A proactive technique for reversal of Hartmann’s procedure: lifting the rectal stump to the abdominal wall

A proactive technique for reversal of Hartmann’s procedure: lifting the rectal stump to the abdominal wall | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report A proactive technique for reversal of Hartmann’s procedure: lifting the rectal stump to the abdominal wall Akio Fukada, Takayuki Ogino, Yuji Fujimoto, Yuki Sekido, Mitsunobu Takeda, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4209709/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Mar, 2025 Read the published version in Techniques in Coloproctology → Version 1 posted 7 You are reading this latest preprint version Abstract Background Reversal of Hartmann’s procedure is complicated owing to dense adhesions resulting from inflammation in the pelvic region. These adhesions pose challenges in identifying the rectum and increase the risk of pelvic organ injuries. Methods We propose a technique to lift and fix the rectal stump to the abdominal wall to diminish adhesions to the rectum and facilitate identification of the rectal stump. Results The patient underwent Hartmann's procedure for generalized peritonitis resulting from perforation of the sigmoid colon. The abdominal cavity was significantly contaminated with fecal ascites, and postoperative pelvic adhesions were anticipated. Therefore, the rectal stump was lifted. The outcomes demonstrated that despite the presence of dense adhesions in the abdominal cavity, the rectal segment was promptly identified during reversal of Hartmann’s procedure. The procedure proceeded smoothly and was deemed satisfactory. Conclusions The technique of lifting and fixing the rectal stump to the abdominal wall is useful in cases where dense pelvic adhesions are anticipated during the subsequent reversal of Hartmann’s procedure. Hartmann’s procedure Reversal of Hartmann’s procedure surgery diverticulitis laparoscopy Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Hartmann's procedure (HP) involves the resection of the diseased left-sided colon, accompanied by the creation of a proximal end colostomy and suture closure of the distal rectal stump. HP is typically reserved for emergency cases of left-sided colonic diseases, such as complicated diverticulitis, obstructing or perforated left-sided colonic tumors, and traumatic injuries associated with fecal contamination. In these high-risk emergency patients, HP is effective in circumventing the complexities associated with rectal anastomosis and avoiding postoperative anastomotic complications. Several studies have suggested that peritoneal lavage or primary anastomosis with a diverting ileostomy for perforated diverticulitis is preferable to HP in particular patients [ 1 – 3 ]. However, prioritizing sepsis control and devising surgical strategies to manage damage are paramount to ensure patient survival. Additionally, maintaining intestinal continuity can be challenging in cases with compromised intestinal status; hence, HP is frequently chosen in emergency situations. The reversal of colostomy after HP, known as the reversal of Hartmann’s procedure (RHP), poses a significant challenge. Severe inflammation after RHP can lead to intra-abdominal adhesions and residual rectal atrophy. Consequently, tasks such as adhesiolysis, identification of the rectal stump, and anastomosis are technically demanding during RHP. In recent years, laparoscopic surgery has become increasingly favored for nonmalignant surgeries [ 4 ]. Many studies have reported that laparoscopic RHP offers superior outcomes compared with laparotomy, including faster recovery and improved outcomes [ 5 – 7 ]. However, a notable challenge of laparoscopic RHP is the high rate of conversion to open surgery. The conversion rate is reported to be approximately 12%, with extensive adhesions being the most common cause, followed by factors related to the rectal stump [ 8 ]. Surgeons often encounter difficulties in identifying the rectal stump during RHP because it may retract into the lower pelvis and become obscured by fibrotic tissue. Challenges in identifying rectal stumps induced by rectal atrophy or severe pelvic adhesions can also impede successful completion of RHP. To address the challenges associated with RHP, we propose a novel technique for laparoscopic RHP, in which the rectal stump is elevated to the anterior abdominal wall. TECHNICAL DESCRIPTION The purpose of this procedure is to facilitate easy identification of the rectal stump during RHP by lifting it during the initial HP and fixing it to the abdominal wall. Initially, two sites of firm tissue near the rectal stump were selected and nonabsorbable threads were stitched to each site (Fig. 1 a, 1 b). Subsequently, the sutured nonabsorbable threads were percutaneously retracted using Endoclose (Medtronic Inc., MN, USA) and fixed to the abdominal wall at the right and left positions just cephalad to the pubic bone (Fig. 1 c). It is crucial to note the position at which the nonabsorbable threads are sewn to exclude vulnerable areas and prevent tissue tearing under tension during elevation. Preserving the rectal stump as much as possible is vital as it serves as an important site for later anastomosis. Additionally, when pulling up a non-absorbable thread, the rectum should be carefully handled to avoid exerting excessive tension on the tissue. Subsequent RHP is typically performed a few months after a favorable postoperative course. During the subsequent RHP, the rectal stump fixed to the abdominal wall in the previous operation was held in a lifted position, facilitating easy identification of the rectum (Fig. 1 d). In addition, unnecessary maneuvers for adhesion dissection are reduced, thereby minimizing the risk of organ damage. Without fixation, rectal stumps are covered by other pelvic organs and firmly adhere to the surrounding tissue, requiring extensive adhesion dissection (Fig. 2 ). This technique can be easily performed with minimal effort to relieve these burdens. After detaching the fixed threads and ensuring sufficient rectal mobility, laparoscopic rectal anastomosis was performed. CASE PRESENTATION A 63-year-old man presented to our hospital with lower abdominal pain and signs of peritoneal irritation. Contrast-enhanced computed tomography showed free air around the sigmoid colon and liver surface (Fig. 3 a). In response to a diagnosis of diffuse peritonitis caused by perforated sigmoid diverticulitis, an emergency HP was performed (Fig. 3 b). At the end of surgery, the rectal stump was firmly lifted and fixed to the abdominal wall. Four months later, he underwent laparoscopic RHP. After the colostomy was taken down, the laparoscopic procedure was commenced. The patient had developed generalized peritonitis postoperatively and exhibited extensive adhesions within the abdominal cavity. Upon dissection of the abdominal wall adhesions, the rectal stump lifted to the anterior abdominal wall was easily detected (Fig. 4 a). The rectum was mobilized near the peritoneal reflection with detachment of adhesions in the pelvic cavity (Fig. 4 b). The rectal stump was resected at the level of the promontorium, and colorectal intracorporeal anastomosis was performed using the double stapling technique (Fig. 4 c). The postoperative course was uneventful, and the patient was discharged without complications. DISCUSSION HP is performed in patients with poor general condition or at high risk of anastomotic leakage. Primary anastomosis is typically avoided in cases of severe inflammation of the pelvic cavity and edema of the residual rectal wall. RHP was subsequently performed after the patient's condition stabilized and upon request. RHP has been performed by laparotomy; however, in recent years, it has been increasingly performed laparoscopically. Laparoscopic RHP offers advantages over open surgery, including reduced postoperative pain, shorter hospitalization, and fewer postoperative complications [ 9 ]. However, this requires technical proficiency and can be complex. Identification of the rectal stump is essential during RHP. Most patients undergoing HP present with purulent or fecal peritonitis, which leads to significant adhesions in the pelvic cavity. These adhesions can obscure the rectal stump, which may become atrophic and retract deep into the pelvis. Separating the rectal stump from the surrounding pelvic viscera, such as the bladder, uterus, and vagina, can be challenging. Even when the rectal stump is marked with a nonabsorbable suture material during HP, it can be difficult to identify the rectum because of adhesions. In such cases, careful procedures are required to avoid serious complications such as pelvic organ injuries and bleeding. Presacral venous bleeding during rectal mobilization is uncommon, but can be challenging to control and potentially life-threatening. When laparoscopic dissection of adhesions is not feasible, open conversion is necessary. Previous reports have indicated an open conversion rate of 9–50% in laparoscopic RHP [ 7 ]. For most cases, the need for conversion is attributed to intra-abdominal adhesions, difficult rectal identification, and rectal damage [ 8 ]. For a safe surgery, it is necessary to overcome the problem of ensuring a rectal stump. Surgeons have introduced several innovations to solve the problems with RHP [ 10 ], such as fixing the rectal stump to the fascia of the anterior sacral surface [ 11 ], using an endoscope inserted through the anus to provide light for rectal stump identification [ 12 ], and retrograde injection of saline through a urethral balloon to delineate rectal boundaries [ 13 ]. Lifting of the rectal stump to the abdominal wall offers several advantages. First, it facilitates identification of the rectal stump as it is fixed to the abdominal wall. The identified rectum is a marker when performing intraperitoneal adhesion dissection, which may reduce the risk of accidental organ injury. Second, it helps reduce adhesions around the rectal stump, thereby decreasing the risk of rectal injury and surgeon stress. Third, it may lessen rectal atrophy. In patients with rectal atrophy, it is necessary to mobilize the rectum deep in the pelvic region to facilitate anastomosis. The most important aspect of RHP is avoiding rectal injury and performing safe anastomoses. However, in cases where the residual rectal length is insufficient, or the rectum cannot be lifted adequately, fixing it to the abdominal wall is challenging. Additionally, this technique may not be suitable if the rectal tissues are fragile, as it may place tension on the rectum during lifting. In our patient, there were no complications associated with this technique, however, further studies are required to confirm its efficacy. CONCLUSION We describe a new technique for laparoscopic RHP in which the rectal stump is elevated to the abdominal wall. This technique could be beneficial for reducing the complexity of RHP. However, further studies are required to confirm its efficacy. Declarations Compliance with Ethical Standards Disclosure of potential conflicts of interest: The authors declare no conflicts of interest associated with this paper. Ethical review: This report was approved by the institutional review board of Osaka University Hospital. Informed consent: The patients consented that data about their surgery and follow up could be used and published in the context of clinical research. Author contributions: AF and YF drafted the manuscript; TO revised it critically; and YS, MT, TH, AH, NM, MU, TM, HE, and YD conceived the study, participated in its design and coordination, and helped draft the manuscript. All authors approved the final manuscript. Acknowledgments: No acknowledgments to declare. References Swank HA, Vermeulen J, Lange JF, Mulder IM, van der Hoeven JAB, Stassen LPS, et al. (2010) The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann’s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037). BMC Surg 10:29. https://doi.org/10.1186/1471-2482-10-29 Angenete E, Thornell A, Burcharth J, Pommergaard HC, Skullman S, Bisgaard T, et al. (2016) Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis the first results from the randomized controlled trial DILALA. Ann Surg 263(1):117–122. https://doi.org/10.1097/SLA.0000000000001061 Oberkofler CE, Rickenbacher A, Raptis DA, Lehmann K, Villiger P, Buchli C, et al. (2012) A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 256(5):819–26; discussion 826. https://doi.org/10.1097/SLA.0b013e31827324ba Ogino T, Mizushima T, Matsuda C, Mori M, Doki Y (2020) Essential updates 2018/2019: colorectal (benign) Recent updates (2018–2019) in the surgical treatment of benign colorectal diseases. Ann Gastroenterological Surg 4(1):30–38. https://doi.org/10.1002/ags3.12304 Yang PF, Morgan MJ (2014) Laparoscopic versus open reversal of Hartmann’s procedure: a retrospective review. ANZ J Surg 84(12):965–969. https://doi.org/10.1111/ans.12667 Ng DCK, Guarino S, Yau SLC, Fok BKL, Cheung HYS, Li MKW, Tang CN (2013) Laparoscopic reversal of Hartmann’s procedure: safety and feasibility. Gastroenterol Rep (Oxf) 1(2):149–152. https://doi.org/10.1093/gastro/got018 Celentano V, Giglio MC, Bucci L (2015) Laparoscopic versus open Hartmann’s reversal: a systematic review and meta-analysis. Int J Colorectal Dis 30(12):1603–1615. https://doi.org/10.1007/s00384-015-2325-4 Lucchetta A, De Manzini N (2016) Laparoscopic reversal of Hartmann procedure: is it safe and feasible? Update Surg 68(1):105–110. https://doi.org/10.1007/s13304-016-0363-2 Toro A, Ardiri A, Mannino M, Politi A, Di Stefano A, Aftab Z, et al. (2014) Laparoscopic reversal of Hartmann’s procedure: state of the art 20 years after the first reported case. Gastroenterol Res Pract 2014:530140. https://doi.org/10.1155/2014/530140 Madura JA, Fiore AC (1983) Reanastomosis of a Hartmann rectal pouch. Am J Surg 145(2):279–280. https://doi.org/10.1016/0002-9610(83)90081-8 Garancini M, Delitala A, Tamini N, Polese M, Giani A, Giardini V (2016) Rectal stump suspension: a novel technique to facilitate and shorten totally laparoscopic Hartmann reversal. Int J Colorectal Dis 31(4):919–920. https://doi.org/10.1007/s00384-015-2306-7 Yamamoto D, Sakimura Y, Kitamura H, Tsuji T, Kadoya S, Bando H (2021) Standardization of laparoscopic reversal of the Hartmann procedure: A single-center report. Asian J Endosc Surg 14(3):653–657. https://doi.org/10.1111/ases.12902 Rosen MJ, Cobb WS, Kercher KW, Sing RF, Heniford BT (2005) Laparoscopic restoration of intestinal continuity after Hartmann’s procedure. Am J Surg 189(6):670–674. https://doi.org/10.1016/j.amjsurg.2005.03.007 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Mar, 2025 Read the published version in Techniques in Coloproctology → Version 1 posted Editorial decision: Revision requested 11 Nov, 2024 Reviews received at journal 01 Jun, 2024 Reviewers agreed at journal 05 May, 2024 Reviewers invited by journal 05 May, 2024 Editor assigned by journal 05 May, 2024 Submission checks completed at journal 03 Apr, 2024 First submitted to journal 02 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4209709","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":287123770,"identity":"0135a1f6-36d8-445f-91a1-d1a9443f2e01","order_by":0,"name":"Akio Fukada","email":"","orcid":"","institution":"Osaka University","correspondingAuthor":false,"prefix":"","firstName":"Akio","middleName":"","lastName":"Fukada","suffix":""},{"id":287123772,"identity":"3aee89d2-65c3-43eb-adf2-a54a73f03e6c","order_by":1,"name":"Takayuki Ogino","email":"data:image/png;base64,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","orcid":"","institution":"Osaka University","correspondingAuthor":true,"prefix":"","firstName":"Takayuki","middleName":"","lastName":"Ogino","suffix":""},{"id":287123773,"identity":"77250b45-6305-475c-aba4-f1ba9e5f3263","order_by":2,"name":"Yuji Fujimoto","email":"","orcid":"","institution":"Osaka University","correspondingAuthor":false,"prefix":"","firstName":"Yuji","middleName":"","lastName":"Fujimoto","suffix":""},{"id":287123775,"identity":"e25dd10c-62af-4f4e-a6ff-297768c12b56","order_by":3,"name":"Yuki Sekido","email":"","orcid":"","institution":"Osaka University","correspondingAuthor":false,"prefix":"","firstName":"Yuki","middleName":"","lastName":"Sekido","suffix":""},{"id":287123777,"identity":"79992069-e440-4e17-ad6f-ccb9367e4f6a","order_by":4,"name":"Mitsunobu Takeda","email":"","orcid":"","institution":"Osaka University","correspondingAuthor":false,"prefix":"","firstName":"Mitsunobu","middleName":"","lastName":"Takeda","suffix":""},{"id":287123780,"identity":"20180057-9599-489e-9d8c-3d27d184616b","order_by":5,"name":"Tsuyoshi Hata","email":"","orcid":"","institution":"Osaka University","correspondingAuthor":false,"prefix":"","firstName":"Tsuyoshi","middleName":"","lastName":"Hata","suffix":""},{"id":287123783,"identity":"0b03fd42-d06c-47f9-a48a-379c491ee721","order_by":6,"name":"Atsushi Hamabe","email":"","orcid":"","institution":"Osaka University","correspondingAuthor":false,"prefix":"","firstName":"Atsushi","middleName":"","lastName":"Hamabe","suffix":""},{"id":287123784,"identity":"8b0fc31c-b4f1-474e-a011-8a18c5c118cf","order_by":7,"name":"Norikatsu Miyoshi","email":"","orcid":"","institution":"Osaka University","correspondingAuthor":false,"prefix":"","firstName":"Norikatsu","middleName":"","lastName":"Miyoshi","suffix":""},{"id":287123785,"identity":"8bfda890-09c1-4f44-a151-ed7b1e7eb8e6","order_by":8,"name":"Mamoru Uemura","email":"","orcid":"","institution":"Osaka University","correspondingAuthor":false,"prefix":"","firstName":"Mamoru","middleName":"","lastName":"Uemura","suffix":""},{"id":287123788,"identity":"df6aeca8-3442-40a5-bc7b-f4657fcc99b4","order_by":9,"name":"Tsunekazu Mizushima","email":"","orcid":"","institution":"Osaka Police Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tsunekazu","middleName":"","lastName":"Mizushima","suffix":""},{"id":287123789,"identity":"cb21c6df-6214-4a7f-b30a-e9f902cc1ae9","order_by":10,"name":"Hidetoshi Eguchi","email":"","orcid":"","institution":"Osaka University","correspondingAuthor":false,"prefix":"","firstName":"Hidetoshi","middleName":"","lastName":"Eguchi","suffix":""},{"id":287123790,"identity":"7855891b-eab6-497b-af5b-7f4639686860","order_by":11,"name":"Yuichiro Doki","email":"","orcid":"","institution":"Osaka University","correspondingAuthor":false,"prefix":"","firstName":"Yuichiro","middleName":"","lastName":"Doki","suffix":""}],"badges":[],"createdAt":"2024-04-03 03:44:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4209709/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4209709/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10151-025-03128-0","type":"published","date":"2025-03-24T15:56:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54322458,"identity":"ae055555-950d-4b6f-b5e4-8dde7dcb67d9","added_by":"auto","created_at":"2024-04-08 19:50:05","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":200883,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea)\u003c/strong\u003e The rectal stump was lifted to the abdominal wall using sutures in the HP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb)\u003c/strong\u003e Two points near the rectal stump were stitched with nonabsorbable sutures, which were left long enough for elevation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ec)\u003c/strong\u003e The rectum fixed to the abdominal wall was confirmed to be lifted during RHP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ed)\u003c/strong\u003e The lifted rectum is indicated by the triangular arrow\u003c/p\u003e","description":"","filename":"Fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4209709/v1/ac057ed1f9d2729925c56b9f.jpg"},{"id":54322457,"identity":"04d027cb-c384-4a44-85c1-2cce21d956a1","added_by":"auto","created_at":"2024-04-08 19:50:05","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":127660,"visible":true,"origin":"","legend":"\u003cp\u003eThe intricate adhesions in the pelvic cavity make it difficult to identify the buried rectal segment. Adhesions are particularly severe in the Douglas fossa, and careful debridement is required to prevent injury to the uterus, ureters, and blood vessels\u003c/p\u003e","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4209709/v1/b072b80707b4a6c4435050ee.jpg"},{"id":54322456,"identity":"ed112bb0-2e60-493d-bb33-301b5b518998","added_by":"auto","created_at":"2024-04-08 19:50:05","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":98636,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea)\u003c/strong\u003e Contrast-enhanced computed tomography showed free air around the sigmoid colon, as indicated by a triangular arrow.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb)\u003c/strong\u003e Intraoperatively, the perforation of the sigmoid colon was identified, with the perforation indicated by the triangular arrow\u003c/p\u003e","description":"","filename":"Fig.3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4209709/v1/2c1c3c4898c84f14a3a4f993.jpg"},{"id":54322459,"identity":"c68e49b7-ace2-4e94-95fa-4683d5e6cf0e","added_by":"auto","created_at":"2024-04-08 19:50:05","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":193852,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea)\u003c/strong\u003e The rectal stump, lifted to the abdominal wall, was easily detected after detaching the abdominal wall adhesions. A triangular arrow indicates the non-absorbable sutures fixed to the abdominal wall\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb)\u003c/strong\u003e Although the rectum had slight adhesion, it was easily mobilized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ec)\u003c/strong\u003e The anastomosis was performed using the double stapling technique.\u003c/p\u003e","description":"","filename":"Fig.4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4209709/v1/8126bf63a896919cde317341.jpg"},{"id":79604768,"identity":"50752445-3fdb-4c8e-96ac-16700c5483f2","added_by":"auto","created_at":"2025-03-31 16:04:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":980899,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4209709/v1/bc07fbfa-04a8-44f8-9c89-49627c2b8fcf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A proactive technique for reversal of Hartmann’s procedure: lifting the rectal stump to the abdominal wall","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eHartmann's procedure (HP) involves the resection of the diseased left-sided colon, accompanied by the creation of a proximal end colostomy and suture closure of the distal rectal stump. HP is typically reserved for emergency cases of left-sided colonic diseases, such as complicated diverticulitis, obstructing or perforated left-sided colonic tumors, and traumatic injuries associated with fecal contamination. In these high-risk emergency patients, HP is effective in circumventing the complexities associated with rectal anastomosis and avoiding postoperative anastomotic complications. Several studies have suggested that peritoneal lavage or primary anastomosis with a diverting ileostomy for perforated diverticulitis is preferable to HP in particular patients [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, prioritizing sepsis control and devising surgical strategies to manage damage are paramount to ensure patient survival. Additionally, maintaining intestinal continuity can be challenging in cases with compromised intestinal status; hence, HP is frequently chosen in emergency situations.\u003c/p\u003e \u003cp\u003eThe reversal of colostomy after HP, known as the reversal of Hartmann\u0026rsquo;s procedure (RHP), poses a significant challenge. Severe inflammation after RHP can lead to intra-abdominal adhesions and residual rectal atrophy. Consequently, tasks such as adhesiolysis, identification of the rectal stump, and anastomosis are technically demanding during RHP. In recent years, laparoscopic surgery has become increasingly favored for nonmalignant surgeries [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Many studies have reported that laparoscopic RHP offers superior outcomes compared with laparotomy, including faster recovery and improved outcomes [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, a notable challenge of laparoscopic RHP is the high rate of conversion to open surgery. The conversion rate is reported to be approximately 12%, with extensive adhesions being the most common cause, followed by factors related to the rectal stump [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Surgeons often encounter difficulties in identifying the rectal stump during RHP because it may retract into the lower pelvis and become obscured by fibrotic tissue. Challenges in identifying rectal stumps induced by rectal atrophy or severe pelvic adhesions can also impede successful completion of RHP.\u003c/p\u003e \u003cp\u003eTo address the challenges associated with RHP, we propose a novel technique for laparoscopic RHP, in which the rectal stump is elevated to the anterior abdominal wall.\u003c/p\u003e"},{"header":"TECHNICAL DESCRIPTION","content":"\u003cp\u003eThe purpose of this procedure is to facilitate easy identification of the rectal stump during RHP by lifting it during the initial HP and fixing it to the abdominal wall. Initially, two sites of firm tissue near the rectal stump were selected and nonabsorbable threads were stitched to each site (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). Subsequently, the sutured nonabsorbable threads were percutaneously retracted using Endoclose (Medtronic Inc., MN, USA) and fixed to the abdominal wall at the right and left positions just cephalad to the pubic bone (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec). It is crucial to note the position at which the nonabsorbable threads are sewn to exclude vulnerable areas and prevent tissue tearing under tension during elevation. Preserving the rectal stump as much as possible is vital as it serves as an important site for later anastomosis. Additionally, when pulling up a non-absorbable thread, the rectum should be carefully handled to avoid exerting excessive tension on the tissue. Subsequent RHP is typically performed a few months after a favorable postoperative course.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDuring the subsequent RHP, the rectal stump fixed to the abdominal wall in the previous operation was held in a lifted position, facilitating easy identification of the rectum (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed). In addition, unnecessary maneuvers for adhesion dissection are reduced, thereby minimizing the risk of organ damage. Without fixation, rectal stumps are covered by other pelvic organs and firmly adhere to the surrounding tissue, requiring extensive adhesion dissection (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This technique can be easily performed with minimal effort to relieve these burdens. After detaching the fixed threads and ensuring sufficient rectal mobility, laparoscopic rectal anastomosis was performed.\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":" \u003cp\u003eA 63-year-old man presented to our hospital with lower abdominal pain and signs of peritoneal irritation. Contrast-enhanced computed tomography showed free air around the sigmoid colon and liver surface (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea). In response to a diagnosis of diffuse peritonitis caused by perforated sigmoid diverticulitis, an emergency HP was performed (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb). At the end of surgery, the rectal stump was firmly lifted and fixed to the abdominal wall. Four months later, he underwent laparoscopic RHP. After the colostomy was taken down, the laparoscopic procedure was commenced. The patient had developed generalized peritonitis postoperatively and exhibited extensive adhesions within the abdominal cavity. Upon dissection of the abdominal wall adhesions, the rectal stump lifted to the anterior abdominal wall was easily detected (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ea). The rectum was mobilized near the peritoneal reflection with detachment of adhesions in the pelvic cavity (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eb). The rectal stump was resected at the level of the promontorium, and colorectal intracorporeal anastomosis was performed using the double stapling technique (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ec). The postoperative course was uneventful, and the patient was discharged without complications.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eHP is performed in patients with poor general condition or at high risk of anastomotic leakage. Primary anastomosis is typically avoided in cases of severe inflammation of the pelvic cavity and edema of the residual rectal wall. RHP was subsequently performed after the patient's condition stabilized and upon request.\u003c/p\u003e \u003cp\u003eRHP has been performed by laparotomy; however, in recent years, it has been increasingly performed laparoscopically. Laparoscopic RHP offers advantages over open surgery, including reduced postoperative pain, shorter hospitalization, and fewer postoperative complications [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, this requires technical proficiency and can be complex. Identification of the rectal stump is essential during RHP. Most patients undergoing HP present with purulent or fecal peritonitis, which leads to significant adhesions in the pelvic cavity. These adhesions can obscure the rectal stump, which may become atrophic and retract deep into the pelvis. Separating the rectal stump from the surrounding pelvic viscera, such as the bladder, uterus, and vagina, can be challenging. Even when the rectal stump is marked with a nonabsorbable suture material during HP, it can be difficult to identify the rectum because of adhesions. In such cases, careful procedures are required to avoid serious complications such as pelvic organ injuries and bleeding. Presacral venous bleeding during rectal mobilization is uncommon, but can be challenging to control and potentially life-threatening.\u003c/p\u003e \u003cp\u003eWhen laparoscopic dissection of adhesions is not feasible, open conversion is necessary. Previous reports have indicated an open conversion rate of 9\u0026ndash;50% in laparoscopic RHP [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. For most cases, the need for conversion is attributed to intra-abdominal adhesions, difficult rectal identification, and rectal damage [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. For a safe surgery, it is necessary to overcome the problem of ensuring a rectal stump. Surgeons have introduced several innovations to solve the problems with RHP [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], such as fixing the rectal stump to the fascia of the anterior sacral surface [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], using an endoscope inserted through the anus to provide light for rectal stump identification [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and retrograde injection of saline through a urethral balloon to delineate rectal boundaries [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLifting of the rectal stump to the abdominal wall offers several advantages. First, it facilitates identification of the rectal stump as it is fixed to the abdominal wall. The identified rectum is a marker when performing intraperitoneal adhesion dissection, which may reduce the risk of accidental organ injury. Second, it helps reduce adhesions around the rectal stump, thereby decreasing the risk of rectal injury and surgeon stress. Third, it may lessen rectal atrophy. In patients with rectal atrophy, it is necessary to mobilize the rectum deep in the pelvic region to facilitate anastomosis. The most important aspect of RHP is avoiding rectal injury and performing safe anastomoses. However, in cases where the residual rectal length is insufficient, or the rectum cannot be lifted adequately, fixing it to the abdominal wall is challenging. Additionally, this technique may not be suitable if the rectal tissues are fragile, as it may place tension on the rectum during lifting. In our patient, there were no complications associated with this technique, however, further studies are required to confirm its efficacy.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWe describe a new technique for laparoscopic RHP in which the rectal stump is elevated to the abdominal wall. This technique could be beneficial for reducing the complexity of RHP. However, further studies are required to confirm its efficacy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eCompliance with Ethical Standards\u003c/p\u003e\n\u003cp\u003eDisclosure of potential conflicts of interest: The authors declare no conflicts of interest associated with this paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical review:\u0026nbsp;This report was approved by the institutional review board of Osaka University Hospital.\u003c/p\u003e\n\u003cp\u003eInformed consent: The patients consented that data about their surgery and follow up could be used and published in the context of clinical research.\u003c/p\u003e\n\u003cp\u003eAuthor contributions:\u0026nbsp;AF and YF drafted the manuscript; TO revised it critically; and YS, MT, TH, AH, NM, MU, TM, HE, and YD conceived the study, participated in its design and coordination, and helped\u0026nbsp;draft the manuscript. All authors approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgments: No acknowledgments to declare.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSwank HA, Vermeulen J, Lange JF, Mulder IM, van der Hoeven JAB, Stassen LPS, et al. (2010) The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann\u0026rsquo;s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037). BMC Surg 10:29. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1471-2482-10-29\u003c/span\u003e\u003cspan address=\"10.1186/1471-2482-10-29\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAngenete E, Thornell A, Burcharth J, Pommergaard HC, Skullman S, Bisgaard T, et al. (2016) Laparoscopic lavage is feasible and safe for the treatment of perforated diverticulitis with purulent peritonitis the first results from the randomized controlled trial DILALA. Ann Surg 263(1):117\u0026ndash;122. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/SLA.0000000000001061\u003c/span\u003e\u003cspan address=\"10.1097/SLA.0000000000001061\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOberkofler CE, Rickenbacher A, Raptis DA, Lehmann K, Villiger P, Buchli C, et al. (2012) A multicenter randomized clinical trial of primary anastomosis or Hartmann\u0026rsquo;s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 256(5):819\u0026ndash;26; discussion 826. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/SLA.0b013e31827324ba\u003c/span\u003e\u003cspan address=\"10.1097/SLA.0b013e31827324ba\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOgino T, Mizushima T, Matsuda C, Mori M, Doki Y (2020) Essential updates 2018/2019: colorectal (benign) Recent updates (2018\u0026ndash;2019) in the surgical treatment of benign colorectal diseases. Ann Gastroenterological Surg 4(1):30\u0026ndash;38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/ags3.12304\u003c/span\u003e\u003cspan address=\"10.1002/ags3.12304\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang PF, Morgan MJ (2014) Laparoscopic versus open reversal of Hartmann\u0026rsquo;s procedure: a retrospective review. ANZ J Surg 84(12):965\u0026ndash;969. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ans.12667\u003c/span\u003e\u003cspan address=\"10.1111/ans.12667\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg DCK, Guarino S, Yau SLC, Fok BKL, Cheung HYS, Li MKW, Tang CN (2013) Laparoscopic reversal of Hartmann\u0026rsquo;s procedure: safety and feasibility. Gastroenterol Rep (Oxf) 1(2):149\u0026ndash;152. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/gastro/got018\u003c/span\u003e\u003cspan address=\"10.1093/gastro/got018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCelentano V, Giglio MC, Bucci L (2015) Laparoscopic versus open Hartmann\u0026rsquo;s reversal: a systematic review and meta-analysis. Int J Colorectal Dis 30(12):1603\u0026ndash;1615. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00384-015-2325-4\u003c/span\u003e\u003cspan address=\"10.1007/s00384-015-2325-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLucchetta A, De Manzini N (2016) Laparoscopic reversal of Hartmann procedure: is it safe and feasible? Update Surg 68(1):105\u0026ndash;110. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s13304-016-0363-2\u003c/span\u003e\u003cspan address=\"10.1007/s13304-016-0363-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToro A, Ardiri A, Mannino M, Politi A, Di Stefano A, Aftab Z, et al. (2014) Laparoscopic reversal of Hartmann\u0026rsquo;s procedure: state of the art 20 years after the first reported case. Gastroenterol Res Pract 2014:530140. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1155/2014/530140\u003c/span\u003e\u003cspan address=\"10.1155/2014/530140\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMadura JA, Fiore AC (1983) Reanastomosis of a Hartmann rectal pouch. Am J Surg 145(2):279\u0026ndash;280. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/0002-9610(83)90081-8\u003c/span\u003e\u003cspan address=\"10.1016/0002-9610(83)90081-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarancini M, Delitala A, Tamini N, Polese M, Giani A, Giardini V (2016) Rectal stump suspension: a novel technique to facilitate and shorten totally laparoscopic Hartmann reversal. Int J Colorectal Dis 31(4):919\u0026ndash;920. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00384-015-2306-7\u003c/span\u003e\u003cspan address=\"10.1007/s00384-015-2306-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYamamoto D, Sakimura Y, Kitamura H, Tsuji T, Kadoya S, Bando H (2021) Standardization of laparoscopic reversal of the Hartmann procedure: A single-center report. Asian J Endosc Surg 14(3):653\u0026ndash;657. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ases.12902\u003c/span\u003e\u003cspan address=\"10.1111/ases.12902\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRosen MJ, Cobb WS, Kercher KW, Sing RF, Heniford BT (2005) Laparoscopic restoration of intestinal continuity after Hartmann\u0026rsquo;s procedure. Am J Surg 189(6):670\u0026ndash;674. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.amjsurg.2005.03.007\u003c/span\u003e\u003cspan address=\"10.1016/j.amjsurg.2005.03.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Hartmann’s procedure, Reversal of Hartmann’s procedure, surgery, diverticulitis, laparoscopy","lastPublishedDoi":"10.21203/rs.3.rs-4209709/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4209709/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eReversal of Hartmann\u0026rsquo;s procedure is complicated owing to dense adhesions resulting from inflammation in the pelvic region. These adhesions pose challenges in identifying the rectum and increase the risk of pelvic organ injuries.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe propose a technique to lift and fix the rectal stump to the abdominal wall to diminish adhesions to the rectum and facilitate identification of the rectal stump.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe patient underwent Hartmann's procedure for generalized peritonitis resulting from perforation of the sigmoid colon. The abdominal cavity was significantly contaminated with fecal ascites, and postoperative pelvic adhesions were anticipated. Therefore, the rectal stump was lifted. The outcomes demonstrated that despite the presence of dense adhesions in the abdominal cavity, the rectal segment was promptly identified during reversal of Hartmann\u0026rsquo;s procedure. The procedure proceeded smoothly and was deemed satisfactory.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe technique of lifting and fixing the rectal stump to the abdominal wall is useful in cases where dense pelvic adhesions are anticipated during the subsequent reversal of Hartmann\u0026rsquo;s procedure.\u003c/p\u003e","manuscriptTitle":"A proactive technique for reversal of Hartmann’s procedure: lifting the rectal stump to the abdominal wall","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-08 19:50:00","doi":"10.21203/rs.3.rs-4209709/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-11T17:56:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-02T03:54:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272220823695753698703252853035748396918","date":"2024-05-06T01:17:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-05T20:25:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-05T20:24:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-03T04:50:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"Techniques in Coloproctology","date":"2024-04-03T03:43:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"techniques-in-coloproctology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tcol","sideBox":"Learn more about [Techniques in Coloproctology](http://link.springer.com/journal/10151)","snPcode":"10151","submissionUrl":"https://submission.nature.com/new-submission/10151/3","title":"Techniques in Coloproctology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"db31d968-6b95-498c-b964-f02ab7e9aca4","owner":[],"postedDate":"April 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T15:58:42+00:00","versionOfRecord":{"articleIdentity":"rs-4209709","link":"https://doi.org/10.1007/s10151-025-03128-0","journal":{"identity":"techniques-in-coloproctology","isVorOnly":false,"title":"Techniques in Coloproctology"},"publishedOn":"2025-03-24 15:56:50","publishedOnDateReadable":"March 24th, 2025"},"versionCreatedAt":"2024-04-08 19:50:00","video":"","vorDoi":"10.1007/s10151-025-03128-0","vorDoiUrl":"https://doi.org/10.1007/s10151-025-03128-0","workflowStages":[]},"version":"v1","identity":"rs-4209709","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4209709","identity":"rs-4209709","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}