2006 and September 2020 in a single center in Japan, were retrospectively evaluated. Patient characteristics and perioperative data were collected from the medical and surgical records and assessed.

RESULTS

Overall, 15 and 19 patients underwent OHR and LHR, respectively, between January 2006 and September 2020. LHR was associated with less blood loss (median: 15 mL vs 185 mL; P < .001) and shorter hospital stays (9 days vs 14 days; P = .023) than OHR. There was no significant difference in postoperative complications between LHR and OHR (26.3% vs 40.0%, P = .475). However, two severe anastomotic complications in LHR were observed in patients with the stump below the peritoneal reflection. No significant difference in outcomes was observed between LHR patients who underwent open and laparoscopic HP.

CONCLUSION

LHR resulted in positive outcomes regarding estimated blood loss and postoperative hospitalization, compared with OHR. Although the postoperative complications between LHR and OHR were not significant, patients with the stump below the peritoneal reflection may be at a high risk of anastomotic complications.

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.

Laparoscopic Hartmann Reversal: Experiences From a Developing Country

Purpose

Laparoscopic surgery is considered a promising approach for Hartmann reversal but is also a complicated major surgical procedure. We conducted a retrospective analysis at a city hospital in Vietnam to evaluate the treatment technique and outcomes of laparoscopic Hartmann reversal (LHR).

Methods

A colorectal surgery database in 5 years between 2015 and 2019 (1,175 cases in total) was retrieved to collect 35 consecutive patients undergoing LHR.

Results

The patients had a median age of 61 years old. The median operative time was 185 minutes. All the procedures were first attempted laparoscopically with a conversion rate of 20.0% (7 of 35 cases). There was no intraoperative complication. Postoperative mortality and morbidity were 0 and 11.4% (2 medical, 1 deep surgical site infection, and 1 anastomotic leak required reoperation) respectively. The median time to first bowel activity was 2.8 days and median length of hospital stay was 8 days.

Conclusion

When performed by skilled surgeons, LHR is a feasible and safe operation with acceptable morbidity rate.

Laparoscopic Versus Open Hartmann Reversal: A Case-Control Study

Background

Laparoscopic reversal of Hartmann's procedure (LHR) offers reduced morbidity compared with open Hartmann's reversal (OHR). The aim of this study is to compare the outcome of laparoscopic versus open Hartmann reversal.

Materials and Methods

Thirty-four patients who underwent Hartmann reversal between January 2017 and July 2019 were evaluated. Patients underwent either LHR (n = 17) or OHR (n = 17). Variables such as numbers of patients, patient's age, sex, body mass index (BMI), comorbidities, ASA (American Society of Anesthesiology) score, indication for previous open sigmoid resection, mean operation time, rate of conversion to open surgery, length of hospital stay, mortality, and morbidity were retrospectively evaluated.

Results

The two groups of patients were homogeneous for gender, age, body mass index, cause of primary surgery, time to reversal, and comorbidities. In 97% of the cases, HP was done by open surgery. Our data revealed no difference in mean operation time (LHR: 180.5 ± 35.1 vs. OHR: 225.2 ± 48.4) and morbidity rate, although, in OHR group, there were more severe complications. Less intraoperative blood loss (LHR: 100 ± 40 mL vs. OHR: 450 ± 125 mL; p value <0.001), shorter time to flatus (LHR: 2.4 days vs. OHR: 3.6 days; p value <0.021), and shorter hospitalization (LHR: 4.4 vs. OHR: 11.2 days; p value <0.001) were observed in the LHR group. Mortality rate was null in both groups. Discussion. LHR is feasible and safe even for patients who received a primary open Hartmann's procedure. We suggest careful patient's selection allowing LHR procedures to highly skilled laparoscopy surgeons.

Diverticulitis: An Update From the Age Old Paradigm

For a disease process that affects so many, we continue to struggle to define optimal care for patients with diverticular disease. Part of this stems from the fact that diverticular disease requires different treatment strategies across the natural history- acute, chronic and recurrent.

To understand where we are currently, it is worth understanding how treatment of diverticular disease has evolved. Diverticular disease was rarely described in the literature prior to the 1900’s. In the late 1960’s and early 1970’s, Painter and Burkitt popularized the theory that diverticulosis is a disease of Western civilization based on the observation that diverticulosis was rare in rural Africa but common in economically developed countries. Previous surgical guidelines focused on early operative intervention to avoid potential complicated episodes of recurrent complicated diverticulitis (e.g., with free perforation) that might necessitate emergent surgery and stoma formation. More recent data has challenged prior concerns about decreasing effectiveness of medical management with repeat episodes and the notion that the natural history of diverticulitis is progressive. It has also permitted more accurate grading of the severity of disease and permitted less invasive management options to attempt conversion of urgent operations into the elective setting, or even avoid an operation altogether.

The role of diet in preventing diverticular disease has long been debated. A high fiber diet appears to decrease the likelihood of symptomatic diverticulitis. The myth of avoid eating nuts, corn, popcorn, and seeds to prevent episodes of diverticulitis has been debunked with modern data. Overall, the recommendations for “diverticulitis diets” mirror those made for overall healthy lifestyle – high fiber, with a focus on whole grains, fruits and vegetables.

Diverticulosis is one of the most common incidental findings on colonoscopy and the eighth most common outpatient diagnosis in the United States. Over 50% of people over the age of 60 and over 60% of people over age 80 have colonic diverticula. Of those with diverticulosis, the lifetime risk of developing diverticulitis is estimated at 10–25%, although more recent studies estimate a 5% rate of progression to diverticulitis. Diverticulitis accounts for an estimated 371,000 emergency department visits and 200,000 inpatient admissions per year with annual cost of 2.1–2.6 billion dollars per year in the United States. The estimated total medical expenditure (inpatient and outpatient) for diverticulosis and diverticulitis in 2015 was over 5.4 billion dollars. The incidence of diverticulitis is increasing.

Besides increasing age, other risk factors for diverticular disease include use of NSAIDS, aspirin, steroids, opioids, smoking and sedentary lifestyle. Diverticula most commonly occur along the mesenteric side of the antimesenteric taeniae resulting in parallel rows. These spots are thought to be relatively weak as this is the location where vasa recta penetrate the muscle to supply the mucosa. The exact mechanism that leads to diverticulitis from diverticulosis is not definitively known.

The most common presenting complaint is of left lower quadrant abdominal pain with symptoms of systemic unwellness including fever and malaise, however the presentation may vary widely. The gold standard cross-sectional imaging is multi-detector CT. It is minimally invasive and has sensitivity between 98% and specificity up to 99% for diagnosing acute diverticulitis. Uncomplicated acute diverticulitis may be safely managed as an out-patient in carefully selected patients. Hospitalization is usually necessary for patients with immunosuppression, intolerance to oral intake, signs of severe sepsis, lack of social support and increased comorbidities. The role of antibiotics has been questioned in a number of randomized controlled trials and it is likely that we will see more patients with uncomplicated disease treated with observation in the future

Acute diverticulitis can be further sub classified into complicated and uncomplicated presentations. Uncomplicated diverticulitis is characterized by inflammation limited to colonic wall and surrounding tissue. The management of uncomplicated diverticulitis is changing. Use of antibiotics has been questioned as it appears that antibiotic use can be avoided in select groups of patients. Surgical intervention appears to improve patient’s quality of life. The decision to proceed with surgery is recommended in an individualized manner.

Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Abscesses can be treated with percutaneous drainage if the abscess is large enough. The optimal long-term strategy for patients who undergo successful non-operative management of their diverticular abscess remains controversial. There are clearly patients who would do well with an elective colectomy and a subset who could avoid an operation all together however, the challenge is appropriate risk-stratification and patient selection. Management of patients with perforation depends greatly on the presence of feculent or purulent peritonitis, the extent of contamination and hemodynamic status and associated comorbidities. Fistulas and strictures are almost always treated with segmental colectomy.

After an episode of acute diverticulitis, routine colonoscopy has been recommended by a number of societies to exclude the presence of colorectal cancer or presence of alternative diagnosis like ischemic colitis or inflammatory bowel disease for the clinical presentation. Endoscopic evaluation of the colon is normally delayed by about 6 weeks from the acute episode to reduce the risk associated with colonoscopy. Further study has questioned the need for endoscopic evaluation for every patient with acute diverticulitis. Colonoscopy should be routinely performed after complicated diverticulitis cases, when the clinical presentation is atypical or if there are any diagnostic ambiguity, or patient has other indications for colonoscopy like rectal bleeding or is above 50 years of age without recent colonoscopy.

For patients in whom elective colectomy is indicated, it is imperative to identify a wide range of modifiable patient co-morbidities. Every attempt should be made to improve a patient’s chance of successful surgery. This includes optimization of patient risk factors as well as tailoring the surgical approach and perioperative management. A positive outcome depends greatly on thoughtful attention to what makes a complicated patient “complicated”.

Operative management remains complex and depends on multiple factors including patient age, comorbidities, nutritional state, severity of disease, and surgeon preference and experience. Importantly, the status of surgery, elective versus urgent or emergent operation, is pivotal in decision-making, and treatment algorithms are divergent based on the acuteness of surgery. Resection of diseased bowel to healthy proximal colon and rectal margins remains a fundamental principle of treatment although the operative approach may vary.

For acute diverticulitis, a number of surgical approaches exist, including loop colostomy, sigmoidectomy with colostomy (Hartmann’s procedure) and sigmoidectomy with primary colorectal anastomosis. Overall, data suggest that primary anastomosis is preferable to a Hartman’s procedure in select patients with acute diverticulitis. Patients with hemodynamic instability, immunocompromised state, feculent peritonitis, severely edematous or ischemic bowel, or significant malnutrition are poor candidates. The decision to divert after colorectal anastomosis is at the discretion of the operating surgeon. Patient factors including severity of disease, tissue quality, and comorbidities should be considered. Technical considerations for elective cases include appropriate bowel preparation, the use of a laparoscopic approach, the decision to perform a primary anastomosis, and the selected use of ureteral stents.

Management of the patient with an end colostomy after a Hartmann’s procedure for acute diverticulitis can be a challenging clinical scenario. Between 20 – 50% of patients treated with sigmoid resection and an end colostomy after an initial severe bout of diverticulitis will never be reversed to their normal anatomy. The reasons for high rates of permanent colostomies are multifactorial. The debate on the best timing for a colostomy takedown continues. Six months is generally chosen as the safest time to proceed when adhesions may be at their softest allowing for a more favorable dissection. The surgical approach will be a personal decision by the operating surgeon based on his or her experience. Colostomy takedown operations are challenging surgeries. The surgeon should anticipate and appropriately plan for a long and difficult operation. The patient should undergo a full antibiotic bowel preparation. Preoperative planning is critical; review the initial operative note and defining the anatomy prior to reversal. When a complex abdominal wall closure is necessary, consider consultation with a hernia specialist. Open surgery is the preferred surgical approach for the majority of colostomy takedown operations. Finally, consider ureteral catheters, diverting loop ileostomy, and be prepared for all anastomotic options in advance.

Since its inception in the late 90’s, laparoscopic lavage has been recognized as a novel treatment modality in the management of complicated diverticulitis; specifically, Hinchey III (purulent) diverticulitis. Over the last decade, it has been the subject of several randomized controlled trials, retrospective studies, systematic reviews as well as cost-efficiency analyses. Despite being the subject of much debate and controversy, there is a clear role for laparoscopic lavage in the management of acute diverticulitis with the caveat that patient selection is key.

Segmental colitis associated with diverticulitis (SCAD) is an inflammatory condition affecting the colon in segments that are also affected by diverticulosis, namely, the sigmoid colon. While SCAD is considered a separate clinical entity, it is frequently confused with diverticulitis or inflammatory bowel disease (IBD). SCAD affects approximately 1.4% of the general population and 1.15 to 11.4% of those with diverticulosis and most commonly affects those in their 6th decade of life. The exact pathogenesis of SCAD is unknown, but proposed mechanisms include mucosal redundancy and prolapse occurring in diverticular segments, fecal stasis, and localized ischemia. Most case of SCAD resolve with a high-fiber diet and antibiotics, with salicylates reserved for more severe cases. Relapse is uncommon and immunosuppression with steroids is rarely needed. A relapsing clinical course may suggest a diagnosis of IBD and treatment as such should be initiated. Surgery is extremely uncommon and reserved for severe refractory disease.

While sigmoid colon involvement is considered the most common site of colonic diverticulitis in Western countries, diverticular disease can be problematic in other areas of the colon. In Asian countries, right-sided diverticulitis outnumbers the left. This difference seems to be secondary to dietary and genetic factors. Differential diagnosis might be difficult because of similarity with appendicitis. However accurate imaging studies allow a precise preoperative diagnosis and management planning. Transverse colonic diverticulitis is very rare accounting for less than 1% of colonic diverticulitis with a perforation rate that has been estimated to be even more rare. Rectal diverticula are mostly asymptomatic and diagnosed incidentally in the majority of patients and rarely require treatment. Giant colonic diverticula (GCD) is a rare presentation of diverticular disease of the colon and it is defined as an air-filled cystic diverticulum larger than 4 cm in diameter. The pathogenesis of GCD is not well defined.

Overall, the management of diverticular disease depends greatly on patient, disease and surgeon factors. Only by tailoring treatment to the patient in front of us can we achieve optimal outcomes.

Trans-stomal single-port laparoscopic Hartmann's reversal is an efficacious and efficient procedure: a case-controlled study

BACKGROUND

Hartman's reversal remains challenging and is associated with a widely variable success rate. In a previous study, we reported that laparoscopy may lower the mortality and morbidity rates of the procedure. The aim of the current study was to assess the operative results of single-port laparoscopic Hartmann's reversal (SP-HR) as compared to the more standard, multi-port laparoscopic variant (MP-HR).

METHODS

We performed a retrospective, non-randomized, case-controlled study of 44 consecutive patients who had SP-HR (Group A) compared to 44 patients who had MP-HR (Group B). The study was conducted in a high-volume colorectal unit in a 1200-bed university affiliated hospital, The Poissy-Saint Germain Medical Complex, France.

RESULTS

Preoperative patients' characteristics (sex, body mass index, American Society of Anesthesiologists status, prior surgery, comorbidities, colonic disease) were comparable in both groups. The conversion rate was 13.6% and 4.5% in Group A and in Group B, respectively (p = 0.084) and consisted of placement of any additional ports. Conversion to open surgery did not occur in any patient in either group (p = 1). Mean operative time was shorter in Group A than in in Group B, (105 vs. 155 min; p = 0.0133). The mortality rate was 2.2% in Group A and 0% in Group B (p = 0.3145). The overall morbidity rate was 11.4% in Group A and 18.2% in Group B (p = 0.5344). The median length of hospital stay was significantly shorter in Group than in Group B (4.8 vs. 6.8 days; p = 0.0102).

CONCLUSIONS

The SP-HR technique was found to be safe and efficient. It compares favorably with MP-HR. Moreover, indirect cost savings could be induced by the reduction in the length of 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.

Laparoscopic reversal of Hartmann's procedure: A single-center experience

INTRODUCTION

Laparoscopic reversal of Hartmann's procedure (LHR) is considered a technically complex major surgical procedure. We present a retrospective analysis of a single-institution experience that assesses the treatment patterns and outcomes of patients who underwent LHR.

MATERIALS AND SURGICAL TECHNIQUE

The study involved patients who underwent LHR between January 2004 and December 2017. All patients had previously undergone a conventional Hartmann's procedure for acute complicated diverticulitis or cancer. Patients were placed in a supine position with their legs spread apart and their left arm out to the side. Access into the abdomen was obtained through open laparoscopy, with a 12-mm trocar for a 30° laparascope inserted at the periumbilical site. We placed between three and five trocars depending on the level of operative difficulty encountered. The first surgical step was to dissect any existing adhesions, and then rectal mobilization was systematically performed to ensure the feasibility of the end-to-end anastomosis and to avoid bladder injury. The stoma was mobilized on the level of the abdominal wall and then freed from the fascia. We used a circular stapler to reestablish a tension-free anastomosis. Over 13 years, 20 patients underwent LHR. No patient required a temporary colostomy or ileostomy.

DISCUSSION

Reversal of Hartmann's procedure involves high operative morbidity and mortality, and usually only relatively young and healthy patients are eligible for reversal. Our results are consistent with previously published literature regarding the advantages of LHR compared to the conventional technique. However, high-level evidence is still needed.

Emergency Hartmann's Procedure and Its Reversal: A Totally Laparoscopic 2-Step Surgery for the Treatment of Hinchey III and IV Diverticulitis

BACKGROUND

Hartmann's procedure (HP) followed by reversal restoration is the first choice for treatment of diffuse diverticular peritonitis. There is no unanimous consensus regarding the use of laparoscopy to treat the same condition.

METHODS

Data from 60 patients with diverticular diffuse peritonitis who underwent urgent HP followed by laparoscopic reversal were retrospectively analyzed. Patients were divided into 2 groups according to the open or laparoscopic HP (OHP, 24 patients; LHP, 36 patients). Outcomes were measured in terms of functional recovery, morbidity, mortality, and length of hospital stay.

RESULTS

HPs showed no differences among the groups in terms of operative time, blood loss, and length of intensive care unit stay. Overall morbidity was significantly lower in LHP than in OHP, corresponding to 33.3% and 66.7% respectively ( P = .018). The incidence of both surgical and medical complications was higher in OHP than in LHP (41.7% vs 22.2% [ P = .044] and 45.8% vs 24.3% [ P = .023], respectively). Mortality was 16.6% for each group. LHP showed a faster return to bowel movements and a shorter hospital stay than OHP. The secondary intestinal reversal was possible in 92% of cases, successfully completed laparoscopically in 91.3%. No patients of LHP group required a conversion to open intestinal reversal.

CONCLUSION

LHP for treatment of diverticular diffuse peritonitis showed significantly lower morbidity, faster recovery, shorter hospital stay, and higher rates of successful laparoscopic reversal when compared with OHP.

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.

Hartmann's reversal: a comparative study between laparoscopic and open approaches

BACKGROUND

A reversal of Hartmann's procedure can be performed using either a laparoscopic or open approach. However, laparoscopic reversal (LR) of Hartmann's procedure is challenging. This study was designed to compare the results between open and laparoscopic approaches.

METHODS

This was a retrospective study of prospectively collected data. We analysed 29 patients who received Hartmann's reversal at Korea University Anam Hospital between April 2007 and September 2014. All patients underwent either LR (n = 17) or open reversal (OR, n = 12).

RESULTS

Patient characteristics were similar between the LR and OR groups. There was also no difference in mean operation time (212.5 versus 251.8 min), diversion ileostomy, length of hospital stay, postoperative analgesic days, time to diet resumption (3.9 versus 6.2 days) or complication rate. Although the time to resuming a solid diet was not different between the two groups (P = 0.053), bowel movement occurred faster in LR patients (LR versus OR, 1.8 versus 2.8 days, P = 0.020). Patients in the LR group also had less blood loss during surgery (114.1 versus 594.2 mL, P = 0.026). There were no mortalities in this study.

CONCLUSION

LR of Hartmann's procedure resulted in faster bowel function recovery than the open method. Laparoscopic approaches are feasible even for patients who received an open Hartmann's procedure.

Considerations in Stoma Reversal

Temporary stomas are frequently used in the management of diverticulitis, colorectal cancer, and inflammatory bowel disease. These temporary stomas are used to try to mitigate septic complications from anastomotic leaks and to avoid the need for reoperation. Once acute medical conditions have improved and after the anastomosis has been proven to be healed, stomas can be reversed. Contrast enemas, digital rectal examination, and endoscopic evaluation are used to evaluate the anastomosis prior to reversal. Stoma reversal is associated with complications including anastomotic leak, postoperative ileus, bowel obstruction, enterocutaneous fistula, and, most commonly, surgical site infection. Furthermore, many stomas, which were intended to be temporary, may not be reversed due to postoperative complications, adjuvant therapy, or prohibitive comorbidities.

Reversal of the Hartmann's procedure: A comparative study of laparoscopic versus open surgery

BACKGROUND:

The Hartmann's operation, although less frequently performed today, is still used when initial colonic anastomosis is too risky in the short term. However, the subsequent procedure to restore gastrointestinal continuity is associated with significant morbidity and mortality.

PATIENTS AND METHODS:

The review of an institutional review board (IRB)-approved prospectively maintained database provided data on the Hartmann's reversal procedure performed by either laparoscopic or open technique at our institution. The data collected included: demographic data, operative approach, conversion for laparoscopic cases and perioperative morbidity and mortality.

RESULTS:

Over a 14-year period from January 1997 to August 2011, 74 Hartmann's reversal procedures were performed (laparoscopic surgery—49, open surgery—25). The average age was 55 years for the laparoscopic and 57 years for the open surgery group, respectively. Male patients represent 61% of both groups. There was no significant difference in operative time between the two groups (149 min vs 151 min; P = 0.95), and there was a tendency to lower morbidity (3/49—7.3% vs 4/25—16%; P = 0.24) in the laparoscopic surgery group. In the laparoscopic group, eight patients (16.3%) were converted to open surgery, mostly due to severe adhesions. The length of hospital stay was significantly shorter for the laparoscopic group (5 days vs 7 days; P = 0.44).

CONCLUSIONS:

The Hartmann's reversal procedure can be safely performed in the majority of the cases using a laparoscopic approach with a low morbidity rate and achieving a shorter hospital stay.

Laparoscopic treatment of complicated colonic diverticular disease: A review

Up to 10% of acute colonic diverticulitis may necessitate a surgical intervention. Although associated with high morbidity and mortality rates, Hartmann’s procedure (HP) has been considered for many years to be the gold standard for the treatment of generalized peritonitis. To reduce the burden of surgery in these situations and as driven by the accumulated experience in colorectal and minimally-invasive surgery, laparoscopy has been increasingly adopted in the management of abdominal emergencies. Multiple case series and retrospective comparative studies confirmed that with experienced hands, the laparoscopic approach provided better outcomes than the open surgery. This technique applies to all interventions related to complicated diverticular disease, such as HP, sigmoid resection with primary anastomosis (RPA) and reversal of HP. The laparoscopic approach also provided new therapeutic possibilities with the emergence of the laparoscopic lavage drainage (LLD), particularly interesting in the context of purulent peritonitis of diverticular origin. At this stage, however, most of our knowledge in these fields relies on studies of low-level evidence. More than ever, well-built large randomized controlled trials are necessary to answer present interrogations such as the exact place of LLD or the most appropriate sigmoid resection procedure (laparoscopic HP or RPA), as well as to confirm the advantages of laparoscopy in chronic complications of diverticulitis or HP reversal.

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.

[Damage of reconstructive operations in patients after urgent obstructive resection of colon]

It was performed comparative analysis of results of reconstructive operations in 116 patients with terminal colostomy after urgent obstructive resection of colon. Damage of reconstructive operations which differ by only access was estimated. Midline access was used in 49 patients, parastomal - in 51 cases. Laparoscopic operation was applied in 16 patients. The most traumatic method was middle laparotomy for restoration of colonic integrity. Laparoscopic operations and parastomal access are less invasive. Laparoscopic operations are accompanied by longer duration, greater blood loss and later restoration of intestinal motility pattern in comparison with surgery through parastomal access. It is associated with duration and damage of adhesiotomy stage.

Laparoscopic Reversal of Hartmann's Procedure: State of the Art 20 Years after the First Reported Case

Introduction. Aim of the present work is to review the literature to point out the role of laparoscopic reversal of Hartmann procedure. Material and Methods. Number of patients, age, sex, etiology, Hinchey classification, interval between procedure and reversal, position of the first trocars, mean operative time (min), number and causes of conversion, length of stay, mortality, complications, and quality of life were considered. Results. 238 males (52.4%) and 216 females (47.6%) between 38 and 67 years were analyzed. The etiology was diverticulitis in 292 patients (72.1%), carcinoma in 43 patients (10.6%), and other in 70 patients (17.3%). Only 7 articles (22.6%) reported Hinchey classification. The interval between initial procedure and reversal was between 50 and 330 days. The initial trocar was open positioned in 182 patients (43.2%) through umbilical incision, in 177 patients (41.9%) in right upper quadrant, and in 63 patients (14.9%) in colostomy site. The operative time was between 69 and 285 minutes. A total of 83 patients (12.1%) were converted and the causes were reported in 67.4%. The length of stay was between 3 and 12 days. 5 patients (0.7%) died. The complications concern 112 cases (16.4%). Conclusion. The laparoscopic Hartmann's reversal is safer and achieves faster positive results.

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.

Robotic-assisted reversal of Hartmann's procedure for diverticulitis

The minimally invasive laparoscopic approach for the reversal of Hartmann's procedure (HP) has been shown to be a safe and feasible approach associated with low morbidity and fast recovery. Robotic surgery has not yet been described for HP reversal. We report the case of an 84-year-old man originally operated on in an emergency setting by conventional HP for complicated diverticulitis who underwent a robotic-assisted HP reversal. The surgical procedure and the post-operative follow-up were uneventful, with low post-operative pain, early return to bowel function, and discharge at day 3. The robotic surgery appeared to be a safe, feasible, and valuable approach for HP reversal.