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