Open Hartmann Procedure
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The Hartmann procedure involves resection of the rectosigmoid colon with creation of a colostomy. It was first described by Henri Albert Hartmann at the 30th Congress of the French Surgical Association in 1921. Hartmann reported two patients with obstructive cancer of the sigmoid colon, whom he treated by performing a laparotomy with creation of a proximal colostomy and sigmoid resection with closure of the rectal stump.
Hartmann developed this procedure as a response to the high mortality associated with the abdominoperineal resection described by Miles in 1908. With the Hartmann procedure, operative mortality was 8.8% (compared with 38% with the Miles resection) because “cases were as uneventful as a procedure for a cold appendix.” [1]
Although the Hartmann procedure was initially developed for the treatment of distal colonic adenocarcinoma, the indications have progressed with the times. [2]
Currently, the most common indication for a Hartmann procedure is complicated diverticulitis (see the images below). Diverticula are small (0.5-1 cm in diameter) outpouchings of the colon that occur at the sites of vascular penetration between the single mesenteric taenia and one of the antimesenteric taeniae. [3]
The wide spectrum of symptoms associated with diverticulitis has led to the formation of the Hinchey classification system. [4] In this system, complicated diverticulitis is staged as follows:
Surgery is indicated in about 20-30% of cases of diverticulitis, with recurrent diverticulitis being the most common surgical indication.
Resection with primary anastomosis may be considered for Hinchey stage I or II diverticulitis. Sometimes, this involves performing an elective resection after percutaneous drainage of a paracolic or pelvic abscess. The timing of elective resection depends on the amount of inflammation seen on computed tomography (CT), as well as on the clinical scenario; however, it is usually done about 6 weeks after the most recent attack. The Hartmann procedure remains the preferred treatment for Hinchey stages III and IV.
The next most common indication for a Hartmann procedure is rectosigmoid cancer. The following scenarios of rectosigmoid carcinoma necessitate performing the Hartmann procedure:
Less commonly, the procedure may be done for ischemia, volvulus, iatrogenic perforation of the colon during colonoscopy or by a foreign body, lymphoma, metastatic cancer to the pelvis, Crohn disease, trauma, anastomotic dehiscence, pseudomembranous colitis, rectal prolapse, leiomyosarcoma, ulcerative colitis, radiation injuries, retroperitoneal bleeding, or pneumatosis cystoides [5]
A Hartmann procedure can also be performed whenever a colon resection is needed and a primary anastomosis cannot be safely done—for example, in patients who are hemodynamically unstable during the operation or who are severely immunocompromised or malnourished.
There are few contraindications for the Hartmann procedure. In fact, it is usually the procedure of choice when other, more extensive operations are contraindicated. In elective cases, medical optimization of the patient’s health status, along with controlled operating conditions, usually renders a Hartmann procedure unnecessary. In emergency situations, where a Hartmann procedure is most often performed, severe systemic imbalances may preclude even this operation.
Systemic conditions unfavorable to the performance of a Hartmann procedure include the following:
If a patient is too unstable and a long operation would be life-threatening, alternatives may be considered. Laparoscopic or open peritoneal lavage and placement of an intraoperative drain to treat purulent peritonitis have been reported. This can be done either with or without a diverting loop ileostomy or colostomy. Morbidity is low with this approach, and the option of future reoperation for definitive treatment when the patient is more stable is now available.
Gentile et al studied 30 elderly patients with Hinchey grade II-III acute diverticulitis, of whom 14 (mean age, 62.6 years) underwent laparoscopic lavage and drainage (LLD) and 16 (mean age, 64.8 years) underwent the Hartmann procedure. [6] They found that the LLD group had better outcomes with respect to total operating time, admission to the intensive care unit (ICU), restoration of bowel function, mobilization, and duration of hospital stay.
Ceresoli et al, in a systematic review and meta-analysis of studies comparing laparoscopic lavage with sigmoid resection in patients with Hinchey grade III diverticulitis, found that the two procedures were essentially equivalent with respect to mortality but that the former was associated with a higher reoperation rate and a higher incidence of intra-abdominal abscess. [7]
Another alternative in an unstable patient is to perform a temporary abdominal closure (the authors prefer the V.A.C. [Vacuum Assisted Closure] system [Kinetic Concepts, San Antonio, TX]) and serial abdominal washouts, often at the ICU bedside, followed by definitive operative treatment when the patient recovers from sepsis.
Whenever possible, an enterostomal therapy nurse (EOTN) should be consulted for preoperative patient skin marking. A study by Bass et al showed that preoperative evaluation by an EOTN (including skin marking and patient education) reduced the number of early and late colostomy complications. [8] Early complications were defined as any adverse event occurring within 30 days of stoma creation, late complications as those occurring after 30 days.
Complications seen in this study included necrosis, stenosis, retraction, prolapse, parastomal infection or hernia, problematic location, skin problems, bleeding, and fistulization. [8] The results reported were statistically significant and indicated that the total complication rate decreased from 44% to 33%. The early complication rate decreased from 32% to 23%; the late complication rate decreased from 12% to 9%.
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Barbieux J, Plumereau F, Hamy A. Current indications for the Hartmann procedure. J Visc Surg. 2016 Feb. 153 (1):31-8. [Medline].
Welch JP, Cohen JL, Barczak R. Diverticulitis. Ashley SW, Cance WG, Chen H, et al, eds. ACS Surgery: Principles & Practice. 7th ed. Toronto: BC Decker; 2014.
Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978. 12:85-109. [Medline].
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Gentile V, Ferrarese A, Marola S, Surace A, Borello A, Ferrara Y, et al. Perioperative and postoperative outcomes of perforated diverticulitis Hinchey II and III: open Hartmann’s procedure vs. laparoscopic lavage and drainage in the elderly. Int J Surg. 2014. 12 Suppl 2:S86-9. [Medline].
Ceresoli M, Coccolini F, Montori G, Catena F, Sartelli M, Ansaloni L. Laparoscopic lavage versus resection in perforated diverticulitis with purulent peritonitis: a meta-analysis of randomized controlled trials. World J Emerg Surg. 2016. 11 (1):42. [Medline]. [Full Text].
Bass EM, Del Pino A, Tan A, Pearl RK, Orsay CP, Abcarian H. Does preoperative stoma marking and education by the enterostomal therapist affect outcome?. Dis Colon Rectum. 1997 Apr. 40(4):440-2. [Medline].
Walsh CJ, Jamieson NV, Fazio VW. Top Tips in Gastrointestinal Surgery. London: Blackwell Science; 1999.
Cohen JL, Welch JP, Reines L. Procedures for diverticular disease. Ashley SW, Cance WG, Chen H, et al, eds. ACS Surgery: Principles & Practice. 7th ed. Toronto: BC Decker; 2014.
Zollinger Jr RM, Zollinger Sr RM. Zollinger’s Atlas of Surgical Operations. 8th ed. New York: McGraw-Hill; 2003.
Fry RD, Mahmoud NN. Segmental resection for diverticulitis. Fischer JE, ed. Mastery of Surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2007. Vol 1:
Forgione P, Cataldo P. Colostomy. Oper Tech Gen Surg. 2003 Dec. 5 (4):264-72.
[Guideline] Antoniou SA, Agresta F, Garcia Alamino JM, et al. European Hernia Society guidelines on prevention and treatment of parastomal hernias. Hernia. 2017 Nov 13. [Medline]. [Full Text].
Khosraviani K, Campbell WJ, Parks TG, Irwin ST. Hartmann procedure revisited. Eur J Surg. 2000 Nov. 166(11):878-81. [Medline].
Lubbers EJ, de Boer HH. Inherent complications of Hartmann’s operation. Surg Gynecol Obstet. 1982 Nov. 155(5):717-21. [Medline].
Boulos PB, O’Bichere A. Complications of colorectal surgery. Hakim NS, Papalois VE, eds. Surgical Complications: Diagnosis and Treatment. London: Imperial College Press; 2007.
Angel Mario Morales Gonzalez, MD Assistant Professor of Surgery/Colorectal Surgery, Associate Surgical Clerkship Director, Paul L Foster School of Medicine, Texas Tech University Health Sciences Center
Angel Mario Morales Gonzalez, MD is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons
Disclosure: Nothing to disclose.
Ziad N Kronfol, MD Resident Physician, Department of Surgery, Texas Tech University Health Sciences Center
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine
Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.
Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine
Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.
Medscape Reference thanks Dawn Sears, MD, Associate Professor of Internal Medicine, Division of Gastroenterology and Hepatology, Scott and White Memorial Hospital; and Dan C Cohen, MD, Fellow in Gastroenterology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine, for assistance with the video contribution to this article.
Open Hartmann Procedure
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