Hartmann’s Procedure: Comprehensive Surgical Guide for Surgeons

Hartmann’s procedure is a well-established surgical technique primarily used in cases of complicated diverticular disease, colorectal cancer, and other severe conditions of the colon. The procedure involves the resection of a diseased segment of the bowel, typically the sigmoid colon, and the creation of an end colostomy with the closure of the rectal stump. This article provides a detailed overview of Hartmann’s procedure, exploring its indications, preoperative evaluation, contraindications, surgical techniques, postoperative care, possible complications, alternative options, prognosis, and more.

Indications for Hartmann’s Procedure

Hartmann’s procedure is often indicated in emergency situations where primary anastomosis is deemed too risky. Some common indications include:

1. Complicated Diverticulitis: When diverticulitis leads to perforation, abscess formation, or fistula, Hartmann’s procedure may be the best option to control sepsis and manage the disease.
2. Colorectal Cancer: In cases of obstructing or perforated colorectal cancer, particularly in the left colon, this procedure is often chosen to remove the tumor and prevent further complications.
3. Trauma: Severe traumatic injuries to the colon that result in significant contamination or devascularization may require this procedure.
4. Ischemic Colitis: When the blood supply to the colon is compromised, leading to necrosis, Hartmann’s procedure can be necessary to remove the affected bowel segment.
5. Radiation Enteritis: Severe radiation-induced damage to the bowel may necessitate resection and colostomy formation to relieve symptoms and prevent further complications.

Preoperative Evaluation

A thorough preoperative evaluation is crucial to assess the patient’s overall condition and to plan the surgical approach:

1. Clinical Assessment: A complete medical history and physical examination should be conducted, focusing on the patient’s abdominal symptoms, bowel habits, and any previous abdominal surgeries.
2. Laboratory Tests: Blood tests, including complete blood count (CBC), electrolytes, renal function, and coagulation profile, are essential to assess the patient’s fitness for surgery.
3. Imaging Studies:
   • CT Scan: A contrast-enhanced CT scan is often performed to evaluate the extent of the disease, identify any abscesses, perforations, or fistulas, and determine the best surgical approach.
   • Colonoscopy: While typically avoided in acute settings due to the risk of perforation, colonoscopy may be useful in elective cases to visualize the lesion and obtain biopsies if needed.
4. Cardiac and Pulmonary Evaluation: In patients with significant comorbidities, a thorough cardiac and pulmonary evaluation is necessary to assess surgical risk.
5. Nutritional Assessment: Malnourished patients may benefit from preoperative nutritional support to optimize their condition before surgery.

Contraindications

While Hartmann’s procedure is a versatile and life-saving surgery, it is not appropriate for all patients:

1. Poor Surgical Candidates: Patients with advanced cardiac or pulmonary disease, who are unlikely to tolerate general anesthesia and major abdominal surgery, may not be suitable candidates.
2. Extensive Peritoneal Contamination: In cases of widespread peritoneal contamination where anastomosis would still be risky, alternative approaches such as damage control surgery may be considered.
3. Short Bowel Syndrome: In patients with pre-existing short bowel syndrome, further resection could exacerbate nutritional deficiencies, making Hartmann’s procedure less favorable.

Surgical Techniques and Steps

Hartmann’s procedure can be performed using either an open or laparoscopic approach, depending on the surgeon’s preference and the patient’s condition:

1. Anesthesia: The procedure is performed under general anesthesia, with the patient positioned in a supine position.
2. Incision:
   • Open Approach: A midline laparotomy is typically performed to provide wide exposure to the abdominal cavity.
   • Laparoscopic Approach: Several small incisions are made for the introduction of laparoscopic instruments.
3. Mobilization of the Colon: The sigmoid colon and rectum are mobilized by dissecting along the avascular plane of Toldt. The inferior mesenteric artery is often ligated to facilitate mobilization.
4. Resection of the Diseased Segment: The diseased segment of the colon is identified and resected. Care is taken to ensure that the proximal margin is healthy to minimize the risk of future complications.
5. Formation of the End Colostomy: The proximal end of the colon is brought out through a separate incision in the left lower quadrant and matured as an end colostomy. The colostomy is secured to the skin with interrupted sutures.
6. Closure of the Rectal Stump: The distal rectal stump is either closed with a stapler or sutured manually. It is left in situ, with or without drainage depending on the degree of contamination.
7. Irrigation and Closure: The peritoneal cavity is thoroughly irrigated with warm saline to remove any residual contaminants. The abdominal wall is then closed in layers.

Postoperative Care

Postoperative care is critical to ensure optimal recovery and minimize complications:

1. Pain Management: Adequate pain control, typically with a combination of opioids and non-opioid analgesics, is essential in the early postoperative period.
2. Fluid and Electrolyte Management: Close monitoring of fluid and electrolyte balance is necessary, especially in patients with significant fluid losses.
3. Early Mobilization: Encouraging early mobilization can help reduce the risk of deep vein thrombosis (DVT) and pulmonary complications.
4. Nutritional Support: Nutritional support, including parenteral nutrition if necessary, should be initiated early to promote healing and recovery.
5. Stoma Care: Education on stoma care is essential for patients who will manage their colostomy at home. Consultation with a stoma nurse is recommended.
6. Infection Prevention: Prophylactic antibiotics may be continued postoperatively, and the surgical site should be monitored closely for signs of infection.

Possible Complications

Like any major surgery, Hartmann’s procedure carries risks of complications:

1. Infection: Surgical site infections, intra-abdominal abscesses, and sepsis are possible, particularly in cases with significant contamination.
2. Stomal Complications: Complications such as retraction, prolapse, or parastomal hernia can occur with the colostomy.
3. Anastomotic Leak: In cases where an anastomosis is performed, there is a risk of leakage, leading to peritonitis and sepsis.
4. Fistula Formation: The rectal stump can occasionally develop a fistula, particularly if there is residual disease or infection.
5. Bowel Obstruction: Adhesions and strictures can lead to postoperative bowel obstruction, requiring further intervention.

Different Techniques and Alternatives

While Hartmann’s procedure is a standard approach, there are variations and alternatives that may be considered:

1. Reversal of Hartmann’s Procedure: In selected patients, the colostomy can be reversed at a later stage, with the re-establishment of intestinal continuity. This is often done after 6-12 months, once the patient has recovered and any infection or inflammation has resolved.
2. Primary Anastomosis: In stable patients with minimal contamination, primary resection with anastomosis may be considered instead of Hartmann’s procedure.
3. Damage Control Surgery: In patients with severe contamination or hemodynamic instability, a staged approach with damage control surgery, followed by delayed anastomosis, may be appropriate.

Prognosis and Outcome

The prognosis after Hartmann’s procedure depends on the underlying condition and the patient’s overall health:

1. Short-Term Outcomes: In emergency settings, the procedure has a higher morbidity and mortality rate due to the severity of the underlying disease and the patient’s condition.
2. Long-Term Outcomes: Patients who undergo successful reversal of Hartmann’s procedure generally have good long-term outcomes, with improved quality of life. However, some patients may live with a permanent colostomy, depending on their health and surgical considerations.
3. Quality of Life: For patients with a permanent colostomy, quality of life is largely determined by their adaptation to living with a stoma. Psychological support and education are crucial.

Average Cost

The cost of Hartmann’s procedure varies widely depending on the country, healthcare system, and whether it is performed as an emergency or elective surgery. On average, the cost may range from $20,000 to $60,000, including hospital stay, surgery, and postoperative care. The cost of reversal surgery, if performed, would be additional.

Recent Advances

Recent advances in the surgical field have aimed to improve the outcomes of Hartmann’s procedure:

1. Laparoscopic Hartmann’s Procedure: The use of laparoscopic techniques has been shown to reduce postoperative pain, shorten hospital stays, and decrease the incidence of wound infections compared to open surgery.
2. Enhanced Recovery After Surgery (ERAS) Protocols: Implementation of ERAS protocols has led to faster recovery times, reduced hospital stays, and lower complication rates.
3. Biological Mesh in Stoma Creation: The use of biological mesh in stoma creation has been explored as a means to reduce the incidence of parastomal hernias.
4. Robotic-Assisted Surgery: Robotic-assisted approaches offer greater precision and control, potentially reducing the risk of complications, although these are not yet widely adopted for Hartmann’s procedure.