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

1. 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%)