What is Hartmann's procedure (Hartmann's operation)?

From the Guidelines

Hartmann's procedure should be preferred to simple colostomy for left colon obstruction, as it is associated with shorter overall hospital stay and reduced need for multiple operations, without increasing perioperative morbidity 1.

Overview of Hartmann's Procedure

Hartmann's procedure is a surgical operation that involves removing a diseased portion of the colon, creating a temporary colostomy, and closing off the rectal stump. This procedure is typically performed in emergency situations such as obstructing colorectal cancer, perforated diverticulitis, or traumatic colon injuries when primary anastomosis is too risky.

Indications and Benefits

The main advantage of Hartmann's procedure is that it allows for definitive treatment of the acute condition while minimizing the risk of anastomotic leak in an emergency setting. According to the 2017 WSES guidelines on colon and rectal cancer emergencies, Hartmann's procedure should be preferred to simple colostomy for left colon obstruction, as it is associated with shorter overall hospital stay and reduced need for multiple operations, without increasing perioperative morbidity 1.

Key Considerations

Some key considerations for Hartmann's procedure include:

• The procedure is typically reserved for emergency situations where primary anastomosis is too risky.
• Loop colostomy should be reserved for unresectable tumors, severely ill patients, or those who are too unfit for major surgical procedures or general anesthesia 1.
• Resection and primary anastomosis (RPA) should be the preferred option for uncomplicated malignant left-sided large bowel obstruction in the absence of other risk factors 1.
• The role of diverting stoma in RPA is not supported by evidence, and its use is not recommended 1.

Post-Operative Care and Reversal

Recovery from Hartmann's procedure typically involves 5-7 days of hospitalization, followed by stoma care education and adaptation to living with a colostomy. Many patients undergo a second surgery (Hartmann's reversal) about 3-6 months later to reconnect the bowel and restore normal intestinal continuity, though this depends on the patient's overall health, the underlying condition, and resolution of the initial problem.

From the Research

Hartmann's Procedure Overview

• Hartmann's procedure is a surgical operation that involves the removal of a portion of the colon, typically the sigmoid colon, and the creation of a colostomy [(2,3,4)].
• The procedure is often performed in emergency situations, such as in cases of acute perforated diverticulitis or colorectal cancer [(2,3,4)].
• Hartmann's procedure can be used as a temporary measure to divert fecal flow and allow the colon to heal, with the possibility of reversal at a later time [(2,5)].

Indications and Outcomes

• The procedure is commonly used in cases of left-sided colonic disease, particularly in emergency situations where anastomosis is not feasible 3.
• Studies have shown that Hartmann's procedure is associated with high rates of morbidity and mortality, ranging from 15% to 50% [(3,5)].
• The reversal of Hartmann's procedure can be complicated, with reported rates of major complications ranging from 31% to 44% [(2,5)].
• Factors associated with increased risk of complications after Hartmann's reversal include ASA 4 classification, liver disease, and BMI < 30 5.

Comparison with Other Surgical Procedures

• Primary resection with anastomosis has been compared to Hartmann's procedure in the treatment of acute colonic diverticulitis, with some studies suggesting lower mortality rates with primary resection 6.
• However, the choice of procedure ultimately depends on the individual patient's condition and the surgeon's expertise [(2,3,6)].

Reversal of Hartmann's Procedure

• The decision to reverse Hartmann's procedure should be made on a case-by-case basis, taking into account the patient's overall health and the risk of complications [(2,5)].
• Reversal of Hartmann's procedure can be performed laparoscopically, with similar outcomes to open reversal 5.
• Anastomotic leakage is a potential complication of Hartmann's reversal, with reported rates ranging from 4% to 10% [(2,5)].