The Evolution of Minimally Invasive Techniques in Restoration of Colonic Continuity

Abstract

Restoration of bowel continuity after Hartmann's procedure is considered technically challenging and is associated with high morbidity and mortality. This is the main reason why restoration of intestinal continuity is often not attempted. Over the past decade, considerable international experience has gained on this topic with new minimally invasive techniques being developed. This review details the evolution of minimally invasive techniques in restoration of colonic continuity after Hartmann's procedure. A comprehensive search of PubMed and Embase was done. Different restoration modalities were included. Eight studies, from six different countries, in which multiport laparoscopic restoration of continuity was compared to conventional open restoration of bowel continuity, were included. In the total of 254 patients, continuity was restored laparoscopically compared with 255 patients in which continuity was performed in open fashion. Restoration of bowel continuity via trephine access was also reported; three studies including 37 patients were included in this review. Single-port restoration of bowel continuity after Hartmann's procedure is a natural evolution of multiport laparoscopy and trephine access. Six studies reporting on single-port reversal of Hartmann's procedure were included with a total of 75 patients. Single-port access in combination with a transanal approach has also been reported; however, data are extremely limited as there is only one study in the published literature. Success of restoration of bowel continuity with less morbidity and mortality has been demonstrated throughout the evolution of the different surgical techniques. In this review advantages of different approaches for restoration of bowel continuity after Hartmann's procedure are discussed. Furthermore, surgical techniques are described, pictorial guides are added for some techniques, and flowcharts are given for easy use during clinical decision-making.

Reversal of Hartmann's Procedure: Evaluating Outcomes of Single-Port Laparoscopic Approach Versus Conventional Approach

“…Although the CL technique for restoration of intestinal continuity has gained popularity due to its advantageous nature, it involves extensive adhesiolysis in which may increase the risk of paralytic ileus or bowel lacerations [ 19 ]. SPLR uses the existing colostomy site as the entry point.…”

Stoma

“…In the ongoing quest to find the optimal technique for reversal of HP, several laparoscopic, hand assisted and SP techniques have been described. 36 Laparoscopic reversal of HP was introduced in 1993 and was shown to have advantages over classic open reconstruction. 37,38 Even though laparoscopy has its merits and positive effects, technical difficulties of this approach must be acknowledged, especially after open index surgeries with peritonitis.…”