What is Hartmann's procedure in adults with diverticulitis or colorectal cancer?

What is Hartmann's Procedure

Hartmann's procedure is a surgical resection of the rectosigmoid colon with closure of the rectal stump and creation of an end colostomy on the abdominal wall, performed primarily in emergency settings for perforated diverticulitis, left-sided colorectal cancer with perforation or obstruction, and other left-sided colonic emergencies. 1, 2, 3

Surgical Technique

The operation involves the following steps:

• Resection of the diseased sigmoid colon and upper rectum with removal of the pathologic segment 3
• Closure of the distal rectal stump (or creation of a mucus fistula as a modification) 4
• Creation of an end colostomy brought through the abdominal wall, typically in the left lower quadrant 3, 5
• Minimal manipulation of infarcted bowel during resection to prevent release of endotoxins, potassium, and bacteria into circulation 1

Primary Indications

Emergency Settings - Diverticulitis

Hartmann's procedure is the recommended operation for critically ill patients with diffuse peritonitis from perforated diverticulitis, particularly those with multiple comorbidities or hemodynamic instability. 1, 2

The procedure should be performed in:

• Patients with non-viable or perforated colon requiring urgent sigmoid resection 1
• Hemodynamically unstable patients with peritonitis 1, 2
• Patients with significant comorbidities including elevated ASA score, coagulopathy, acidosis, or hypothermia that add prohibitive risk to primary anastomosis 1
• Critically ill patients where the risk of anastomotic leak would be catastrophic 1, 2

Emergency Settings - Colorectal Cancer

The procedure is widely accepted for perforated left-sided colorectal cancer requiring both peritonitis control and adequate oncologic resection. 2

• Malignant left-sided colonic obstruction in high-risk patients is a primary indication 2
• Obstructing or perforated sigmoid and rectal cancers where primary anastomosis carries excessive risk 3

Other Indications

The procedure is also performed for:

• Sigmoid volvulus with non-viable colon or failed endoscopic detorsion 1
• Ischemic bowel of the left colon 3
• Iatrogenic perforations during colonoscopy or other procedures 3
• Severe colitis requiring emergency resection 3

Clinical Decision-Making: Hartmann's vs. Primary Anastomosis

In clinically stable patients without significant comorbidities, primary resection with anastomosis (with or without diverting stoma) may be considered instead of Hartmann's procedure. 1, 2

However, the evidence shows:

• No clear mortality difference between Hartmann's procedure and primary anastomosis in emergency settings 1
• Hartmann's procedure had 8% mortality vs. 5% for primary anastomosis in one series of sigmoid volvulus, though this reflected selection of sicker patients for Hartmann's 1
• Anastomotic leak rates of 7-12% occur with primary anastomosis in emergency settings 1
• Overall morbidity of 42% and mortality of 20% reported for Hartmann's procedure in emergency sigmoid volvulus 1

The key clinical pitfall is attempting primary anastomosis in unstable patients—when in doubt, choose Hartmann's procedure for safety. 1, 2

What NOT to Do

Laparoscopic peritoneal lavage should NOT be considered the treatment of choice for diffuse peritonitis from perforated diverticulitis. 1, 2

Recent high-quality trials (SCANDIV, LADIES, DILALA) demonstrated:

• Significantly higher reoperation rates with lavage compared to resection 1, 2
• Increased intra-abdominal abscess formation after lavage 1, 2
• No reduction in severe postoperative complications and worse outcomes in secondary endpoints 1
• Comparable mortality but unacceptable failure rates requiring conversion to resection 1

Postoperative Antibiotic Management

Target Gram-negative bacilli and anaerobes for perforated colorectal pathology with peritonitis. 2

Duration of therapy:

• 4 days if adequate source control achieved in immunocompetent patients 2
• Up to 7 days in immunocompromised or critically ill patients 2

For septic shock, use:

• Meropenem 1g every 6 hours by extended infusion, OR 2
• Doripenem 500mg every 8 hours by extended infusion, OR 2
• Imipenem/cilastatin 500mg every 6 hours by extended infusion 2

Postoperative Monitoring

Monitor for complications by assessing:

• Fever, tachycardia, hypotension, altered mental status indicating infection or sepsis 2, 6
• Abdominal tenderness, distention, or peritoneal signs suggesting intra-abdominal infection 2, 6
• Obtain blood cultures if fever present and monitor CRP as inflammatory marker 2, 6
• CT abdomen/pelvis if concern for intra-abdominal abscess or rectal stump leak 2, 6

Immunocompromised patients warrant particularly close monitoring as they may have atypical presentations with less pronounced inflammatory markers despite serious infections. 2, 6

Reversal Considerations

Restoration of bowel continuity after Hartmann's procedure occurs in a significantly low percentage of patients and is associated with substantial morbidity. 7, 5

Common reasons patients remain with permanent colostomy:

• Disease progression or metastasis in cancer patients 5
• Advanced age and multiple comorbidities 5
• Frozen pelvis or technical difficulties at attempted reversal 5
• Patient preference to avoid another major operation 7

Reversal rates are higher for benign disease (diverticulitis) compared to colorectal cancer. 5