Colostomy Reversal (Hartmann's Reversal)
The procedure to reconnect the colon after a traumatic injury requiring emergency colostomy is called a Hartmann's reversal or colostomy takedown, which involves anastomosing the proximal colon to the distal rectal stump to restore bowel continuity. 1
Understanding the Initial Emergency Procedure
When severe anorectal trauma causes colonic transection or perforation requiring emergency surgery, the standard approach is Hartmann's procedure, which involves:
- Resection of the damaged colon segment
- Creation of an end colostomy (bringing the proximal colon through the abdominal wall)
- Closure of the distal rectal stump (Hartmann's pouch) 2, 3
This damage control approach is preferred in unstable patients with severe trauma, peritoneal contamination, or hemodynamic instability, as it minimizes operative time while controlling the septic source 3, 4.
The Reversal Procedure
Terminology
The reversal operation is formally called:
Technical Approach
The procedure involves reconnecting the proximal colon (from the colostomy) to the distal rectal stump through either:
- Open laparotomy (traditional approach requiring midline incision) 6
- Laparoscopic or robotic-assisted technique (minimally invasive, reserved for experienced surgeons in favorable cases) 4, 5
The anastomosis can be performed using:
- Hand-sewn technique
- Stapled anastomosis (using circular staplers with an anvil placed in the proximal colon and stapler inserted transanally) 3, 5
Critical Timing Considerations
Reversal should be delayed until the patient has fully recovered from the initial trauma and any physiologic derangements have resolved 4. Specific contraindications to early reversal include:
- Severe metabolic acidosis (pH < 7.2)
- Hypothermia (< 35°C)
- Coagulopathy
- Hemodynamic instability requiring inotropic support 4
Most reversals are performed weeks to months after the initial injury, though only a minority of patients (significantly low percentage) ultimately undergo reversal due to medical comorbidities, patient preference, or surgical complexity 1.
Complications and Outcomes
Morbidity Rates
Hartmann's reversal remains a complicated operation with significant morbidity 1. Key complications include:
- Anastomotic leak rates of 3.5-30% in emergency settings (compared to 5-10% in elective cases) 4
- Intra-abdominal abscess formation (28% overall colon-related complication rate) 7
- Wound infections
- Prolonged hospital stays (average 8.4 days for end colostomy reversal) 6
Comparison to Loop Colostomy Reversal
If the initial surgery created a loop colostomy instead of an end colostomy (Hartmann's), reversal is substantially easier with:
- Shorter hospital stays (5.5 vs 8.4 days)
- Less intraoperative blood loss (99.4 vs 260.7 mL)
- Fewer overall complications
- No requirement for laparotomy (can be done locally) 6
However, loop colostomies are generally not appropriate for severe traumatic injuries requiring resection 3.
Common Pitfalls
- Attempting reversal too early before complete physiologic recovery increases anastomotic leak risk 4
- Underestimating surgical complexity: Hartmann's reversal involves extensive adhesiolysis, potential splenic flexure mobilization, and challenging pelvic dissection 5
- Inadequate patient counseling: Patients should understand the 28% re-revision rate and possibility of remaining with permanent colostomy 4
- Not considering protective diverting ileostomy: For high-risk anastomoses (low rectal, significant tension, poor tissue quality), a temporary diverting loop ileostomy should be created to protect the anastomosis 5