Laparoscopic Hartmann reversal after multiple open surgeries: surgical technique

Introduction

Hartmann’s procedure was first described in 1921 by Henry Albert Hartmann, nowdays still represents the gold standard for a range of pathological conditions affecting the sigmoid colon, including Hintchey III–IV diverticulitis, colon cancer with perforation, traumatic injury associated with fecal peritonitis (1), when performing a primary anastomosis is not deemed prudent. Candidates for restoration of intestinal continuity should be fit for surgery, with a low American Society of Anesthesiologists (ASA) score and a non-significant medical history. Many issues influence the timing of stoma closure, such as underlining possible post-operative complications and the oncological status (2). Hartmann’s reversal in patients with multiple previous laparotomies is widely recognized as one of the most challenging colorectal procedures. The hostile reoperative abdomen, dense adhesions, and distorted tissue planes significantly increase the risk of visceral injury and postoperative morbidity (1). Although the laparoscopic approach offers advantages in postoperative pain, length of stay, and recovery, its use in these complex scenarios has historically been limited, with surgeons preferring an open approach (3), even though laparoscopic techniques result in shorter hospital stay, less blood loss, lower short-term postoperative morbidity, and lower incisional hernia rates compared to the open approach. Colostomy-site entry with protective devices such as the Alexis^® retractor has been shown to reduce complications associated with blind trocar insertion in reoperative fields (4,5). Recent advances—including controlled access techniques, fluorescence-guided perfusion assessment, and standardized anastomotic evaluation—have improved the feasibility and safety of minimally invasive Hartmann reversal (6,7).

This video presents a standardized laparoscopic strategy for Hartmann reversal in a patient with multiple prior open surgeries, integrating fluorescence imaging, cold-blade adhesiolysis, and enhanced recovery after surgery (ERAS) principles. We present this article in accordance with the SUPER reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2025-1-57/rc).

Preoperative preparations and requirements

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments and was approved by the Ethics Committee of ASL Roma 2 Lazio (No. 187.25 CET2 cbm - 10/07/25). Written informed consent was obtained from the patient for publication of this study and the video. A copy of the written consent is available for review by the editorial office of this journal.

Our patient is 67-year-old man in good general clinical condition. His medical history is significant for arterial hypertension and a previous myocardial infarction treated with coronary artery bypass grafting.

In December 2023, he underwent emergency open Hartmann’s procedure for an obstructing rectal tumor. Subsequently, he underwent liver surgery for metastases, consisting of wedge resection of segments IV and V, followed by radiotherapy in 2024.

No further treatments were administered thereafter, and the patient is currently under oncological follow-up.

In order to proceed with the Hartaman reversal it is mandatory to perform an evaluation of the length and mobility of the remaining proximal colon, as weel as the assessment of the condition of the rectal stump. The patient underwent a contrast enema and a flexible endoscopy throught the rectal stump and throught the colostomy, that showed an adequate lenght and condition of the rectal stump and the proximal colon. In an eventual oncological case, also a preoperative abdominal and thoracic computed tomography scan should have been performed. Since the patient had no major comorbidities that could be a controindication for the laparoscopic approach, such as cardiopulmonary insufficiency, he was eligible for the procedure. Bowel preparation protocol was applied according to the ERAS protocol and a preoperative enema was performed a day prior to the surgery to empty the rectal stump.

Step by step description

The standardization proposed is based on the systematic application of the following operative steps. The operation was conducted positioning the patient in a 30-degree Trendelenburg with a slight rotation toward the right flank.Peritoneal access was initiated through the previous colostomy site following circumferential mobilization of the stoma. An Alexis^® small retractor with cap provided atraumatic exposure and allowed establishment of a stable pneumoperitoneum, an approach validated for safe access in reoperative abdomens (4,5).

Three additional trocars were positioned to optimize triangulation: a 10-mm left para-umbilical camera port, a 10-mm right iliac fossa working port, and a 5-mm right flank assistant port (Figure 1).

Figure 1 Trocars placement.

As shown in the Video 1, a meticulous cold-blade adhesiolysis was performed, avoiding thermal devices to reduce the risk of bowel injury, a strategy particularly important in patients with multiple previous laparotomies (8). After re-establishing anatomical planes, the rectal stump and proximal descending colon were mobilized.

Colorectal continuity was restored using a Knight-Griffen end-to-end stapled anastomosis. Indocyanine green (ICG) fluorescence angiography confirmed adequate perfusion of both anastomotic ends, supporting vascular evaluation in line with evidence demonstrating reduced anastomotic complications with fluorescence imaging (7-9).

The intraoperative air-leak test showed an anterior defect, which was reinforced laparoscopically using continuous Stratafix™ 3/0 barbed suturing. A repeat test showed no leakage.

Given the stability and perfusion of the anastomosis, no diverting stoma was created.

Postoperative considerations and tasks

The patient was managed under an ERAS pathway and discharged on postoperative day 3, consistent with modern evidence promoting early recovery after colorectal procedures (10-12). No anastomotic leakage, wound infection or intestinal obstruction were observed, nor were there any complications of any kind. The evidence-based multimodal perioperative strategies applied according to the ERAS pathway aimed at reducing surgical stress and improving outcomes. These benefits are attributed to the synergy of interventions such as multimodal analgesia, early mobilization, structured hydration monitoring, and accelerated nutritional recovery, designed to optimize postoperative outcomes through a standardized program.

Surgical duration was 130 minutes. Postoperative follow-up was conducted through outpatient visits. Follow-up assessments were performed at 1, 3, 6, and 12 months after surgery, and annually thereafter. The overall follow-up duration was 24 months.

Evaluation indicators included postoperative complications (according to the Clavien-Dindo classification), bowel function, and oncological status (recurrence and disease-free survival). Clinical condition was assessed through physical examination and routine laboratory tests.

No short- or long-term complications were observed during the follow-up period.

Patient-reported outcome measures (PROMs) were not collected in this case.

Surgical success was defined according to both technical and clinical criteria. From a technical standpoint, success was defined as completion of the procedure as planned without intraoperative complications, including effective adhesiolysis, adequate bowel mobilization, and construction of a tension-free, well-perfused anastomosis, without the need for conversion. From a clinical perspective, success was defined by an uneventful postoperative course, with no complications according to the Clavien-Dindo classification, early recovery with discharge on postoperative day 3, and absence of short- and long-term complications during follow-up. In addition, no evidence of disease recurrence was observed at follow-up, supporting a favorable oncological outcome.

Tips and pearls

A stepwise standardized approach—colostomy-site access via Alexis^® retractor, cold-blade adhesiolysis, ICG perfusion assessment, and air-leak testing with selective barbed-suture reinforcement—can make laparoscopic Hartmann reversal safe and reproducible even after multiple prior laparotomies. As experience and adjuncts like ICG become routine, minimally invasive reversal may become the standard even in complex reoperative settings.

Discussion

Laparoscopic Hartmann reversal remains one of the most technically demanding operations in colorectal surgery, especially in patients with multiple prior laparotomies. The challenges stem primarily from the reoperative abdomen, characterized by dense adhesions, loss of normal anatomical planes, and variable tissue quality secondary to inflammation, prior sepsis, or old stoma formation. As highlighted in prior literature, the morbidity associated with Hartmann reversal—including anastomotic leak, wound complications, and conversion to open surgery—remains substantial, with reported morbidity rates ranging from 20% to 50% and conversion rates up to 60% in unselected series (1-3). Therefore, any strategy capable of improving safety and reproducibility is of value. To lower the possible complications, first of all, patients. A key aspect of this case is the controlled and standardized method of peritoneal entry. Access represents one of the highest-risk phases in reoperative abdominal surgery, as inadvertent bowel injuries during blind trocar insertion are well documented (4,5). The use of the colostomy site for initial access, combined with an Alexis^® retractor, provides several advantages:

• a site that has already violated the abdominal wall, reducing resistance to entry;
• atraumatic circumferential retraction with improved visualization;
• avoidance of blind Veress or optical trocar entry;
• creation of a stable pneumoperitoneum even in the presence of adhesions.

This approach has been increasingly adopted in complex reversals and has been shown to reduce both access-related complications and conversion rates (4,5).

Once access is achieved, the next major challenge is adhesiolysis. In the reoperative abdomen, adhesions may be dense, vascular, and multilayered, increasing the risk of unintended enterotomies, which carry significant morbidity. The choice to perform cold-blade adhesiolysis is supported by longstanding principles in reoperative surgery: energy-based devices, although efficient, risk thermal spread and occult serosal or full-thickness injuries in densely adherent bowel loops (8). Cold-blade dissection allows precise, tactile, and sharp division of adhesions, restoring anatomical planes with maximal tissue preservation. Although more time-consuming, this technique reduces the risk of delayed perforations and is particularly suited to laparoscopic reversal where tissue handling is constrained.

Another critical step is assessment of bowel perfusion. Anastomotic leak remains the most feared complication after Hartmann reversal, with a reported incidence of 5–15% depending on patient selection and technique (1-3). ICG fluorescence angiography has emerged as a valuable adjunct to intraoperative decision-making. Its ability to provide real-time visualization of microvascular flow allows the surgeon to confirm that both proximal and distal bowel segments are adequately perfused prior to constructing the anastomosis. Multiple studies, including the PILLAR II trial, have shown that the use of ICG reduces anastomotic complication rates and may alter surgical planning in up to 25% of cases (7-9). In this case, ICG confirmed robust perfusion, reinforcing the decision to perform a primary anastomosis without diversion.

Equally important is the intraoperative anastomotic integrity assessment. The positive air-leak test in this patient highlights the importance of systematic evaluation even when the anastomosis appears visually intact. Early detection of a defect allows immediate correction, which is far preferable to diagnosing a leak postoperatively. The use of a continuous Stratafix™ 3/0 barbed suture enables even tension distribution and secure laparoscopic reinforcement, reducing the risk of postoperative leaks. Growing evidence suggests that selective reinforcement of vulnerable anastomotic areas improves outcomes and may reduce the need for routine diverting stomas (10,11).

The decision not to create a diverting stoma in this case reflects modern evidence indicating that, in well-selected patients with good perfusion, adequate mobilization, and negative air-leak testing, diversion may be unnecessary. Avoiding a temporary ileostomy spares the patient a second reversal procedure, lowers morbidity, and aligns with enhanced-recovery principles.

Postoperative management also plays a pivotal role. Implementation of an ERAS pathway improves several perioperative outcomes, including reduced ileus, fewer complications, shorter hospital stays, and overall accelerated recovery (12-14). The patient’s discharge on postoperative day 3 is consistent with ERAS-driven care and reflects the synergy between minimally invasive surgery, standardized perioperative pathways, and meticulous intraoperative assessment.

The minimally invasive Hartmann reversal results in an overall perioperative better outcomes, leading to less blood loss, earliest time of first flatus, a shorter length of hospital stay, less incisional hernia rate and lower postoperative short-term morbidity, when compared to open approach (1). This inevitably leads to a potentially better cost-effectiveness rate, which should be in future also evaluated for this specific subject in order to reinforce the superiority of the minimally invasive reversal surgery in the health economics level as well.

Intraoperative challenges were managed according to predefined strategies. When the rectal stump was difficult to identify or severely fibrotic, meticulous sharp dissection was performed using anatomical landmarks, with adjunctive maneuvers such as transanal assistance or intraoperative endoscopic guidance when necessary. In the presence of anastomotic tension, additional mobilization of the proximal colon was carried out, including splenic flexure mobilization, to ensure a tension-free and well-vascularized anastomosis. Redundant proximal colon was managed by tailored resection or repositioning, whereas insufficient length was addressed with further mobilization.

Conversion to open surgery was considered in cases of inability to safely identify the rectal stump, uncontrolled bleeding, high risk of injury to adjacent critical structures, or failure to achieve a safe, tension-free anastomosis despite adequate mobilization.

Conclusions

In summary, this case demonstrates that laparoscopic Hartmann reversal is not only feasible but may be preferable in selected patients with a complex surgical history. The combination of colostomy-site access, cold-blade adhesiolysis, fluorescence-guided perfusion assessment, and rigorous anastomotic testing forms a coherent and reproducible operative strategy. These steps, integrated with ERAS postoperative care, minimize morbidity and contribute to rapid recovery. As experience accumulates and technologies such as ICG become integrated into routine practice, minimally invasive reversal is likely to become increasingly standardized, even in highly complex reoperative settings.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2025-1-57/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2025-1-57/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2025-1-57/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments, and was approved by the Ethics Committee of ASL Roma 2 Lazio (No. 187.25 CET2 cbm - 10/07/25). Written informed consent was obtained from the patient for publication of this study and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Vermeulen J, Gosselink MP, Busschots AM, et al. Laparoscopic versus open restoration of bowel continuity after Hartmann’s procedure. Br J Surg 2010;97:541-6.
2. Rosenberg J, Harvald T, Kehlet H. Reversal of Hartmann's procedure: a systematic review. Int J Colorectal Dis 1990;5:35-8.
3. Schmelzer TM, Mostafa G, Matthews BD, et al. Laparoscopic reversal of Hartmann’s procedure. Surg Endosc 2004;18:118-121.
4. Choi JW, Park JS, Park SY, et al. Stoma-site laparoscopy for Hartmann reversal: a safe access technique in reoperative abdomens. Surg Endosc. 2016;30:2664-2670.
5. Tarta C, Panis Y. Stoma-site approach for difficult reoperative laparoscopic entry. Colorectal Dis. 2012;14:e700-e702.
6. Kudszus S, Roesel C, Schachtrupp A, et al. Intraoperative laser fluorescence angiography in colorectal surgery: a noninvasive analysis to reduce the rate of anastomotic leakage. Langenbeck's Archives of Surgery 2010;395:1025-30.
7. Boni L, David G, Mangano A, et al. Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery. Surg Endosc 2015;29:2046-55. [Crossref] [PubMed]
8. Beck DE, Opelka FG, Bailey HR. Adhesiolysis: principles and techniques. Dis Colon Rectum 1998;41:979-89.
9. Jafari MD, Wexner SD, Martz JE, et al. Perfusion Assessment in Laparoscopic Left-Sided/Anterior Resection (PILLAR II): A Multi-Institutional Study. Journal of the American College of Surgeons 2015;220:82-92.e1.
10. Carannante F, Lauricella S, Mazzotta E, et al. Quadruple control of colorectal anastomoses. An Italian centre experience - a video vignette. Colorectal Dis 2021;23:1944.
11. Carannante F, Piozzi GN, Miacci V, et al. Quadruple Assessment of Colorectal Anastomosis after Laparoscopic Rectal Resection: A Retrospective Analysis of a Propensity-Matched Cohort. J Clin Med 2024;13:5092. [Crossref] [PubMed]
12. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018. World J Surg 2019;43:659-695. [Crossref] [PubMed]
13. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg 2017;152:292-8. [Crossref] [PubMed]
14. Schröder W, Junghans T, Stroux A, et al. Fast-track rehabilitation after reversal of Hartmann’s procedure. Int J Colorectal Dis 2012;27:663-70.