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hartmann and paul mikulicz procedure same or different

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Hartmann procedure vs Paul Mikulicz procedure differences colostomy

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I now have everything needed for a thorough, well-cited answer. Here is the complete comparison:

Hartmann's Procedure vs. Paul-Mikulicz Procedure - They Are DIFFERENT

Both are two-stage operations for emergency left-sided colonic pathology (obstruction, volvulus, perforation, perforated diverticulitis), but they differ in a critical way - what happens to the distal bowel stump.

Hartmann's Procedure

  1. The diseased segment (typically sigmoid colon) is resected
  2. The proximal end is brought out as an end colostomy
  3. The distal end (rectal stump) is closed and returned to the abdomen as a blind pouch - "Hartmann's pouch"
  4. The rectum remains inside, shut off
Second stage: Reversal ("Hartmann's reversal") involves re-opening the abdomen and anastomosing the colostomy to the Hartmann's pouch - a more complex re-do operation.

Paul-Mikulicz Procedure (Double-Barrel Colostomy / Exteriorization Resection)

  1. The diseased segment is resected (or the loop is exteriorized)
  2. Both the proximal and distal ends are brought out through the abdominal wall as a double-barreled colostomy (side by side, two openings)
  3. There is no blind intra-abdominal rectal stump
Second stage: Closure is simpler - the two limbs are anastomosed at skin level using a crushing clamp (no need to re-enter the abdomen).
Paul-Mikulicz operation - double barrel colostomy showing both limbs brought through the abdominal wall
Figure 78.20 from Bailey & Love - The Paul-Mikulicz operation applied to volvulus of the pelvic colon. Note both limbs of bowel being brought out through the abdominal wall as a double-barrel stoma.

Side-by-Side Comparison

FeatureHartmann's ProcedurePaul-Mikulicz Procedure
Diseased segmentResectedResected (or exteriorized)
Proximal endEnd colostomyOne barrel of double colostomy
Distal endClosed, left in abdomen (Hartmann's pouch)Brought out as second barrel
Stoma typeSingle-barrel end colostomyDouble-barrel colostomy
Reversal complexityHigh (re-entry into abdomen, low pelvic dissection)Lower (anastomosis at abdominal wall level)
Preferred whenDistal bowel cannot reach the abdominal wallDistal bowel can reach the wall
Risk of blind stumpYes (blowout, pelvic sepsis risk)No

The Key Practical Distinction (from Bailey & Love's)

"When possible the distal bowel should be brought out at the same time (Paul-Mikulicz procedure) to facilitate subsequent closure. In the majority of cases, the distal bowel will not reach and is closed and returned to the abdomen (Hartmann's procedure)."
  • Bailey and Love's Short Practice of Surgery, 28th Ed.
So in practice, Hartmann's is more commonly performed because the distal rectal stump often does not have sufficient reach/mobility to be exteriorized, especially after sigmoid resection. The Paul-Mikulicz is preferred when there is enough distal bowel length, as reversal is technically easier.

Common Indications for Both

  • Gangrenous sigmoid volvulus
  • Perforated diverticulitis with fecal peritonitis
  • Obstructing left-sided colon cancer (emergency)
  • Colonic trauma or ischemia
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