The patient received mechanical bowel cleansing the day before. The rectal stump was cleaned with 250 cc of enema. The patient was fixed and placed in lithotomy position with legs in padded, adjustable stirrups. The rectum was irrigated with diluted iodine solution. Two fields were prepared for both abdominal and perineal accesses. A urinary catheter was inserted in sterile conditions.
A pericolostomic incision is made, and the previous colostomy is individualized up to peritoneal cavity performing adhesiolysis if needed. A 12-mm umbilical trocar is located for a 30º camera. A GelPort Laparoscopic System with three 5-mm trocars is introduced through the colostomy wound. Two additional 5 and 12 mm trocars are placed.
The Lone star retractor was placed to evaluate the rectal stump. The GelPoint Path Transanal Access Platform is introduced through the anal canal with three trocars in a triangle position: two conventional 12-mm trocars and one 10-mm AirSeal trocar, used to perform pneumorectum with steady flow and continuous smoke evacuation. CO2 is insufflated to a pressure of 10–12 mmHg, and it is adapted during the progression of the dissection. A three-dimensional (3D) flexible-tip endoscope is introduced through the inferior trocar for better visualization, as it provides an excellent view intraluminally without having to change the instruments multiple times. Airseal device makes it easier to work laparoscopically, as the cavity is restricted and conventional insufflators are not always able to sufficiently remove the smoke. The goal is to perform a full thickness dissection of the upper part of the rectal stump transanally and then restore transit.
The selected level of the dissection is marked with the hook cautery circumferentially, preserving as much as possible of the rectal stump. Once marked, we first start with a partial thickness dissection that avoids losing the neumorectum prematurely, later progressing to full thickness. It usually starts laterally and continues around the rectum anteriorly and posteriorly. The patient’s right side tends to be the most technically challenging one.
Effective traction and contratraction movements are key for viewing the correct planes, considering that the working field is very narrow and limited and instrument clashing is a highly recurring problem.
At the same time the abdominal dissection is performed. These cases usually present adherent syndrome so it is important to perform a careful dissection to avoid injuries. The combination of laparoscopic and transanal surgery allows in these cases for better and easier identification of the rectal stump, which in many cases is difficult to see due to the adhesions from the previous surgery.
The purse string is then placed transanally in order to be used for the mechanic anastomosis. The stapler spike will be guided through the purse string opening. With the aid of a laparoscopic needle driver, a continuous 2.0 PDS suture is placed at the level of the resection margin. Laparoscopic skills are necessary to perform this step comfortably as the surgeon must suture in a narrow space. Once the purse string is completed, the needle is taken out and the suture will be left untied and referenced outside the transanal platform.
The next step is to finish dissecting the upper part of the rectal stump. The purse string is kept open at this time to pass the energy devices. Special care is to be taken anteriorly where the rectovaginal septum is located. Once introduced into the presacral plane, the mesorectum is mobilized; the posterior dissection proceeds cephalic in the avascular presacral plane. This plane of dissection is extended medially, laterally and interiorly to achieve circumferential rectal mobilization. The dissection is performed circumferentially and progressively to avoid retraction of the contralateral rectum that could complicate the surgical dissection in that side.
Finally, the peritoneal reflection is visualized and divided to achieve the proximal rectal stump removal, with both teams collaborating to complete it. The previous stapler line with the resected tissue was then exteriorized through the anus.
The two teams are then ready to join their planes of dissection. The combined approach allows both teams to work simultaneously and complement each other, as can be seen on the double screen. The insufflation pressures compensate to maintain adequate pneumo in both surgical fields.
The double vision from the two fields at this time offers a great advantage to work without damaging any structure, allowing combined movements of traction and contratraction to release all adhesions and be able to perform the correct anastomosis anatomically and safely.
The Gel Port cap is then removed. In order to guide the stapler through the purse string, a drain is placed on the stapler spike and guided through the rectal stump orifice with transabdominal supervision. Once the stapler spike is visible, the purse string is tied transanally and secured around the spike and the drain can be removed from the spike. The mechanic anastomosis is then performed following the same surgical principles as in regular laparoscopic cases. The doughnut’s integrity is also checked. The anastomosis can be visually tested transanally with the scope. If available at the hospital, the vascularization of the anastomosis can also be checked with indocyanine green.
Hartmann’s reversal is a challenging procedure and should be performed by the safest technique available and tailored to the patient’s case.
Transanal Hartmann’s colostomy reversal assisted by laparoscopy is an alternative to laparoscopic-only or open reconstruction. It can be an option in cases of technically difficult pelvic surgery.