Hartmann's Procedure: Indications and Management
Primary Indications
Hartmann's procedure remains the procedure of choice for critically ill patients with diffuse peritonitis from perforated diverticulitis, particularly those with multiple comorbidities or hemodynamic instability. 1
Specific Clinical Scenarios:
Perforated Diverticulitis with Diffuse Peritonitis:
- Critically ill patients with hemodynamic instability, septic shock, or multiple major comorbidities should undergo Hartmann's procedure 1
- Clinically stable patients without significant comorbidities may be considered for primary resection with anastomosis (with or without diverting stoma) instead 1
- The decision hinges on intraoperative assessment of patient stability through close surgeon-anesthesiologist communication regarding resuscitation effectiveness 1
Perforated Left-Sided Colorectal Cancer:
- Hartmann's procedure is widely accepted and should be generously indicated for emergency scenarios requiring both peritonitis control and adequate oncologic resection (R0 resection) 1
- This addresses both the acute septic emergency and oncologic principles, though prognosis remains poor due to peritoneal tumor dissemination 1
Malignant Left-Sided Colonic Obstruction:
- Hartmann's procedure should be considered the procedure of choice, particularly in high-risk patients 1
- Severely unstable patients may require initial loop transverse colostomy for damage control 1
Contraindications and Alternative Approaches
Laparoscopic peritoneal lavage should NOT be considered the treatment of choice for diffuse peritonitis, as recent trials (SCANDIV, Ladies, DILALA) demonstrated significantly higher reoperation rates and intra-abdominal abscess formation compared to resection, despite comparable mortality 1
Surgical Technique Considerations
Key Technical Points:
- Remove diseased bowel segment completely at first stage 2, 3
- Create end colostomy (typically left lower quadrant) 2
- Close rectal stump (Hartmann's pouch) 2, 4
- If open abdomen is required for abdominal compartment syndrome, delay stoma creation until subsequent operation 1
Reversal of Hartmann's Procedure
Restoration of bowel continuity is achievable in 57-97% of surviving patients but carries significant considerations 2, 5:
- Optimal timing: Wait at least 3 months (average 149 days) between stages to allow inflammation resolution 2, 3
- Reversal morbidity: 4-38.5% complication rate with 0-3.1% mortality in experienced hands 2, 5
- Many patients never undergo reversal: 42-43% of patients do not have colostomy closure due to age, medical contraindications, patient preference, or death 4, 5
Common pitfall: Assuming all patients will undergo reversal—in reality, many elderly patients with multiple comorbidities will have permanent colostomy 4, 6
Postoperative Management
Monitoring for Complications:
- Assess for fever, tachycardia, hypotension, altered mental status indicating infection or sepsis 7
- Evaluate surgical site and check for abdominal tenderness, distention, or peritoneal signs 7
- Obtain blood cultures if fever present; monitor CRP as inflammatory marker 7
- CT abdomen/pelvis if concern for intra-abdominal abscess or rectal stump leak 7
Abscess Management:
- Small abscesses (<3-6 cm): antibiotics alone may suffice 7
- Large abscesses (>3-6 cm): percutaneous drainage plus antibiotics 7
Antibiotic Therapy
For perforated colorectal pathology with peritonitis:
- Target Gram-negative bacilli and anaerobes 1
- Duration: 4 days if adequate source control in immunocompetent patients; up to 7 days in immunocompromised or critically ill patients 1
- Septic shock regimens: Meropenem 1g q6h by extended infusion, Doripenem 500mg q8h by extended infusion, or Imipenem/cilastatin 500mg q6h by extended infusion 1
Special Populations
Immunocompromised patients (including transplant recipients) warrant particularly close monitoring as they may have atypical presentations with less pronounced inflammatory markers despite serious infections 7