VM15 - Not committing too early. Safer robotic trans-abdominal take down of colostomy and fascial closure after rectal stump mobilization and inspection.

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Purpose/Background: Patient is a 66-year male who had an open Hartmann’s resection 2 years ago for perforated diverticulitis and colovesicular fistula. He had an aborted attempt at reversal of colostomy due to hostile pelvis. He was referred to colorectal surgery for a second opinion. Preoperative colonoscopy showed a normal colon and rectal stump. He underwent robotic Hartmann’s reversal and diverting loop ileostomy.

Methods/Interventions: The Da Vinci Robot was ducked using the standard configuration. After extensive lysis of adhesion, prior to take down of colostomy, rectal stump was identified and dissected and mobilized in the TME plane down to the pelvic floor. After ensuring integrity of the stump the stoma was cleared of adhesions up to the mucocutaneous junction robotically. Monopolar scissors were used to separate the bowel from the abdominal wall. The anvil was introduced into the abdomen through the stoma aperture and sutured in the proximal end to perform an end-to-end anastomosis using the EEA stapler. Anastomosis was tested for leak and a diverting loop ileostomy was fashioned. The stoma fascia aperture was closed using a running suture transabdominally.

Results/Outcomes: The patient was discharged after two days without any complication.

Conclusion/Discussion: Hartman’s reversal can be challenging due to unforeseen intrabdominal findings such as inaccessible or unhealthy rectal stump that can preclude an anastomosis. Identifying and inspecting the rectal stump prior to take down of colostomy is integral to a safe operation. The robotic platform allows for ease of access to abdominal wall allowing for detaching the colostomy from abdominal wall trans-abdominally. This helps with operative efficiency, preventing unnecessary undocking and completion of the operation fully robotically.