Hartmann Procedure

History & Background

• Fischer's Mastery of Surgery, 8th ed.

Definition

1. Resection of the diseased segment (typically sigmoid colon/upper rectum)
2. Formation of an end colostomy in the left lower quadrant
3. Oversewing/closure of the rectal stump (the "Hartmann pouch"), which is left in the pelvis

• Schwartz's Principles of Surgery, 11th ed.

Indications

• Perforated diverticulitis with purulent or fecal peritonitis (Hinchey grades 3 and 4) - the most common indication
• Left-sided obstructing colorectal cancer when primary anastomosis is unsafe
• Colorectal trauma with extensive tissue loss
• Left-sided large bowel emergencies in unstable patients or in the setting of gross contamination

• Current Surgical Therapy, 14th ed. | Sabiston Textbook of Surgery

Surgical Technique

• Fluid resuscitation, IV antibiotics, DVT prophylaxis
• Stoma site marking by enterostomal therapy nurse (reduces stoma complications, improves QoL)
• Patient in lithotomy position (allows pelvic access and rectal instrumentation)

1. Midline laparotomy - provides full exposure and allows decompression
2. Retract the sigmoid medially; identify and protect the left ureter and gonadal vessels - if anatomy is unclear, dissect close to the colon to avoid ureteral injury
3. Mobilize the sigmoid colon; splenic flexure mobilization is often required to ensure tension-free colostomy
4. Ligate the inferior mesenteric artery (IMA) - distal to the left colic branch in benign disease; high tie for malignancy
5. Transect bowel at the proximal resection margin in healthy, pliable bowel
6. Transect distally at the proximal rectum - leaving a short rectal stump. A useful tip: resecting only the perforated segment and leaving part of the distal sigmoid makes subsequent reversal easier as the pelvic peritoneum is not disturbed
7. Close the rectal stump (Hartmann pouch) - tack it to the lateral peritoneum and mark it with nonabsorbable sutures to aid identification at reversal
8. Bring proximal colon through a left lower quadrant trephine as a tension-free end colostomy

• Fischer's Mastery of Surgery, 8th ed.

Hartmann Reversal (Takedown)

• Timing: Typically >3 months after initial surgery. Waiting allows healing and facilitates identification of the Hartmann stump. Earlier reversal (<3 months) risks difficult dissection, enterotomies, and poor stump identification due to adhesions. However, very late reversal increases fibrosis and stump identification problems.
• Preoperative workup:
  • Gastrografin enema or flexible endoscopy per rectum - to assess stump length, configuration, and residual sigmoid
  • Bowel prep through the colostomy
  • Consider ureteral stents (especially if anatomy was difficult initially)
• Surgical steps:
  • Low lithotomy position
  • Lyse all adhesions - small bowel adhesions to the Hartmann pouch are almost universal; typically requires adhesiolysis from ligament of Treitz to ileocecal valve
  • Pass a scope or circular stapler sizer per rectum to identify the stump
  • Divide/mobilize the stump
  • Perform colorectal anastomosis with a circular stapler via the transanal route
  • Leak test the anastomosis

• Only ~44% of patients who undergo a Hartmann procedure ever undergo reversal (mean time to reversal: 7.5 months)
• Up to 50% of patients - and higher rates in the elderly - never have the colostomy reversed
• Reversal morbidity: 3-50% (mean 16.3%); mortality: 0-7.1% (mean 1%)
• Compared to closure of a loop ileostomy after primary anastomosis with proximal diversion, Hartmann reversal is associated with higher morbidity due to the extent of the original disease and operation
• Current Surgical Therapy, 14th ed. | Fischer's Mastery of Surgery, 8th ed.

Alternatives to Hartmann's Procedure

Complications

• Stoma-related: Parastomal hernia (~50%), skin excoriation, retraction, prolapse, reduced quality of life
• Intraoperative: Ureteral injury, inadvertent bowel perforation (especially in distended colon)
• Reversal-related: Anastomotic leak, enterotomy during adhesiolysis, ureteral injury, wound infection
• Permanent colostomy in up to 50% of patients - a major long-term consequence

Key Teaching Points

• The Hartmann procedure is a damage control colorectal operation - it sacrifices future convenience for immediate safety
• The decision between Hartmann vs. primary anastomosis with diversion rests on patient stability, degree of contamination, and surgeon judgment
• Stoma marking preoperatively by an enterostomal nurse is strongly recommended - it reduces complications and may determine whether the patient can care for the stoma independently at home
• Marking the rectal stump with nonabsorbable sutures and/or tacking it to the lateral peritoneum facilitates identification at reversal