VM62 - Anvil Through the Stoma and Out-the-Side for Hartmann’s Reversal

Image or Table (Do Not add text here):

Purpose/Background: Our usual approach in Hartmann’s reversal is to take down the colostomy site, remove the stoma, place a purse-string and secure the anvil to the descending colon. We then use the open colostomy site to gain access to the peritoneal cavity. Finally, laparoscopic or robotic trocars are placed for minimally invasive Hartmann’s reversal. This video demonstrates a unique reversed order approach to Hartmann’s colostomy closure. Anvil placement through the colostomy stoma and out-the-side of the intra-abdominal colon in preparation for anastomosis is performed only after lysis of adhesions, preparation of the rectal stump and descending colon.

Methods/Interventions: The patient is a 55-year-old HIV positive male necessitating an emergent open Hartmann’s procedure for stercoral perforation. The patient recovered fully and was deemed stable for ostomy reversal on an elective basis. He was scheduled for robot-assisted colostomy closure 14 weeks later. This video demonstrates the technique.

Results/Outcomes: Given the patient's prior surgical history, an extensive lysis of adhesions was necessary and performed to detach the omentum from the abdominal wall, clear the pelvis of intestinal loops, mobilize the rectal stump, and free the descending sigmoid colon to the level of the stoma at the abdominal wall. The rectal stump was identified by Prolene sutures placed at the time of the index procedure. Once the rectal stump was confirmed adequate for anastomosis, a 29 mm circular stapler anvil with a green sharp tip was placed through the colostomy stoma and exited out-the-side of the descending colon. Next, the colon was transected flush with the abdominal wall with a 60 mm linear robotic stapler with a blue load. The colostomy site where the anvil trocar exits the descending colon wall was reinforced with 2-0 Vicryl. The anastomosis was completed in standard fashion with a 29 powered circular stapler. Finally, the stoma excision is simplified because the robotic dissection from within the peritoneal cavity is already complete. The procedure seems to progress in a more efficient and expedient manner.

Conclusion/Discussion: First described by Dr. Laila Rashidi, our video demonstrates a reverse order approach to Hartmann’s reversal. This unique approach with anvil placement through the colostomy stoma and out-the-side of the intra-abdominal colon in preparation for anastomosis may facilitate the procedure, decrease operative time, result in smaller incisions, and improve cosmesis in certain cases. More experience is needed.