Editing Reversal of Hartmann's


== Prior to consideration of reversal: ==

* Wait 3-6 months after     Hartmann's
* Weight loss as required
* Colonoscopy to rule out     synchronous malignancy

== Potential issues/pitfalls: ==

* Obesity - limits view and     access. Absolutely legitimate to demand weight loss prior to reversal     attempt.
* Dense adhesions
* Risk of injury to ureters,     bladder, vagina, spleen
* Devascularisation of proximal     colon
* Strictured rectal stump
* Suboptimal anastomosis     needing re-diversion

== Preparation ==

* Consider bowel prep
* Consider ureteric stents -     not normally done routinely unless very high burden of adhesions expected
* Decide on open vs     laparoscopic - note a conversion rate of 20-25% if attempting laparoscopic

== Open technique ==

* Lithotomy with body strap
* IDC
* Tape over stoma
* Lower midline laparotomy
* Free up adhesions on left     side of abdomen and pelvic inlet, then insert Omnitract with small bowel     packed away
* Rectal stump identification     and mobilisation
** Identify and avoid both      ureters - may have shifted medially
** Might have to sharply enter      the overlying scar tissue
* Colonic mobilisation
** Take down stoma
** Splenic flexure mobilised      only when necessary
* Anastomosis
** Circular EEA stapler
** Air leak test - if positive,      either redo anastomosis, oversew it, or divert proximally.
* Consider diverting loop     ileostomy and drain in pelvis
* Close stoma defect
** Purse-string has been shown      to reduce infections
* Complete operation and close     wound in layers

== Post-op ==

* Routine antibiotics for 24     hours
* Remove IDC on day 1
* Escalate diet as tolerated

== Complications ==

* Early
** Bleeding
** Enterotomy
** Anastomotic leak
** Intra-abdominal sepsis
** Surgical site infection
* Late
** SBO
** Anastomotic stricture
** Unsatisfactory anorectal      function
** Incisional hernia

[[Category:Colorectal]]