What is the Hartmann procedure and how is it managed post-operatively?

Hartmann's Procedure: Definition and Post-Operative Management

The Hartmann's procedure is a surgical intervention involving sigmoid colon resection with end colostomy creation and rectal stump closure, primarily indicated for left-sided colonic emergencies such as perforated diverticulitis, obstruction due to colorectal cancer, or sigmoid volvulus when primary anastomosis is unsafe.

Definition and Indications

The Hartmann's procedure consists of:

• Resection of the diseased sigmoid colon
• Creation of an end colostomy (usually in the left lower quadrant)
• Closure of the rectal stump without primary anastomosis

Primary Indications

• Left-sided colonic obstruction or perforation 1
• Perforated diverticulitis with generalized peritonitis 1
• Perforated colorectal cancer 1
• Sigmoid volvulus with non-viable bowel 1
• Failed endoscopic detorsion in sigmoid volvulus 1

Patient Selection

Hartmann's procedure is particularly valuable in:

• Critically ill patients with hemodynamic instability 1
• Patients with multiple comorbidities 1
• Patients with diffuse peritonitis 1
• Unstable patients with septic shock 1

Post-Operative Management

Immediate Post-Operative Care (0-7 days)

1. Hemodynamic monitoring and resuscitation

   • Close monitoring of vital signs
   • Fluid resuscitation as needed
   • Correction of electrolyte abnormalities

2. Antibiotic therapy

   • For perforated diverticulitis or peritonitis: 4-7 days of antibiotics 1
   • For immunocompetent, non-critically ill patients with adequate source control: 4 days 1
   • For immunocompromised or critically ill patients: up to 7 days 1
   • Recommended regimens:
     • Piperacillin/tazobactam 4g/0.5g q6h or 16g/2g by continuous infusion 1
     • For septic shock: Meropenem 1g q6h by extended infusion 1

3. Stoma care

   • Early involvement of stoma nurse
   • Education on stoma appliance changes
   • Monitoring for complications (ischemia, retraction, prolapse)

4. Pain management

   • Multimodal analgesia
   • Transition from parenteral to oral analgesics as tolerated

Intermediate Post-Operative Care (1-4 weeks)

1. Nutrition

   • Gradual advancement of diet as tolerated
   • Monitoring for high-output stoma
   • Nutritional supplementation if needed

2. Wound care

   • Regular assessment of surgical site
   • Early identification and management of surgical site infections

3. Mobilization

   • Early ambulation to prevent complications
   • Progressive increase in activity levels

Long-Term Management and Reversal Considerations

1. Timing of reversal

   • Median time to reversal: 11 months (range 4-96 months) 2
   • Minimum 3 months interval recommended between stages 3

2. Reversal rates

   • Only 47-57% of patients undergo reversal 2, 4
   • In national data from England, only 23.3% underwent reversal 5

3. Factors affecting reversal decision

   • Patient preference (30% choose not to undergo reversal) 2
   • Medical fitness (70% deemed high risk or unfit) 2
   • Original pathology (cancer vs. benign disease)
   • Age and comorbidities

4. Reversal procedure complications

   • Overall complication rate: 21% 2
   • Major complications (≥ grade IIIa): 3.7% 2
   • Anastomotic leak rate: approximately 1-3% 2
   • Failure of reversal resulting in permanent stoma: <1% 2

Clinical Pearls and Pitfalls

Pearls

• Hartmann's procedure remains the safest option for emergency left-sided colonic pathology in critically ill patients 1
• The procedure avoids the risks associated with primary anastomosis in unfavorable conditions 3
• Reversal, when performed in properly selected patients, has acceptable morbidity 4

Pitfalls

• Many patients will never undergo reversal and should be counseled accordingly 5
• Restoration of bowel continuity after Hartmann's procedure is associated with significant morbidity 1
• The technical difficulty of reversal increases with longer intervals between procedures, yet a minimum of 3 months is recommended to allow inflammation to resolve 3

Alternative Approaches

• In clinically stable patients without comorbidities, primary resection with anastomosis (with or without diverting stoma) may be considered even in the presence of diffuse peritonitis 1
• Laparoscopic peritoneal lavage is not recommended as first-line treatment for diffuse peritonitis 1

The Hartmann's procedure remains a vital tool in the surgical armamentarium for emergency colorectal surgery, particularly when patient factors or disease severity make primary anastomosis unsafe.