What is a Hartman procedure?

Hartmann's Procedure: A Life-Saving Emergency Colorectal Surgery

The Hartmann's procedure is a surgical technique involving resection of the sigmoid colon or rectum with closure of the rectal stump and creation of an end colostomy, primarily indicated for emergency conditions such as perforated diverticulitis, obstructive or perforated colorectal cancer, and non-viable sigmoid volvulus. 1

Indications

The primary indications for Hartmann's procedure include:

• Left-sided colonic emergencies:

  • Perforated diverticulitis with generalized peritonitis
  • Obstructive or perforated colorectal cancer
  • Sigmoid volvulus with non-viable bowel or failed endoscopic detorsion
  • Anastomotic disruption after anterior resection 2, 1

• Patient-specific factors:

  • Critically ill patients with hemodynamic instability
  • Multiple comorbidities
  • Diffuse peritonitis
  • Septic shock 2, 1

Surgical Technique

The Hartmann's procedure involves:

1. Resection of the diseased segment of colon (typically sigmoid or rectosigmoid)
2. Closure of the rectal stump
3. Creation of an end colostomy with the proximal colon brought through the abdominal wall 3

This approach avoids the risks associated with primary anastomosis in emergency settings, particularly when there is fecal contamination or the patient is hemodynamically unstable.

Clinical Decision Making

When deciding between Hartmann's procedure and other surgical options:

• Hartmann's procedure is preferred over loop colostomy as it's associated with shorter overall hospital stay despite similar mortality and morbidity rates 2

• Hartmann's procedure vs. primary anastomosis:

  • HP is recommended for high-risk patients (critically ill, multiple comorbidities, diffuse peritonitis) 2
  • Primary resection with anastomosis (with or without diverting stoma) may be considered in clinically stable patients without comorbidities 2

• Laparoscopic vs. open approach:

  • Laparoscopic Hartmann's procedure is associated with lower postoperative morbidity compared to open surgery 3
  • However, laparoscopy may not be suitable for all emergency cases, particularly with advanced disease or poor general condition

Outcomes and Complications

• Mortality: Postoperative mortality ranges from 14-21% in emergency settings 4, 5
• Morbidity: Postoperative complication rates of approximately 63% have been reported 4
• Stoma reversal: Only 25-30% of patients undergo restoration of intestinal continuity 6
• Factors affecting reversal: Younger age, non-neoplastic disease, and lower anesthetic risk are predictive of eventual stoma reversal 6

Considerations for Stoma Reversal

Restoration of bowel continuity after Hartmann's procedure:

• Is associated with significant morbidity (up to 55% complication rate) 3
• Should be considered after resolution of the acute condition and optimization of the patient's health status
• May never be performed in many patients due to advanced age, comorbidities, or underlying malignancy 6

Pitfalls and Caveats

• Despite being a life-saving procedure, Hartmann's operation results in a permanent stoma for many patients, with significant impact on quality of life
• The decision between Hartmann's procedure and primary anastomosis should consider both immediate surgical risks and long-term quality of life implications
• Early involvement of stoma care specialists is essential for patient education and adaptation 1
• In cases of perforated colorectal cancer, there is a significant risk of peritoneal carcinomatosis (14-54%) 2

Hartmann's procedure remains a crucial technique in the emergency surgeon's armamentarium, particularly for critically ill patients with left-sided colonic emergencies where the risks of primary anastomosis are prohibitively high.