The reversal of the Hartmann's procedure is the second stage of the operation. To most patients this is the most important part of the whole process. The operation does carry risks and is not as easy and straightforward as reversal of a loop colostomy. Hartmann's procedure involves
another laparotomy and all the inherent risk associated with major bowel surgery.
One of the first remarks that the surgeon will make to the patient is: 'We had to give you a bag, but it's temporary and can be reversed.' The first question the patient has is: 'How long will I have the bag?' One or two patients believe that temporary means that the bag will be reversed before they are discharged home. A number of hospitals are able to give the patient a date for reversal of their colostomy. Unfortunately, this is not possible in most district general hospitals because of the restraints on bed availability and government targets. The reversal operation is not a life-saving procedure and, in the district general hospital, the patient is placed on the general waiting list.
The reversal operation (Keighley and Williams, 1997) is not without risk and will mean another length of stay in hospital. There has been research in Denmark about a fast-track rehabilitation after closure of a Hartmann's procedure from Basse et al. (2000). The conclusion of the study was that the inclusion of the multidisciplinary team after revision of the Hartmann's procedure reduces morbidity and hospital stay. Other hospitals are now performing laparoscopic closure of Hartmann's procedure which is proving to require shorter hospital admission (Sosa et al., 1994; Holland et al., 2002).
The patient's reversal operation may never take place; the patient may prefer not to have further surgery and be at ease with the stoma. Alternatively, the patient may have other medical problems that make surgery not feasible, or the patient may not be medically fit for surgery. Even though the intention of the surgeon will be to reverse the stoma, it may be technically impossible to reverse it and this may not be apparent until during the operation. The reversal of the Hartmann's procedure is not guaranteed and can leave the patient with a permanent end-colostomy.
The patient will need counselling from the specialist nurse about the nature of the surgery and the risks involved. The patient has to appreciate all the risks of an anaesthetic and surgery, as well as the specific risks associated with the reversal. Frequently patients put their lives on hold until the reversal operation, which involves not returning to everyday living, or work, and not seeing anyone outside their immediate family. This will place a strain on their lives and on their loved ones and impede their recovery. The ethos of this surgery is for the patient to return to their normal everyday living as soon as possible. In hospitals where a date for reversal is given to the patient at the time of discharge, a patient can plan and look forward to the future. The British Colostomy Association offers support, help, advice and leaflets on the reversal operation.
The operation involves reopening the old laparotomy scar, taking the colostomy back into the abdomen, and joining the proximal end to the distal end of the colon. The patient will then have two scars: the laparotomy scar and the scar where the colostomy was in the left iliac fossa.
After the operation to reverse the stoma, the patient experiences all the usual postoperative recovery episodes. The patient may experience a time of adjustment with bowel habit. It may mean that motions are looser and more frequent than before surgery or everything could revert back to normal. Some patients take a long time for their bowels to settle after reversal and loose frequent motions are a problem for them. Jelly babies and marshmallows (Black, 2000) work in helping to thicken the output if it is very watery. Incontinence can also be a factor after reversal; usually all these symptoms do settle eventually. Patients need to be aware that their normal bowel habit from before their original surgery has gone and a new habit will emerge. Most patients will recover very well and put all their anxieties of having a colostomy behind them and, for most, they will forget this period in their life. A few will still have problems: usually the length of time that it takes for them to recover and feel well again. Patients who have had surgery on their bowel still have access to the colorectal specialist nurse and will keep in contact if they have any worries.
The stoma care nurse specialist is the most appropriate person to counsel the patient with all the relevant information about reversal of colostomy and the recovery and convalescence period.
Complications of reversal of Hartmann's procedure
One of the main complications for the reversal of Hartmann's procedure surgery is the failure to reverse the stoma. A number of patients do opt not to go through the reversal procedure, some because of the risks of survival; others because they have accepted their colostomy and it has not caused them any problems. The author (CH) did have a 92-year-old patient whom the surgeons asked her to convince that he would be better off with his colostomy reversed. This man said 'My dear, why would I want to go through more surgery? When I go on an outing I don't have to rush to the toilet, my bag is convenient.'
Surgeons do appear to assume that everyone who has a stoma will want to have it reversed. Patients must be given all the options and allied risks, and be left to make up their own minds. For the patient who is desperate for reversal, this is not an option; they want their colostomy reversed at any cost. The patient who goes to theatre expecting to have the colostomy reversed and wakes up with it still there is in a desperate situation.
Patients have usually placed all their hopes and faith in having the colostomy reversed and never for one moment give any consideration to the possibility that it may not be possible. They are counselled at length about all the possible outcomes, but they do not appear to listen or remember that they may wake up with the colostomy. Patients feel let down and that they have somehow failed. These situations do not happen often but the possibility always has to be considered. At some hospitals this problem does not arise and colostomy reversals always happen. When the colostomy is not reversible for whatever reason, patients will require the advice and support of the stoma care nurse. Counselling these patients and offering explanations take all the expertise of the specialist nurses.
Other complications of reversal are wound healing. If the patient had problems with the wound healing after the first operation, the wound may take the same route. The stoma site can, in addition, have problems with healing. This can cause the patient emotional distress, because it will appear to him or her that the colostomy has reappeared. The patient will require wound assessment and appropriate dressing.
Another complication is the slowness of the bowel to resume its role of defecation. Patients often assume that, because they have been starved of food and drink, their bowels have no chance of working and do not appear to appreciate the importance of this complication. Fluid intake needs encouragement as well as diet. As a result of the fact that the patients have been starved, they become dehydrated and this is often the cause of lack of bowel activity. Most patients will have a bowel action by day 10. For those very few who fail to achieve this, it will be necessary for the surgical team to intervene for assessment. The first investigation will be a plain abdominal radiograph and then assessment. Surgery to address this problem is rare.
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