What is a Hartman procedure?

Hartmann's Procedure: A Life-Saving Surgical Intervention

The Hartmann's procedure is a surgical intervention for left-sided colonic emergencies where the diseased segment of colon is resected, the rectal stump is closed, and an end colostomy is created, avoiding primary anastomosis in high-risk situations. 1

Definition and Technique

The Hartmann's procedure involves:

• Resection of the lower sigmoid colon and upper rectum
• Closure of the rectal stump
• Creation of an end colostomy
• No primary anastomosis is performed at the initial operation

Primary Indications

Hartmann's procedure is primarily indicated for:

• Left-sided colonic emergencies:

  • Perforated diverticulitis with generalized peritonitis
  • Obstructive or perforated colorectal cancer
  • Sigmoid volvulus with non-viable bowel
  • Failed endoscopic detorsion of sigmoid volvulus 1

• Patient-specific factors:

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

Advantages Over Alternative Procedures

• Compared to loop colostomy:

  • Hartmann's procedure is associated with shorter overall hospital stay
  • Similar mortality and morbidity rates
  • Removes the diseased segment at the first operation 2, 1

• Compared to primary anastomosis:

  • Avoids the risk of anastomotic leak in high-risk patients
  • Preferred for unstable patients with sepsis
  • Recommended for patients with poor physiological reserve 1

Perioperative Management

Preoperative Care

• Hemodynamic monitoring and resuscitation
• Correction of electrolyte abnormalities
• Antibiotic therapy (typically 4-7 days depending on patient condition) 1

Intraoperative Considerations

• For left-sided obstruction or perforation, Hartmann's procedure is the procedure of choice
• For severely unstable patients with left-sided obstruction, a loop transverse colostomy may be considered as a bridge procedure 2

Postoperative Care

• Early involvement of stoma nurse
• Education on stoma appliance changes
• Monitoring for complications
• Multimodal analgesia
• Gradual advancement of diet as tolerated 1

Outcomes and Complications

• Reversal rates:

  • Only 47% of Hartmann's procedures are reversed according to recent studies 3
  • Median time to reversal is approximately 11 months 3

• Complications:

  • Overall complication rate from reversal is around 21%
  • Major complications (Clavien-Dindo grade IIIa or above) occur in approximately 3.7% of reversals
  • Anastomotic leak rate during reversal is approximately 1-3% 3

• Mortality:

  • 30-day mortality following Hartmann's procedure is approximately 7% 3
  • This reflects the severity of the underlying conditions rather than the procedure itself

Important Considerations

• Reversal challenges:

  • Restoration of bowel continuity after Hartmann's procedure is associated with significant technical difficulty
  • Many patients (up to 53%) never undergo reversal and remain with a permanent stoma 3, 4
  • Reasons for non-reversal include patient choice (30%) and being high-risk or unfit (70%) 3

• Cancer considerations:

  • In cases of perforated colorectal cancer, there is a significant risk of peritoneal carcinomatosis (14-54%) 2
  • This risk should be discussed with patients when obtaining informed consent

Modern Approaches

• Laparoscopic Hartmann's procedure is becoming more common and shows benefits for postoperative morbidity and mortality compared to open approaches 5
• However, laparoscopic approach remains less common due to:
  • Advanced or complicated colorectal cancer
  • Poor general condition of patients
  • Technical difficulties 5

Hartmann's procedure remains a critical life-saving operation in the emergency surgical armamentarium, particularly for left-sided colonic emergencies in high-risk patients.