Laparoscopic Hartmann’s Procedure

Abstract

Hartmann’s procedure, Hartmann’s resection, or Hartmann’s operation is the surgical resection consisting of sigmoidectomy without intestinal restoration. It contains an end-colostomy and closure of a rectal stump. It was first described by Henri Albert Hartmann (1860–1952) for resection of rectal or sigmoid cancer [1]. Nowadays, Hartmann procedure is usually used in treating malignant obstruction of left-sided colon or in emergent conditions, such as sigmoid colon perforation [2], mostly because of diverticulum disease. The advantage of Hartmann’s procedure is reduction in morbidity and mortality in emergent settings because it avoids the possibility of complications from a colorectal anastomosis. For patients with unstable hemodynamic status, or multiple comorbidity or inflammatory condition of the intestinal tissue, which would make performing a colorectal anastomosis difficult or have a higher risk of anastomotic leakage, this procedure is simple and fast, and meanwhile preserve the chance of restoration of intestine continuity after patients’ general condition got improvement. However, the Hartmann reversal rate is variable in different studies, ranging from 0 to 50% [3, 4]. The morbidity rate of Hartmann reversal is up to 55%, and the mortality rate is ranging from 0 to 14% [5–7]. A study showed reversal of Hartmann between 3 and 9 months associated with increased risk of postoperative complications [8]. The mean interval from Hartmann procedure to its reversal is ranging from 7.5 to 9.1 months [3, 5]. We usually delay the reversal of Hartmann’s operation at least 6 months later in our daily practice. Hartmann’s procedure and/or reversal of Hartmann’s procedure could be conventional or laparoscopic. Laparoscopic reversal of Hartmann’s procedure is associated with less complications compared to the conventional method, especially in wound infection, anastomotic leakage, and cardiopulmonary complications [3].

Introduction

Hartmann’s procedure, Hartmann’s resection, or Hartmann’s operation is the surgical resection consisting of sigmoidectomy without intestinal restoration. It contains an end-colostomy and closure of a rectal stump. It was first described by Henri Albert Hartmann (1860–1952) for resection of rectal or sigmoid cancer [1]. Nowadays, Hartmann procedure is usually used in treating malignant obstruction of left-sided colon or in emergent conditions, such as sigmoid colon perforation [2], mostly because of diverticulum disease. The advantage of Hartmann’s procedure is reduction in morbidity and mortality in emergent settings because it avoids the possibility of complications from a colorectal anastomosis. For patients with unstable hemodynamic status, or multiple comorbidity or inflammatory condition of the intestinal tissue, which would make performing a colorectal anastomosis difficult or have a higher risk of anastomotic leakage, this procedure is simple and fast, and meanwhile preserve the chance of restoration of intestine continuity after patients’ general condition got improvement. However, the Hartmann reversal rate is variable in different studies, ranging from 0 to 50% [3, 4]. The morbidity rate of Hartmann reversal is up to 55%, and the mortality rate is ranging from 0 to 14% [5,6,7]. A study showed reversal of Hartmann between 3 and 9 months associated with increased risk of postoperative complications [8]. The mean interval from Hartmann procedure to its reversal is ranging from 7.5 to 9.1 months [3, 5]. We usually delay the reversal of Hartmann’s operation at least 6 months later in our daily practice. Hartmann’s procedure and/or reversal of Hartmann’s procedure could be conventional or laparoscopic. Laparoscopic reversal of Hartmann’s procedure is associated with less complications compared to the conventional method, especially in wound infection, anastomotic leakage, and cardiopulmonary complications [3].

Indications

This procedure is used for left-sided colonic disease, usually in emergent situations, either preoperatively or peri-operatively noted. Generally speaking, when a patient is mandated to a sigmoidectomy, who also has unstable vital signs (shock status) or multiple comorbidities (ASA IV patients), which increase the risks of postoperative complications, especially in anastomotic condition, Hartmann’s procedure is an alternative method. Besides, when the intestine tissue condition is not healthy, such as distention and edematous change resulting from obstruction, ischemic change, and inflammatory fibrosis, or any condition would make a colorectal anastomosis difficult to perform, Hartmann’s procedure provides a damage control method and avoid any complications followed by an anastomosis.

These indications include [9].

• 1. Colorectal cancer obstruction,

• 2. Perforated diverticulitis with peritonitis,

• 3. Ischemic colitis.

• 4. Sigmoid volvulus.

• 5. Anastomotic complications, such as leakage or stricture.

• 6. Abdomen trauma.

Other less common indications

• 1. Severe low anterior syndrome, mostly when a patient received an ultra-low anterior resection complicated with a poor rectal reservoir function.

• 2. Surgery in patients with preexisting anal incontinence.

Contraindications

Patient with unstable hemodynamic status who could not tolerate general anesthesia is contraindicated. Patient who could not tolerate prolonged pneumoperitoneum is contraindicated for laparoscopic Hartmann’s procedure. In an oncological setting, any condition that would compromise the result is a relative contraindication, such as low rectal cancer invading the pelvic floor, in such situation, abdominal-perineal combined resection should be performed.

Preoperative Assessment

Preoperative Preparation

First, an informed consent should be obtained. The indication and risks should be explained to the patient. Most of Hartmann’s procedure is performed under emergent condition, and these patients were initially scheduled to receive an anterior resection or sigmoidectomy with anastomosis, the possibility of stoma creation (either end stoma or loop stoma) should be informed. In fact, we suggest informing the possibility of stoma creation in all colonic procedures before doing a surgery, not only for left-sided colonic lesion. According to many retrospective studies, only half of the patients could receive a reversal of Hartmann’s procedure in the seeing future therefore possible permanent stoma placement should be explained.

Preoperative Testing

Before surgery, one should receive preoperative studies to evaluate the surgical plan and potential life-threatening condition.

Laboratory Studies

Complete blood counts and differential count (CBC/DC), renal function tests (serum BUN and creatinine), electrolytes (Serum sodium and potassium), liver function tests (serum AST and ALT, direct/total bilirubin), pre-transfusion study (ABO and Rh typing), prothrombin time and activated partial thromboplastin time (PT and aPTT), are routinely checked preoperatively in patients who will receive major surgery in our institute.

Chest X-Ray (CxR)

CxR is routinely checked in our institute, it provides information on some major comorbidities, such as pleural effusion, cardiomegaly, or pulmonary tuberculosis (especially in South-East Asia). It is not the gold standard for the diagnosis of lung metastasis in colorectal cancer.

Electrocardiogram (ECG)

Electrocardiograms are noninvasive, quick, and effective in detecting potential heart disease. It is routinely checked in major surgery in our hospital.

Abdominal Computed Tomography (CT)

Abdominal CT scan with intravenous contrast is useful to assess the disease severity in diverticulitis disease or tumor obstruction/perforation. In perforated diverticulitis disease, it provides information to evaluate whether the surgery would be a sigmoidectomy with/without diverting stoma, or Hartmann’s procedure. In a patient who has malignant obstruction or perforation, it provides not only the surgical choices but also the possibility of combined resection of adjuvant organ which invaded by the tumor. Oral or rectal contrast is usually not recommended in emergent condition.

Magnetic Resonance Imaging (MRI)

Pelvic MRI is now widely accepted as the gold standard for rectal malignancy; however, it is usually not available in patients under emergent condition.

OT Setup

Patient’s Position

It is better to put the patient in a modified Trendelenburg lithotomy position (Fig. 1) than in a supine position. However, in many cases, colorectal surgeons are consulted in the operation theater by general surgeons for patients with colonic disease, and these patients are receiving the surgery under the indication of hollow organ perforation initially. In such cases, these patients are usually put in the supine position.

Fig. 1

Trendelenburg lithotomy position

The operator should be positioned to patient’s left and the cameraman positioned next to the operator (Fig. 2). If there is an assistant, he or she should be positioned on the patient’s left side.

Fig. 2

Operator and camera man

Instrumentations

• Trocars:

• 12 mm trocars ×2: One for camera, another as working port

• 5 mm trocars ×2–4.

• Laparoscopic instruments:

  • Bowel grasping forceps ×2–3.

  • Metzenbaum scissor ×1.

  • Hook electrode or spoon electrode ×1.

  • Right angle dissection forceps ×1.

  • Energy devises ×1 (alternative: bipolar forceps).

  • Suction and irrigation system.

Surgical technique

• 1. Under general anesthesia, the patient should be put in modified Trendlenburg lithotomy position.

• 2. A 12 mm camera trocar is inserted near umbilicus. A 12 mm trocar should be inserted via right lower quadrant of abdomen; another 5 mm trocar should be inserted via right abdomen, 8–10 cm away from the 12 mm trocar (Fig. 3a). You can insert an additional 5 mm trocar via left lower quadrant of abdomen for assistant (Fig. 3b).

• 3. Identified the lesion in diseased sigmoid colon or rectum, if there is a perforated hole, do damage control first. Close the perforated hole with sutures and irrigate the peritoneal cavity copiously with warm saline.

• 4. Gently separate the inflamed tissue surrounding the lesion. Use hand instruments to grab a piece of wet gauze and wipe out the adhesive tissue. Avoid direct dissection between severely inflamed tissue unless there is a clear surgical plane.

• 5. Use electrode to free the sigmoid colon from its peritoneal attachment along the line of Toldt proximally from the descending colon and distally to the pelvic inlet (Fig. 4).

• 6. If the lesion is malignant, such as tumor obstruction or tumor perforation, adequate lymph nodes sampling is recommended. Ligate inferior mesentery artery at its root just above abdominal aorta (Fig. 5). Perform complete mesocolon excision as standard colon cancer surgery. If the lesion is benign, such as diverticulitis perforation, stercoral ulcer perforation, or other nonmalignant diseases, dissect mesocolon at the level of marginal vessels to preserve a better blood supply to colon is feasible.

• 7. Select the transection point proximally and distally. If inferior mesentery artery was ligated at its root, bowel transection point at upper rectum would be better. Use endocutter to divide the bowel proximally and distally (Fig. 6).

• 8. Make sure the proximal colon could reach the proposed colostomy site without tension. Make a circular incision at the proposed colostomy site. Split rectus abdominis and pull out the proximal colon through the incision (Fig. 7).

• 9. Enlarge the 12 mm camera port, set a wound protector, and remove the specimen through the incision. Reestablish pneumoperitoneum, check hemostasis, and place a drainage tube if indicated.

• 10. Close the trocar wounds layer by layer. Mature the end-colostomy.

Fig. 3a

Trocar insertion

Fig. 3b Port placements

Fig. 4

Dissection along the white line of Toldt

Fig. 5

Ligate root of inferior mesentery artery

Fig. 6

Divide rectum by endocutter

Fig. 7

Proposed end-colostomy without tension

Complications and Management

Wound Infection

Hartmann’s procedure is usually associated with emergent settings, and therefore has a higher risk of wound infection than elective surgery. Laparoscopic Hartmann’s procedure has less infection rate than conventional Hartmann’s procedure [10] however it still has 5–10% wound infection rate. Adequate fluid drainage with antibiotic treatment for 7–10 days should be given for patients with wound infection. Parastomal infection needs specialized nursing care, treated with adequate abscess drainage and antibiotic therapy.

Ureteral Injury

In the medial-to-lateral approach for sigmoid colon mobilization during the surgery, a surgical plane is made below inferior mesentery artery. The left ureter and gonadal vessels should be swept away and injury to these structures could be avoided if the plane is accurate. Under ideal conditions, a ureter can be identified by Kelly’s sign, a visible vermiculation by direct press. A precise dissection along the surgical plane avoids ureteral injury. However, in the emergent setting, severe inflammatory change and adhesions result in difficulty identifying ureter. Latrogenic ureteral injury has been documented at 0.3–1.5% incidence rate. Despite preventing ureteral injury by inserting a ureteral double-J stent before colon resection remains controversial, it provides immediate identification of ureteral injury. Once the ureter is injured, immediate repair with ureteral stenting placement for 2 weeks avoids reoperation [11]. Usually, the ureteral stent is removed after the ureter was tested and healed.

Urinary Bladder Injury

Bladder injury is a rare complication during colon surgery, the incidence is less than 5% [11]. It is associated with an infectious or inflammatory process. A Foley catheter insertion before surgery avoids potential trocar injury during surgery. Urinary bladder injury is usually identified by urine leakage during surgery, the most reliable confirmation is a visible Foley catheter balloon in the bladder. Immediate repair with a Foley catheter left for 2 weeks is indicated. The Foley catheter will be removed after cystogram is performed.

Vessel Injury

It is more common to see vessel injuries in laparoscopic Hartmann’s procedure than in other laparoscopic surgeries. Severe inflammation, infectious process, and adhesion are risk factors that contribute to vessel injuries. Compare to traditional D3 dissection with vessel ligation at the root of inferior mesentery artery, it occurs more often in vessel ligation along intermittent vessels or marginal vessels. Immediately control the bleeding vessels by laparoscopic energic device or end clips would be helpful.

Bowel Injury

In diverticulitis or tumor perforation diseases, small intestine or right-sided colon may adhere to the inflamed colon. Irrigate the peritoneal cavity with warm saline copiously and gently separate adhesion between bowel loops by grabbing a wet gauze to mimic incidentally bowel injuries. Seromuscular tear of the bowel wall can be repaired by suturing.

Intra-abdominal abscess formation:

A few days after surgery, if persisted fever or positive peritoneal sign was noted, intra-abdominal abscess formation should be considered. It can be diagnosed by abdominal echogram or computed tomography (CT). Superficial abscess just beneath the wound can be drained by opening the wound. Deep abscess in the peritoneal cavity should be treated by percutaneous drainage, either by echogram-guided or CT-guided. Obtain bacterial culture and blood culture sampling and then give empiric antibiotics until the pathogen was yielded in the laboratory, usually 7–10 days of antibiotic treatment is adequate.

Post-OP Care

Adequate fluid maintenance to keep hemodynamic status stable. Vasopressor therapy initially targets a mean artery pressure of 65 mmHg. Intravenous fluid can be tapered after the patient tolerates oral intake. Postoperative ileus is common after emergent colorectal surgery, it ranges from days to weeks. A nasogastric tube indwelling is helpful in poor gastric emptying. Remove nasogastric tube when the drainage gastric juice decreased, and on diet as soon as patients can tolerate. Normalized bowel movement could be observed by feces or gas retention in the colostomy bag.

Education on colostomy nursing care is important for patients and their caregiver, usually their spouse or children. An enterostomal therapist is essential for postoperative care in Hartmann’s procedure. A comprehensive health education avoids most of the complications of colostomy, such as poor appliance, parastomal dermatitis, or dehydration. A patient could be discharged after he/she is well-educated in colostomy care.