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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 Centre

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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 Centre

R 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 74

Laparoscopic 28

Converted 13

Open 33

  • 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

Missing 8 (10%)

Laparoscopic 4 (14%)

Converted 1 (7%)

Open 3 (9%)

Discharged 14 (18%)

Laparoscopic 7 (25%)

Converted 2 (15%)

Open 5 (15%)

Summary of literature

Papers comparing laparoscopic to open reversals highlighted

Significant differences in red

4-month follow-up

Discharged 27 (36%)

Laparoscopic 10 (35%)

Converted 5 (38%)

Open 12 (36%)

12-month follow-up

>12-month follow-up 25 (33%)

Laparoscopic 7 (28%)

Converted 5 (38%)

Open 13 (39%)

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