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The laparoscopic reversal Hartmann's procedure is a challenging technique
showing promising results in comparison to the open method. The laparoscopic
procedure seems to be safer and achieves faster positive results in contrast to
the open reverse Hartmann’s procedure in the hand of Good and trained
laparoscopic surgeon and carefully selected patients. However, before
considering it as a gold standard randomized prospective studies are needed.
INTRODUCTION
The Hartmann’s procedure is a surgical technique first described in
1921 to treat rectal cancer [1]. Through time the method has seen some changes.
The first technique never considered the restoration of the intestinal tract
continuity. Some surgeons added colostomy closure and others started using
laparoscopy [2]. The Reversal of Hartmann’s Procedure (RHP) using laparotomy is
well established and preferred to laparoscopy by many surgeons; the high rate
of adhesions can explain this after Hartmann’s procedure.
However, since
Anderson et al. [3] reported the first case of laparoscopically assisted
colostomy closure, many surgeons have started doing the Laparoscopic Reversal
of Hartmann’s Procedure with somewhat similar outcomes [4].
Through this review,
we are going to discuss the existing data in the literature; seeking the
feasibility of laparoscopic reverse Hartmann’s procedure.
REVIEW
The Hartmann’s
procedure is nowadays less and less used [5]. However, it is still the
preferred technique in emergency settings because of its relative safeness in
patients at high risk of colorectal anastomosis [5]. It is considered, as a
gold standard, in the stercoral peritonitis due to a left colon/rectal perforation.
Around 44% of patients
will undergo bowel continuity restoration after Hartmann's procedure [6]. As
shown by Van de Wall et al. [7] review of the literature Reversal of HP is
accompanied by an essential risk of complications (mean 16.3%, range 3%-50%)
and has an overall mortality rate of 1%. Overall complication rates reported in
a series of open Hartmann’s reversal range from 4%-43%, with Anastomotic
Leakage happening in up to 12% of patients.
There is no consensus
around the time to stoma closure, and the surgeons will decide case by case.
Generally, a 2-3 months period between stoma formation and closure is required
[7].
Two main concerns have
to be assessed before stoma closure the patient’s general status, the etiology
of rectal resection.
With the development
of laparoscopic surgery in the last decade, restoration became a part of the
procedures performed laparoscopically. Surgeons were mainly looking to benefit
from this less invasive method and reduce the overall morbidity [8].
However, two main
hurdles faced the laparoscopic pic approach:
1. A
safe way of entry in a previously operated abdomen
2. The
severe intraabdominal Adhesions [9].
Regarding the way of
entry; the most used technique reported in the literature was umbilical Hasson
technique [10,11]. This method allows a full exploration of the abdominal
cavity, assessment of the feasibility of the procedure; and also allows
dissection of the colostomy under direct vision [4,9]. Other authors started
with the dissection of the colostomy and used the incision
as a way of entry
Regarding the anastomoses, there are also several possibilities
(Hand-sewn suture or by instrument endo-GIA, or circular stapler). The Cochrane
systematic review, the evidence was insufficient to show a superiority of
either of the techniques [14]. We will recommend; leaving the choice to the
surgeon. Surgeons are invited to use the method they are most used to.
Most of the studies made in the topic report less intraoperative
bleeding, shorter hospital stays, less postoperative morbidity especially wound
infection [15,16]. The time to first flatus, the early ambulation and oral
feeding were all achieved faster [17].
In Toro et al. [4] review, the length of hospital stay was 6.2 days. In
Melkonian et al. [8] comparative study, including 74 patients, the hospital
stay was significantly shorter for laparoscopy (5 vs. 7 days).
The laparoscopic reversal has shown less Morbi/mortality compared to
open Hartmann's reversal procedure. The morbidity reported with open Hartmann's
reversal is 4%-43% [8,15] and approximately 15% in the laparoscopic ones
[4,8,15].
The most frequent early complication was colostomy wound infection.
Haughn et al. [18] found that the 6 months morbidity was also higher in the
open surgery arm and this was explained by a higher rate of an incisional
hernia in the open arm. Melkonian et al. [8] reported a case of evisceration in
the open arm which could have been avoided by laparoscopy.
Another main criticism addressed to the laparoscopic reverse Hartmann’s
procedure a longer operative time when compared to the open approach.
In open Hartmann’s procedure, the mean operative time reported in the
literature was 167 min [19]. In laparoscopic Hartmann's method, the mean
operative time was 171.1 min [4]. In other reports, it was even lower than 150
min [8,9]. The difference of expertise between surgeons can easily explain this
difference in operative time.
The data found in the literature is promising; however, we have to take
it cautiously. Most of the data come from retrospective series. Most of the
study, reports bias in patient’s selection.
Some studies avoided the inclusion of cancer patients in the
laparoscopy arm [8] and others showed a tendency to choose more fitted patients
for laparoscopy [9].
The expertise of surgeons performing those procedures is rarely
reported and is a source of bias knowing the importance of having a good
learning curve in surgery. The absence of technique standardization makes it
hard to compare the results from the different data available in the
literature.
Thus, the need for randomized prospective studies before considering
the laparoscopic reverse Hartmann's procedure as a gold standard.
CONCLUSION
The laparoscopic reverse Hartmann's procedure seems to be safer and
achieves faster positive results in comparison to the open reverse Hartmann's
procedure in the hand of Good and trained laparoscopic surgeon and carefully
selected patients. However, before considering it as a gold standard randomized
prospective studies are needed.
1.
Hartmann H (1921)
Rectal surgery. Masson: Paris, France.
2.
Boyden AM (19700) The
surgical treatment of diverticulitis of the colon. Ann Surg 132: 94-109.
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Anderson CA, Fowler DL,
White S, Wintz N (1993) Laparoscopic colostomy closure. Surg Laparosc Endosc 3:
69-72.
4.
Toro A, Ardiri A,
Mannino M, Politi A, Di Stefano A, et al. (2014) Laparoscopic reversal of
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Gastroenterol Res Pract 2014: 1‑8.
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Leong QM, Koh DC, Ho CK
(2008) Emergency Hartmann’s procedure: Morbidity, mortality and reversal rates
among Asians. Tech Coloproctol 12: 21-25.
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Van Hout NM, van der Harst E, Gosselink MP, et al. (2009) Restoration of bowel
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procedure be considered a one-stage procedure? Colorectal Dis 11: 619‑624.
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Shah NA, Hadi A,
Hussain M, Kalim M, Mehreen T, et al. (2016) Experience with early versus
routine enteric stoma closures: A comparative study. J Postgrad Med Inst 30.
8.
Melkonian E, Heine C,
Contreras D, Rodriguez M, Opazo P, et al. (2017) Reversal of the Hartmann’s
procedure: A comparative study of laparoscopic versus open surgery. J Minim
Access Surg 13: 47-50.
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Aboulkacem BM,
Montassar G, Aymen B, Faten S, Yacine BS, et al. (2017) Laparoscopic reversal
of Hartmann procedure: A single surgeon experience. J Gen Pract 5: 3.
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Caselli G, Bambs C,
Pinedo G, Molina ME, Zúñiga A, et al. (2010) Abordaje laparoscópico para la
reconstrucción de tránsito intestinal post-Hartmann: Experiencia de un Centro
sobre 30 pacientes. Cir Esp 88: 314-318.
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T, Campbell R, Tabary N (2009) Laparoscopically assisted Hartman’s reversal is
an efficacious and efficient procedure: A case control study. Minerva Chir 64:
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(2014) Laparoscopic versus open reversal of Hartmann’s procedure: A
retrospective review. ANZ J Surg 84: 965-969.
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Kercher KW, Sing RF, Heniford BT (2005) Laparoscopic restoration of intestinal
continuity after Hartmann’s procedure. Am J Surg 189: 670-674.
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Neutzling CB, Lustosa
SA, Proenca IM, da Silva EM, Matos D (2012) Stapled versus hand-sewn methods
for colorectal anastomosis surgery. Cochrane Database Syst Rev 15: CD003144
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Mazeh H, Greenstein AJ,
Swedish K, Nguyen SQ, Lipskar A, et al. (2009) Laparoscopic and open reversal
of Hartmann's procedure - A comparative retrospective analysis. Surg Endosc 23:
496‑502.
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De'angelis N, Brunetti
F, Memeo R, Batista da Costa J, Schneck AS, et al. (2013) Comparison between
open and laparoscopic reversal of Hartmann’s procedure for diverticulitis.
World J Gastrointest Surg 5: 245-251.
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Golash V (2006)
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18.
Haughn C, Ju B, Uchal
M, Arnaud JP, Reed JF, et al. (2008) Complication rates after Hartmann’s
reversal: Open vs. laparoscopic approach. Dis Colon Rectum 51: 1232-1236.
19.
Okolica D, Bishawi M,
Karas JR, Reed JF, Hussain F, et al. (2012) Factors influencing postoperative
adverse events after Hartmann’s reversal. Colorectal Dis 14: 369‑373.
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