Laparoscopic vs open reversal of Hartmann’s in unselected patients – a teaching centre experience over 8 years including long-term follow-up

Nottingham University Hospitals, Queens Medical CentreR K Maitra, C Maxwell-Armstrong, T Pinkney, J Smith, C Gornall, J H Scholefield, J P Williams, M H Robinson, J F Abercrombie, N C Armitage, A G Acheson

Introduction:Reversal of Hartmann’s has a high reported morbidity and mortality (5% and 50% respectively). Laparoscopic reversal of Hartmann’s was first described in 1996 with a number of studies showing reduced short-term morbidity and hospital stay compared to open procedures. Our series is one of the largest comparing open to laparoscopic reversal of Hartmann’s.

Methods:All laparoscopic cases were maintained on a prospective database from 2003. We identified all open reversals from the same period. Retrospective review of all patients was performed including long-term outcomes and follow up. All patients presenting to 2 consultants had attempted laparoscopic reversals – this constituted 85% (n=35) of the laparoscopic patients.Patients divided into 3 groups – laparoscopically completed procedures (‘laparoscopic’ group), laparoscopic procedures converted to open (‘converted’ group), open procedures (‘open’ group).Conversion rate 31%

• No significant differences in age or sex between the three groups.• More patients in the converted group had previous peritonitis but this was

not statistically significant.• Significantly increased risk of conversion with previous peritonitis

(p=0.034)

Short-term outcomes

• No significant difference in operating times (p=0.658)• Significantly lower post-operative morbidity in laparoscopic group (0.036)• Higher rate of 30-day return to theatre, not significant (p>0.05)• Significantly shorter hospital stay in laparoscopic group (p<0.001)• Significantly lower anastomotic leak • No correlation between operating times and BMI in laparoscopic patients

(r=0.146, p=0.41)• No correlation between surgeon experience and operating times in

laparoscopic patients (r=-0.26, p=0.147)

Long-term outcomes

• No significant difference in re-admission rates (p<0.05)• Significantly lower re-operation rates in laparoscopic compared to

open groups (p=0.009)• Significantly lower rate of stoma-site herniae between laparoscopic

and open groups (p=0.001)

Total 74Laparoscopic 28Converted 13Open 33

4-month follow-up

Discharged 14 (18%)Laparoscopic 7 (25%)Converted 2 (15%)Open 5 (15%)

Missing 8 (10%)Laparoscopic 4 (14%)Converted 1 (7%)Open 3 (9%)

12-month follow-up

Discharged 27 (36%)Laparoscopic 10 (35%)Converted 5 (38%)Open 12 (36%)

>12-month follow-up 25 (33%) Laparoscopic 7 (28%)Converted 5 (38%)Open 13 (39%)

Conclusions:•Laparoscopic reversal has a high conversion rate in unselected patients•Risk of conversion is significantly higher in patients with previous peritonitis•Laparoscopically completed reversals have better outcomes

• Reduced 30-day morbidity• Shorter post-operative hospital stay• Reduced rate of re-operations (small difference)• Fewer stoma-site heraniae

  year

Number of patients (Lap vs open)

operation duration (mins) (Lap vs Open)

Conversion rate (%)

Hospital stay (days) (Lap vs Open)

Mortality (%) (Lap vs Open)

Total morbidity (%) (Lap vs Open)

Re-admissions (%) (Lap vs Open)

Re-operation (%) (Lap vs Open)

                   Macpherson et al 1996 12 162  8       Delgado et al 1998 11 144  7       Kohler et al 1999 19 114 11 7.5  15.8   Vacher et al 2002 38  15 10 2.631579 23.5   

Rosen et al 2005 22 158 9 4.2  14   Khaikin et al 2006 27 228 14.8 6  33   Faure et al 200714 vs 20 143 vs 180 14.39.5 vs 11   14 vs 30    Slawik et al 2008 28 80 7 3 7  11 Carus et al 2008 28 69 17.9 8.6  14.3   

Haughn et al 200861 vs 61 154 vs 200      3.3 vs 16.4 16.4 vs 16.413.1 vs 3.3

Chouillard et al 200944 vs 44 195 vs 160 9.14.8 vs 6.82.2 vs 011.4 vs 28.6    

Mazeh et al 200941 vs 41 193 vs 209 19.56.4 vs 8  4.8 vs 12.1    

Achkasov et al 201036 vs 35 179vs 266 09.1 vs12.9   5.9 vs 9.1    

Svenningsen et al 201021 vs 22 285 vs 158 54 vs 6   10 vs 14    Leroy et al 2011 42 117 9.5 7  19.04762   Hai et al 2011 28 166 0    10.7   

Summary of literaturePapers comparing laparoscopic to open reversals highlightedSignificant differences in red