Overview
Definition:
Hartmann's procedure is a surgical intervention involving the resection of a diseased segment of the colon, creation of a proximal end colostomy, and closure of the distal rectal stump
It is typically performed in emergent situations or for conditions where immediate anastomosis is not feasible due to sepsis, malnutrition, or bowel preparation challenges.
Epidemiology:
While specific incidence rates are difficult to isolate, Hartmann's procedure is commonly utilized for complicated acute diverticulitis, colon cancer with perforation, and large bowel obstruction requiring emergency resection
The prevalence of such conditions, particularly diverticulitis, is significant in Western populations and rising globally.
Clinical Significance:
This procedure is crucial for managing severe colonic pathology that compromises the patient's immediate safety, allowing for staged management
It provides a life-saving intervention by diverting fecal stream and allowing for rectal healing or staged reconstruction
Understanding its indications, execution, and potential for reversal is vital for surgical residents preparing for DNB and NEET SS examinations.
Indications
Emergency Indications:
Perforated colonic diverticulitis
Sepsis from colonic source
Acute sigmoid volvulus with ischemia
Intestinal obstruction with compromised bowel viability
Traumatic bowel injury requiring resection.
Elective Indications:
Severe, unresolving toxic megacolon
Obstructing rectal cancer where distal margins are compromised or immediate anastomosis is unsafe
Following complex pelvic surgery with localized bowel injury.
Contraindications:
Patient unfit for two-stage surgery
Severe malnutrition and hypoalbuminemia precluding wound healing or anastomosis
Active, uncontrolled sepsis requiring immediate source control and drainage
Lack of resources for staged reversal or colostomy care.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination
Assess for sepsis, dehydration, and nutritional status
Evaluate comorbidities: cardiovascular, pulmonary, renal, and glycemic control.
Investigations:
Complete blood count (CBC) to assess for leukocytosis and anemia
Electrolytes, renal function tests (RFTs), liver function tests (LFTs)
Coagulation profile
Blood grouping and cross-matching
Imaging: CT abdomen/pelvis with oral and IV contrast to assess extent of disease, perforation, abscess, and obstruction.
Optimization:
Intravenous fluid resuscitation to correct dehydration and electrolyte imbalances
Broad-spectrum antibiotics covering gram-negative and anaerobic organisms
Nasogastric tube insertion for gastric decompression
Nutritional support if indicated and time permits
Correction of coagulopathy.
Surgical Planning:
Marking of stoma site with patient in standing and supine positions, ensuring adequate mobility and avoidance of bony prominences or previous scars
Discuss stoma type and management with stoma nurse if available.
Procedure Steps
Abdominal Exploration:
Laparotomy (midline or transverse incision) or laparoscopic approach
Thorough exploration to assess the extent of disease, bowel viability, and presence of abscesses or peritonitis
Identify the diseased segment of colon to be resected.
Resection:
Mobilization of the involved colon segment, ligating mesenteric vessels
Resection of the diseased colon segment, ensuring adequate margins proximal and distal to the pathology
For diverticulitis, resection typically includes the sigmoid colon and proximal rectum.
Colostomy Formation:
Creation of an end colostomy from the proximal resected colon
The stoma is matured by everting and suturing the bowel mucosa to the skin at the pre-marked stoma site
Secure the bowel to the abdominal wall to prevent retraction.
Rectal Stump Closure:
The distal rectal stump is carefully closed using staplers (e.g., EEA stapler) or multiple layers of sutures to create a watertight seal
The stump is then usually left in the pelvis without drainage, though some surgeons may consider drainage for specific indications.
Abdominal Closure:
Irrigation of the peritoneal cavity if contamination is present
Careful closure of the abdominal wall in layers
Placement of drains if significant contamination or abscess cavity is present.
Postoperative Care
Immediate Care:
Close monitoring of vital signs, fluid balance, and urine output in a high-dependency unit
Pain management with adequate analgesia (epidural or patient-controlled analgesia)
Nasogastric decompression
Intravenous antibiotics continued for 48-72 hours or as per protocol.
Stoma Care:
Regular assessment of stoma viability, color, and edema
Initiation of stoma care with the help of stoma nurses
Education of the patient and family regarding stoma appliance management, diet, and fluid intake
Gradual transition to oral diet as bowel function returns.
Monitoring For Complications:
Vigilant monitoring for signs of anastomotic leak (if applicable), intra-abdominal abscess, bowel obstruction, stoma complications (ischemia, retraction, necrosis, skin irritation), and wound infection
Early mobilization to prevent deep vein thrombosis and pulmonary complications.
Nutrition And Hydration:
Encourage adequate oral intake as tolerated
Monitor for signs of dehydration
Nutritional support may be required if oral intake is insufficient or prolonged recovery is anticipated.
Complications
Early Complications:
Stoma ischemia or necrosis
Stoma retraction
Wound infection or dehiscence
Intra-abdominal abscess
Bleeding from stoma or surgical site
Paralytic ileus
Urinary tract infection
Pneumonia
Deep vein thrombosis, pulmonary embolism.
Late Complications:
Stoma stenosis
Parastomal hernia
Adhesions leading to bowel obstruction
Rectal stump stump issues (e.g., mucus discharge, bleeding, prolapse)
Social and psychological impact of stoma
Difficulty with stoma reversal surgery.
Prevention Strategies:
Meticulous surgical technique with adequate bowel mobilization and secure stoma formation
Prophylactic antibiotics
Early mobilization and incentive spirometry
Careful stoma site selection
Close postoperative monitoring and prompt management of any deviations
Judicious use of drains
Patient education on stoma care and diet.
Reversal Of Hartmann's Procedure
Indications For Reversal:
Patient's overall condition has improved significantly
Absence of active sepsis
Adequate nutritional status
Bowel preparation is achievable
Patient is motivated and able to care for a stoma temporarily
Stoma is well-functioning and skin is healthy.
Timing Of Reversal:
Typically performed 3-6 months after the initial procedure, allowing for resolution of inflammation, return of bowel tone, and patient recovery
Earlier reversal may be considered in select cases if feasible.
Procedure For Reversal:
Laparoscopic or open approach
Mobilization of the rectal stump and proximal colon
Creation of an anastomosis between the proximal colon and the rectal stump using staplers or sutures
Depending on the surgeon and patient factors, a protective ileostomy or colostomy may be created to decompress the anastomosis and be reversed later.
Complications Of Reversal:
Anastomotic leak (most significant)
Rectal stump stump blowout
Intra-abdominal abscess
Adhesions and bowel obstruction
Stomal site issues (if a temporary diversion is created)
Pelvic sepsis.
Key Points
Exam Focus:
Hartmann's procedure is a staged surgical approach for severe colonic pathology, primarily indicated in emergencies like perforated diverticulitis
Key components include resection, end colostomy, and stapled rectal stump closure
Reversal is typically performed after a significant interval.
Clinical Pearls:
Adequate stoma site selection is paramount to prevent future complications like parastomal hernia or skin breakdown
Thorough preoperative assessment and optimization are critical, especially for emergency cases
Postoperative stoma care education is essential for patient recovery and quality of life.
Common Mistakes:
Inadequate bowel preparation or patient optimization for emergency cases
Poor stoma site selection leading to appliance issues
Delay in recognizing and managing stoma complications or intra-abdominal sepsis
Premature reversal attempts in unwell patients
Failure to adequately counsel patients on stoma care and potential for reversal.