VM72 - Robot Takedown Hartmann's for Endometriosis

Image or Table (Do Not add text here):

Purpose/Background: Deep infiltrating endometriosis is an aggressive form of endometriosis that may involve the whole pelvis including the surrounding colon and rectum. Deep infiltrating endometriosis preferentially affects the rectouterine pouch, or the pouch of Douglas, with extension to the uterine ligaments, the ureters, bladder, and with preferential invasion into the anterior rectal wall. Rectal shaving is usually recommended in lesions that affect the rectal wall because it avoids the need to open and suture the rectal wall. However, this may not be feasible with the deeper involvement of the colon such as in cases when a fistula develops from chronic inflammation. Colonic resection, such as Hartmann's procedure, may be indicated in cases of colo-ovarian or rectovaginal fistulas.

Reversal of Hartmann’s procedure is one of the most difficult procedures done by colorectal surgeons because of its high morbidity rate and unpredictable operative findings especially for patients who underwent multiple previous operations that may lead to adhesions. However, this is not a contraindication to minimally invasive surgery. We present a case of a patient who underwent Hartmann’s procedure and drainage of pelvic abscess 1 year prior for pelvic abscess and colo-ovarian fistula, who successfully underwent robotic assisted reversal of Harmann’s, hysterectomy, and salphingo-oophorectomy.

Methods/Interventions: This is a case of a 42-year-old female known to have endometriosis who previously underwent Hartmann’s procedure left salpingo-oophorectomy, and drainage of pelvic abscess and colo-ovarian fistula secondary to Deep Infiltrating Endometriosis. After 1 year, the patient was desirous of stoma reversal. Gynecology service also planned to do hysterectomy for definitive treatment of her endometriosis. The patient was then admitted for robotic assisted hysterectomy and reversal of Hartmann’s.

Results/Outcomes: Stoma was taken down and a glove port was inserted for diagnostic laparoscopy. Laparoscopic adhesiolysis was done to establish access for the robotic ports. Robotic-assisted adhesiolysis was done to identify the rectal stump. Gynecology proceeded with hysterectomy and right salphingo-oopherectomy. End-to-end anastomosis between descending colon and rectal stump was then done with a circular stapler. The procedure was successfully done through a robotic-assisted approach with 6 hours total duration for the whole procedure. Patient discharged well on the 5th postoperative day with no complications.

Conclusion/Discussion: We have described a case of a 42-year-old female who underwent, who successfully underwent a Robotic Assisted Reversal of Hartmann’s Procedure, Hysterectomy Right Salphingo-oophorectomy which had an uncomplicated postoperative course. We have demonstrated that although difficult, the reversal of Hartmann’s with dense adhesions from previous surgeries and history of endometriosis can be safely and successfully done through minimally invasive surgery.