What is a Hartmann procedure?

What is a Hartmann Procedure?

The Hartmann procedure is a two-stage surgical operation involving sigmoid colon resection with creation of an end colostomy and closure of the rectal stump, originally described by French surgeon Henri Hartmann in 1923 for rectosigmoid cancer. 1, 2, 3

Surgical Technique

The operation consists of:

• Resection of the diseased sigmoid colon segment 4, 2
• Creation of an end colostomy (bringing the proximal colon through the abdominal wall) 4
• Closure of the distal rectal stump (leaving it in the pelvis) 1, 3
• Potential second-stage reversal operation to restore bowel continuity at a later date 5, 3

Primary Clinical Indications

Emergency Situations (Most Common)

Perforated diverticulitis with diffuse peritonitis is the most frequent indication, accounting for 44-54% of cases. 1, 5

Other emergency indications include:

• Sigmoid volvulus with non-viable or perforated colon when endoscopic detorsion fails 4
• Obstructive left-sided colorectal cancer in high-risk patients 4, 1
• Ischemic bowel requiring resection 2, 3
• Anastomotic leak after previous colorectal surgery 2, 6
• Iatrogenic perforations during colonoscopy or other procedures 2, 3

Patient Selection Criteria

Hartmann's procedure should be performed in:

• Critically ill patients with hemodynamic instability (hypotension, septic shock) 4, 1
• Patients with multiple comorbidities or ASA score ≥3 4, 7
• Patients with prohibitive anastomotic risk factors: coagulopathy, acidosis (pH <7.2), or hypothermia (<35°C) 4, 7
• Patients with poorly controlled diabetes 5, 7

When to Avoid Hartmann's Procedure

Primary resection with anastomosis (with or without diverting ileostomy) should be considered in:

• Clinically stable patients without significant comorbidities 4, 1
• Younger patients with good physiologic reserve 8
• Patients where the colon appears viable and well-perfused 4

The decision should be based primarily on patient condition and comorbidity rather than the extent of peritonitis alone. 8

Important Surgical Considerations

Intraoperative Management

• Resect infarcted bowel without detorsion and with minimal manipulation to prevent release of endotoxins, potassium, and bacteria into circulation 4
• If open abdomen is required for abdominal compartment syndrome, delay stoma creation until a subsequent operation 1
• Full oncological anterior resection is not typically needed for benign pathology like sigmoid volvulus 4

Laparoscopic Approach

• Laparoscopic Hartmann's should only be performed by surgeons with substantial colorectal expertise in selected favorable cases 5, 7
• Recent data show twofold increase in anastomotic leaks with laparoscopic approach in emergency settings, though overall morbidity is similar 4

Outcomes and Reversal Rates

Only approximately 47-57% of patients who undergo Hartmann's procedure eventually have their bowel continuity restored. 5, 3

Key outcome data:

• In-hospital mortality: 8-20% depending on indication and patient condition 4, 3
• Overall morbidity: 21-54% 5
• Reversal surgery morbidity: substantial, with complications in up to 28% requiring re-revision 7
• Average time to reversal: approximately 149 days 3

Critical Pitfalls to Avoid

• Do NOT perform laparoscopic peritoneal lavage instead of resection for diffuse peritonitis—recent trials show significantly higher reoperation rates and worse outcomes 4, 1
• Do NOT attempt primary anastomosis in patients with acidosis, hypothermia, coagulopathy, or hemodynamic instability 4, 1, 7
• Do NOT underestimate the technical difficulty and morbidity of reversal surgery when counseling patients 5
• For colorectal cancer patients, do NOT attempt reversal until neoadjuvant chemoradiotherapy is completed and full oncologic staging is performed 5, 7

Postoperative Management

Antibiotic therapy targeting Gram-negative bacilli and anaerobes:

• Duration: 4 days if adequate source control in immunocompetent patients 1
• Up to 7 days in immunocompromised or critically ill patients 1
• Septic shock regimens: Meropenem 1g q6h, Doripenem 500mg q8h, or Imipenem/cilastatin 500mg q6h by extended infusion 1

Monitoring for complications:

• Assess for fever, tachycardia, hypotension, altered mental status indicating infection or sepsis 1
• Obtain blood cultures if fever present; monitor CRP as inflammatory marker 1
• CT abdomen/pelvis if concern for intra-abdominal abscess or rectal stump leak 1