Overview
Definition:
Hartmann's procedure is a surgical operation involving the resection of a diseased segment of the colon, creation of an end colostomy, and closure of the distal rectal stump
It is typically performed as an emergency procedure for severe colonic pathology that precludes primary anastomosis.
Epidemiology:
While not a common elective procedure, Hartmann's procedure is frequently employed in acute settings such as perforated diverticulitis, complicated sigmoid volvulus, large bowel obstruction with ischemia, and sometimes for rectal cancer requiring diversion
Incidence is directly related to the prevalence of these emergent conditions.
Clinical Significance:
This procedure is a critical tool in the management of life-threatening colonic emergencies
Its significance lies in providing a safe option for bowel diversion when primary reconstruction is not feasible, thereby preventing fecal peritonitis and improving patient survival in acute settings
Understanding its indications, execution, and potential for reversal is vital for surgical residents preparing for board examinations.
Indications
Absolute Indications:
Perforated diverticulitis with diffuse peritonitis
Obstructing sigmoid volvulus refractory to detorsion
Ischemic colitis with transmural necrosis
Severe fecal impaction with perforation or risk of perforation
Acute sigmoid or rectal cancer with obstruction or perforation.
Relative Indications:
Unfavorable patient physiological status precluding extensive surgery
Severe sepsis with hemodynamic instability
Localized peritonitis that can be controlled with resection and diversion
Prior pelvic radiation therapy compromising anastomosis.
Contraindications:
Patient unfit for any surgery
Clearable distal obstruction below the planned resection site where primary anastomosis might be considered
Extensive intra-abdominal adhesions that would make dissection perilous.
Preoperative Preparation
Resuscitation And Stabilization:
Aggressive fluid resuscitation
Broad-spectrum intravenous antibiotics covering gram-negative and anaerobic organisms
Correction of electrolyte imbalances
Blood product transfusion as needed
Hemodynamic monitoring.
Imaging And Investigations:
Computed tomography (CT) scan of the abdomen and pelvis with oral and IV contrast to assess the extent of disease, perforation, and obstruction
Plain abdominal X-rays may show free air
Blood tests including CBC, electrolytes, renal function, liver function tests, coagulation profile, and lactate.
Anesthesia Considerations:
General anesthesia with endotracheal intubation is usually preferred
Careful anesthetic management is required due to the patient's often critical condition
Postoperative pain control planning is essential.
Surgical Team Preparation:
Clear communication regarding the extent of resection anticipated
Availability of appropriate surgical instruments and staplers
Adequate lighting and surgical team experience.
Procedure Steps
Abdominal Exploration:
Laparotomy (midline or transverse incision) to assess the extent of pathology, bowel viability, and presence of peritonitis
Identification of the diseased segment, usually sigmoid colon or rectum.
Resection Of Diseased Segment:
Mobilization of the affected colon segment
Ligation of mesentery vessels
Division of the colon proximal and distal to the diseased part
The distal end is carried to the abdominal wall as a colostomy, and the proximal stump is stapled or oversewn.
Rectal Stump Management:
The rectal stump is meticulously closed with sutures or staples to create a watertight seal
It is then typically left in the pelvis or retroperitoneum
Care is taken to avoid tension on the suture line.
Colostomy Formation:
The proximal end of the colon is brought out through a separate stab incision in the left lower quadrant of the abdominal wall, creating a sigmoid colostomy
The colostomy is matured by everting the mucosa
Placement of a colostomy bag
Meticulous wound closure.
Postoperative Care
Monitoring And Pain Management:
Close monitoring of vital signs, urine output, and abdominal distension
Aggressive pain management with patient-controlled analgesia (PCA) or epidural anesthesia
Monitoring for signs of complications like ileus, infection, or bleeding.
Fluid And Electrolyte Management:
Intravenous fluid therapy to maintain hydration and electrolyte balance
Monitor serum electrolytes, particularly potassium and sodium
Gradual reintroduction of oral intake as bowel function returns.
Wound Care And Colostomy Management:
Routine wound care
Regular emptying and monitoring of the colostomy appliance
Patient education on colostomy care, skin protection, and dietary modifications
Early mobilization to prevent deep vein thrombosis and pulmonary complications.
Antibiotic Therapy:
Continue broad-spectrum antibiotics postoperatively, adjusting based on intraoperative findings and culture results
Duration typically depends on the severity of infection and patient response.
Complications
Early Complications:
Wound infection
Intra-abdominal abscess
Retained intra-abdominal swabs or instruments
Anastomotic leak if a diversion was not fully employed
Bleeding from the mesentery or staple lines
Paralytic ileus
Colostomy retraction, prolapse, or ischemia.
Late Complications:
Stomal stenosis or hernia
Adhesions leading to bowel obstruction
Rectal stump stump leakage or fistula formation
Incisional hernia
Psychological impact of having a colostomy
Failure to reverse the colostomy due to patient factors or local issues.
Prevention Strategies:
Meticulous surgical technique, especially in rectal stump closure
Adequate antibiotic prophylaxis and therapy
Proper stoma siting and maturation
Early mobilization and adequate analgesia
Careful patient selection and preoperative optimization
Close postoperative monitoring for early detection of complications.
Reversal Of Hartmann's Procedure
Indications For Reversal:
Patient is medically fit
No signs of active sepsis or peritonitis
Successful resolution of the primary pathology
Adequate bowel preparation
Absence of significant adhesions or local inflammation at the rectal stump site.
Timing Of Reversal:
Typically performed 3-6 months after the initial procedure, allowing for resolution of inflammation and fibrosis
However, this can vary based on patient recovery and surgeon preference.
Surgical Technique For Reversal:
Laparotomy or laparoscopic approach
Mobilization of the colon and rectal stump
Reconnection of the colon and rectum, usually with stapled or hand-sewn anastomosis
Creation of a defunctioning ileostomy may be considered in high-risk patients
Strict bowel preparation is crucial.
Potential Challenges During Reversal:
Dense adhesions in the pelvis
Fibrosis and poor tissue quality at the rectal stump
Bleeding
Difficulty in achieving a tension-free anastomosis
Risk of anastomotic leak and subsequent peritonitis.
Key Points
Exam Focus:
Hartmann's procedure is a life-saving diversion for emergent colonic pathology
Key indications include perforation, obstruction, and ischemia
The procedure involves resection, colostomy, and rectal stump closure
Reversal is a secondary procedure usually done after 3-6 months.
Clinical Pearls:
Always assess patient stability before embarking on Hartmann's
Ensure adequate bowel prep for reversal
Consider a defunctioning loop ileostomy if intraoperative findings suggest high risk of anastomotic leak during reversal
Proper stoma siting is paramount for long-term patient comfort.
Common Mistakes:
Performing primary anastomosis in a contaminated field or on unprepared bowel
Inadequate rectal stump closure leading to leak
Poor stoma siting causing skin excoriation or hernia
Delaying reversal due to perceived complexity without proper assessment of patient fitness.