From the Guidelines
Hartmann's procedure is a surgical operation that involves removing the diseased portion of the colon, closing off the rectal stump, and creating a temporary colostomy on the abdominal wall, and it is typically performed in emergency situations when primary anastomosis is considered too risky due to infection, inflammation, or poor tissue quality 1.
Overview of Hartmann's Procedure
Hartmann's procedure is usually performed to treat conditions such as sigmoid colon cancer, diverticulitis, or traumatic injuries. The procedure involves several key steps:
- Removing the affected segment of bowel
- Suturing the remaining rectal portion closed
- Bringing the proximal end of the colon through the abdominal wall to form a stoma This allows stool to be collected in an external bag attached to the skin.
Indications for Hartmann's Procedure
The procedure is typically indicated in emergency situations where primary anastomosis is not feasible due to various factors such as:
- Infection
- Inflammation
- Poor tissue quality It is often considered the procedure of choice for left-sided obstruction or perforation, especially in unstable patients 1.
Key Considerations
Some important considerations for Hartmann's procedure include:
- The colostomy is usually temporary, with a second operation (Hartmann's reversal) performed later to reconnect the bowel and restore normal bowel function
- The procedure reduces the risk of anastomotic leak, which can be life-threatening
- The decision to perform Hartmann's procedure should be individualized based on the patient's overall condition and the specific circumstances of the case 1.
Recent Guidelines and Recommendations
Recent guidelines and studies suggest that Hartmann's procedure is an effective and safe option for certain conditions, such as acute left-sided colonic diverticulitis in immunocompromised patients 1. However, the choice between Hartmann's procedure and other surgical options, such as resection and primary anastomosis, should be based on the individual patient's needs and circumstances 1.
From the Research
Definition of Hartmann's Procedure
- Hartmann's procedure, also known as Hartmann's operation, is a surgical procedure that involves the resection of the lower part of the sigmoid and the upper part of the rectum, resulting in a permanent sigmoid colostomy 2, 3, 4.
- The procedure typically involves a rectosigmoid resection, blind closure of the rectum, and terminal sigmostomy 2.
Indications for Hartmann's Procedure
- The indications for Hartmann's procedure have broadened over the years to include complicated diverticulitis, ischemic bowel, iatrogenic perforations, volvulus, and colitis 3.
- It is commonly performed emergently for infectious, inflammatory, or malignant processes 5.
- Advanced or complicated rectosigmoid neoplasm, moderate biological condition of the patient, peritoneal sepsis, intestinal occlusion, and fragile colonic wall are also indications for the procedure 4.
Outcomes and Complications
- Hartmann's procedure is recognized as a safe and efficacious option for the surgeon confronted with complex pathology of the rectosigmoid area, with acceptable morbidity and mortality 3.
- However, the procedure requires secondary reconstruction, which may be associated with complications 2.
- Morbidity and mortality rates for colostomy reversal surgery after Hartmann's procedure can be significant, with rates ranging from 34% to 8.3% 6.
- Factors that influence the decision to operate and the outcome of the procedure include the patient's ASA score, BMI, and the presence of comorbidities such as liver disease 5, 6.
Surgical Approach
- The procedure can be performed using an open or laparoscopic approach, with laparoscopy potentially offering benefits in terms of postoperative morbidity and mortality 4.
- However, the percentage of laparoscopic Hartmann procedures remains low due to the complexity of the procedure and the difficulties of reversal 4.