No, Small Bowel Obstruction and Hartmann's Procedure Are Fundamentally Different Entities
Small bowel obstruction is a clinical condition (blockage of the small intestine), while Hartmann's procedure is a specific surgical operation (sigmoid resection with end colostomy and rectal stump closure)—they are not comparable entities. 1
Understanding the Distinction
What Small Bowel Obstruction Is
- Small bowel obstruction refers to mechanical or functional blockage of the small intestine, preventing normal passage of intestinal contents 2
- Common causes include adhesions from prior surgery, hernias, malignancy, and inflammatory conditions 2
- Treatment depends on the underlying cause and may range from conservative management to various surgical interventions 2
What Hartmann's Procedure Is
- Hartmann's procedure is a specific surgical technique involving resection of diseased sigmoid colon, creation of an end colostomy, and closure of the rectal stump 1
- It was originally introduced for sigmoid and rectal cancers but is now primarily performed for complicated left-sided colonic emergencies 3
- The procedure is most commonly indicated for perforated diverticulitis, obstructing left-sided colorectal cancer in high-risk patients, and sigmoid volvulus with non-viable bowel 1
When These Two Concepts Intersect
Hartmann's as Treatment for Large (Not Small) Bowel Obstruction
- Hartmann's procedure may be performed to treat malignant left-sided large bowel obstruction, particularly in high-risk patients with hemodynamic instability, multiple comorbidities, or ASA score ≥3 1
- For obstructing left-sided colorectal cancer, primary resection with anastomosis is preferred in stable patients without risk factors, while Hartmann's is reserved for critically ill patients 2, 1
- The procedure addresses large bowel (colon) obstruction, not small bowel obstruction 4, 2
Small Bowel Obstruction as a Complication After Hartmann's
- Paradoxically, small bowel obstruction can occur as a postoperative complication following Hartmann's procedure 5
- The incidence of small bowel obstruction is significantly higher in patients who develop rectal stump leakage after Hartmann's (69.2%) compared to those without this complication (15.7%) 5
- Unexplained small bowel obstruction after Hartmann's procedure may be an important early diagnostic clue for rectal stump leakage 5
Critical Clinical Pitfalls
- Do not confuse the anatomic location: Small bowel obstruction involves the jejunum and ileum, while Hartmann's procedure addresses sigmoid colon pathology 2, 1
- Recognize that Hartmann's is one of many surgical options for large bowel obstruction—not a synonym for the condition itself 2
- Small bowel obstruction requires its own diagnostic and therapeutic algorithm that is entirely separate from the decision-making process for performing Hartmann's procedure 2
The Reversal Challenge
- Only 23.3% of patients who undergo Hartmann's procedure eventually have their bowel continuity restored 6
- Reversal of Hartmann's remains a complicated operation with significant morbidity, contributing to the low reversal rate 7
- The median time to reversal is approximately 285 days when it does occur 6