What is Hartmann's Reversal?
Hartmann's reversal is the surgical procedure to restore bowel continuity after a Hartmann's procedure by reconnecting the remaining colon to the rectal stump and closing the colostomy, though it carries substantial morbidity with complication rates of 21-54% and only achieves successful reversal in approximately 47% of patients who initially undergo Hartmann's procedure. 1, 2, 3
Understanding the Original Hartmann's Procedure
Hartmann's procedure involves resection of diseased sigmoid colon, creation of an end colostomy, and closure of the rectal stump, leaving it in the pelvis. 1 This is performed emergently for:
- Perforated diverticulitis with diffuse peritonitis (most common at 44-54%) 1, 3
- Obstructing or perforated colorectal cancer (32%) 3
- Abdominal trauma, volvulus, or other emergencies (16-24%) 2, 3
The procedure is specifically recommended for critically ill patients with multiple comorbidities or hemodynamic instability, as it avoids the high risk of anastomotic leak in emergency settings. 1, 4
The Reversal Operation: Technical Details
The reversal involves takedown of the colostomy, mobilization of both the proximal colon and rectal stump, and creation of a colorectal anastomosis. 2 This can be performed via:
- Open approach (traditional, used in 78% of cases) 5
- Laparoscopic approach (requires significant expertise, 22% of cases, with 42% conversion rate to open) 2, 5
The laparoscopic approach, when successful, results in faster return of bowel function (2.8 vs 4.0 days to flatus), shorter hospital stay (6.7 vs 10.8 days), and fewer complications (14% vs 31%), though it requires longer operative time and has high conversion rates. 5
Timing Considerations
The median interval between Hartmann's procedure and reversal is 7-14 months. 2, 6 Key timing factors include:
- Oncology patients must complete neoadjuvant chemoradiotherapy and staging workup before reversal 7
- Adequate time for resolution of inflammation and adhesions from the index operation 2
- Patient optimization of comorbidities, nutritional status, and anemia 7
Morbidity and Complications
The overall complication rate ranges from 21-54%, with major complications (Clavien-Dindo ≥3) occurring in 23-32% of patients. 2, 8 Specific complications include:
- Postoperative ileus (most common at 32%) 2
- Surgical site infection (15-22%) 2, 6
- Anastomotic leak (3-6%) 2, 8, 3
- Intra-abdominal abscess requiring drainage (6.7%) 8
- Mortality (4-8.3%) 6, 8
High-Risk Patient Factors
Patients at increased risk for complications include those with:
- ASA score ≥3-4 (associated with significantly higher morbidity and mortality) 6, 8
- High BMI >30 (paradoxically, BMI <30 was associated with worse outcomes in one study, though obesity generally increases risk) 6, 8
- Liver disease 8
- Diabetes with poor glycemic control 7
- Multiple previous abdominal operations 5
Success Rates and Permanent Stomas
Only 47% of patients who undergo Hartmann's procedure ultimately achieve stoma reversal, meaning 53% remain with permanent colostomies. 3 Reasons for non-reversal include:
- Patient choice (30% of non-reversed cases) 3
- High surgical risk or medical unfitness (70% of non-reversed cases) 3
- Technical failure at attempted reversal (<1-2%) 2, 3
Among those who undergo attempted reversal, 98% achieve successful restoration of continuity. 2
Role of Surgical Expertise
Procedures performed by colorectal specialists have significantly lower morbidity and mortality compared to general surgeons. 6 The World Journal of Emergency Surgery recommends that laparoscopic reversal should be reserved for experienced surgeons in selected favorable cases. 7
Common Pitfalls
- Attempting reversal in physiologically unstable patients with acidosis, hypothermia, or coagulopathy (these patients should not undergo reversal) 7
- Inadequate preoperative optimization of comorbidities and nutritional status 7
- Underestimating the technical difficulty and morbidity of the procedure when counseling patients 1
- Failure to obtain specialized colorectal surgical expertise for complex cases 6