Robotic Hartmann’s reversal—feasibility and technical aspects

Hartmann’s reversal as a staged procedure after emergency surgery is a major abdominal operation with undeniable skill-demanding steps. The robotic approach and its advantages seem to be a safe and feasible technique and could overcome necessary technical compromises of laparoscopy, ensuring a significant reduction in restoration failures or conversion.


Introduction
Hartmann's resection is usually an emergency colectomy for colonic perforations, such as for complicated diverticulitis in critically ill patients [1], obstructions (cancer, inflammatory bowel diseases) [2] and trauma in the setting of faecal peritonitis or in frial patients to avoid morbidity and mortality associated with anastomotic leaks and as a temporising measure to restore patients' conditions [3].
Facing with colostomy patients could raise several technical issues due to the presence of significant and extensive intraperitoneal adhesions with increased risks for inadvertent enterotomies.
Furthermore, especially in cases of previous purulent or faecal peritonitis, pelvis may appear inaccessible and "frozen" such to make bowel continuity restoration unsuccessful even after a reasonable waiting time of 3-6 months from the primary procedure and resulting in an overall reversal rate of around 50% [4,5].
Traditionally performed in an open fashion to control hostile abdomens, Hartmann's reversals have significantly benefited from advances in minimally invasive laparoscopic and robotic surgery, even if the former presents undeniable additional technical limitations making the approach complex and laborious, especially in the initial stages for adhesiolysis.The robotic technique, recently described by de'Angelis et al. [6], would seem to have overcome such limitations by offering advantages of accuracy and precision without resorting to tricks or compromises and resulting in a significant reduction in conversion rates.
Here, we present our robotic Hartmann's reversal technique using DaVinci Xi System ®, highlighting the advantages and challenges to a hostile abdomen.The procedure was performed in accordance with the ethical standards and the Declaration of Helsinki (revised on 2013).
Written consent was provided by the patient for the procedure and for scientific iconographic and video purposes according to the Italian Society of Surgery form.

Preoperative preparation and port placement
The patient is in 15° Trendelemburg right-side rotated lithotomy position.Expecting the presence of extensive visceral adhesions from the previous open surgery, pneumoperitoneum is induced by Verres needle on Palmer's point in the left upper quadrant.
Robotic docking requires a correct planning of surgical phases for an optimal approach to both the splenic flexure and pelvis.For this reason, we usually adopt a modified port placement similar to a left colectomy, by placing trocars posterior and parallel to a line joining the right anterior superior iliac spine and the intersection between the left midclavicular and subcostal lines.
We believe that this setting overcomes unnecessary intraoperative double docking and allows a good control in both the retromesocolic and pelvic approaches.When using the DaVinci Xi System ®, it is our practice to place a 12 mm optical trocar in the right flank as lateral as possible and equidistant between Arm 3 and Arm 4.
The optical trocar will be reserved for the assistant for traction/countertraction or suction manoeuvres and will be connected to the Air-Seal System ®.A peculiarity of the Xi generation is the possibility of proceeding with reduced pneumoperitoneum procedures by exploiting the external traction effect of robotic arms.Therefore, our procedures are carried out at a pressure of 8 mmHg with considerable benefits in terms of hemodynamic stability and postoperative pain.
The 8 mm Trocar 1 (T1) is placed in the epigastrium.The remaining three ports are 6-8 cm equidistant in-line placed.T4 is usually a 12 mm port to allow the introduction of the mechanical stapler.We prefer to use atraumatic Cadiere grasper through T1, bipolar forceps at T2, monopolar scissors (and EndoStaplers) at T4, while camera is held at T3 (Fig. 1).

Peritoneal adhesiolysis and rectal stump dissection
Using sharp dissection, bipolar grasper and atraumatic Cadiere forceps for countertraction, extensive and gentle adhesiolysis is gained.The intraperitoneal colostomy segment is circumferentially freed.Then after, a stepwise approach to pelvis is gained with dissection of ileal adhesions form peritoneal recesses (especially from Jonnesco's and left-side mesopelvis) and surrounding structures such as ovaries, adnexae, uterus and rectal stump (Fig. 2).The blind segment is sharply dissected with its proximal mesorectum in order to achieve and adequate mobilization and allow a recut of the stump.In fact, it is common to perform a further rectal resection due to concomitant post-inflammatory dystrophic and stenotic phenomena causing distortion of the visceral lumen (Figs. 3, 4).

Left colon and splenic flexure mobilization
The second phase of the procedure involves the medial-tolateral mobilization of the descending colon and the splenic flexure with inferior mesenteric retrovenous access and respecting the Toldt-Gerota embryonic attachment plans (Fig. 5).If challenges arise during retromesocolic mobilization due to mesocolic retraction or visceral obesity, we usually proceed with a Melani's transmesocolic [7] or supramesocolic approach.During the phases of colon dissection, we believe that an on-site colostomy loop is essential to ensure physiological traction of the afferent segment and to facilitate the identification of the correct embryonic planes.

Colostomy breakdown
The colostomy limb is then intraperitoneally dissected from the fascia and subcutaneous tissue.This is followed by resolution of the pneumoperitoneum, colostomy dissection, introduction of EEA anvil, extraction of the resected rectal stump, intra-abdominal colic reposition and bilayer myofascial synthesis of the parietal defect.It is not our practice to perform additional service minilaparotomies to extract resected rectal segments.

Colorectal anastomosis
Regaining pneumoperitoneum and reinstating robotic control, the EEA stapler is inserted transanally.Using robotic arms, the anvil can be mated to the stapler and, before proceeding to the anastomosis, we employ the Firefly® immunoflorescent technology for a qualitative and quantitative perfusion assessment by indocyanine green infusion (Fig. 6).In the case of reduced intraluminal dimensions not allowing an adequate transit of the EEA, we proceed with a termino-lateral transanal anastomosis on the anterior rectal side with a 25-Charrière stapler (Fig. 7).Leak test is routinely performed.

Advantages of robotic Hartmann's reversal procedures
Technical issues for Hartmann's reversal usually arise when an extensive adhesiolysis and the identification of the rectal stump is claimed.Previous peritonitis can complicate and even preclude access to the peritoneal cavity.However, robotic technology allows natural and accurate movements fully comparable to an open approach.The lack of tactile feedback, however, is mitigated by a visual adaptation allowing to apply proper traction forces.Another peculiarity of robotic surgery is the Xi 30° bottom-to-up orientation visual system allowing ergonomic movements.Finally, similar to laparoscopy, the robotic platform allows intraoperative perfusion assessments (FireFly technology®) with qualitative and quantitative estimation of indocyanine green uptake during the anastomotic phase.

Discussion
Experiences about robotic-assisted Hartmann's reversal is quite limited to few case reports [6, 8-10]and only to a retrospective study.Giuliani et al. [11] reported a mean operating time of 240 min with no conversion cases neither the need for diverting loop ileostomies.With a mean hospital stay of 6 days, minor complications occurred in 12.4% of patients.
No randomized controlled trials evaluating indications or advantages of robotic Hartmann's reversal procedure over laparoscopic or open approach have not still published to this date.
It is, therefore, quite difficult to be able to give an exhaustive definition and a clear collocation of the robotic rationale in the restoration of intestinal continuity.However, the scarcity of evidence would seem to point towards a post-operative course comparable to laparoscopy with the addition of a drastic reduction in conversion rates.

Conclusions
Robotic surgery for Hartmann's reversal is a skill-demanding technique as feasible and safe as laparoscopy.Multicentre studies and RCTs are needed.