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Hemostasis in minimally invasive surgery causes tissue damage. Regardless of the method of production of thermal energy, a quick and safe coagulation is essential for its clinical use. In this study we examined the tissue damage in the isolated perfused pig liver using monopolar, bipolar, cold plasma, and ultrasonic coagulation. In a minimally invasive in vitro setup, a 2-3 cm slice of the edge of the perfused pig liver was resected. After hemostasis was achieved, liver tissue of the coagulated area was given to histopathological examination. The depth of tissue necrosis, the height of tissue loss, and the time until sufficient hemostasis was reached were analyzed. The lowest risk for extensive tissue damage could be shown for the bipolar technique, combined with the highest efficiency in hemostasis. Using cold plasma, coagulation time was longer with a deeper tissue damage. Monopolar technique showed the worst results with the highest tissue damage and a long coagulation time. Ultrasonic coagulation was not useful for coagulation of large bleeding areas. In summary, bipolar technique led to less tissue damage and best coagulation results in our minimally invasive model. These results could be important to recommend bipolar coagulation for clinical use in minimally invasive surgery.

In general, reversal of Hartmann's procedure is associated with a high morbidity and therefore leads to a low rate of intestinal restoration. Reversal of Hartmann's procedure has to be seen as a complex abdominal operation with the same possible complications as in other colorectal resections. By using the laparoscopic technique, operative access trauma by laparotomy can be minimized. After introducing single-port access into laparoscopic surgery beginning with cholecystectomies and sigmoid resections, we started with the first single-port laparoscopic reversal of Hartmann's procedure in January 2010. After excision of the colostoma, mobilization, and reponing into the abdominal cavity, the single-port trocar was placed at the stoma incision without any extra scar. We investigated whether the single-port laparoscopic reversal is as safely feasible as the "conventional" laparoscopic procedure. Till December 2010, single-port reversal operation was performed in 8 patients 2-4 months after Hartmann's procedure because of complicated diverticulitis. No conversion to "conventional" laparoscopic or open procedure was necessary in 1 patient one extra 5 mm trocar was used. The average operation time was 74 min. Except for one wound complication, the postoperative course was uncomplicated. The patients were discharged after 4 to 8 postoperative days. Single-port reversal of Hartmann's procedure has showed as a new method for minimizing the access trauma even further than "conventional" laparoscopic surgery.