Reversal of Hartmann's

Hugh Gallagher

Powerpoint File

Introduction: Traditionally reversal of Hartmann’s operation is carried out via a formal laparotomy and can be technically demanding and can lead to significant morbidity related to anastomotic leaks, wound infection and incisional herniation.

44-49% of patients elect not to undergo reversal and the conversion rates for laparoscopic assisted reversal vary between 9-15% and morbidity rates up to 23.55% have been quoted.

The aim of this study was to assess the feasibility and outcomes of laparoscopic assisted reversal of Hartmann’s operation in a heterogeneous group of patients and to specifically identify factors associated with conversion to open surgery.

Methods: We retrospectively reviewed the outcome of 10 patients that underwent the above procedure and looked at demographics, underlying pathology, ASA grades, operating time, reasons for conversion to laparotomy, hospital stay and complications.

Results: 10 patients were included in this study; nine had reversal of Hartmann’s operation and one an Ileorectal anastomosis after subtotal colectomy previously. There were 5 males and 5 females, age range-33-62, 7 patients had resection for perforated diverticular disease, 1 for a Rectal carcinoma, 1 for endometriosis and one had a stoma following sphincter injury and dynamic Gracilopasty.There was 3 ASA grade I patient, 3 ASA grade II and 3 ASA grade III patients.7 patients had laparoscopic assisted procedures and 3 had conversions to open surgery. All the three patients needing conversions had large incisional herniae that required Reeve-Stoppa repairs; one in addition had dense pelvic adheshions and a splenic flexure injury. Operating time ranged from 1 hour 20 minutes to 6 hours 10 minutes for the laparoscopic group and 2 hours 30 minutes to 8 hours 30 minutes for the converted group. Hospital stay in the laparoscopic group ranged from 5-7 days and in the open group 9-33 days. The laparoscopic group had no immediate post-op complications and one patient developed a superficial wound infection in the open surgery group. One patient in each group developed incisional herniation at the original stoma site that has not required any intervention. One patient in the laparoscopic group has developed an anastomotic stricture which has been dilated endoscopically

Discussion: Laparoscopic reversal of Hartmann’s can certainly be performed with a significantly low morbidity but incisional herniation from the previous laparotomy is an important rate limiting factor-necessitating conversion when the hernia itself demands repair on its own merit.