Hartmann's Procedure
What the Examiner Expects
Resection of the sigmoid colon with creation of an end colostomy and oversewing/stapling of the rectal stump (Hartmann's pouch), avoiding an anastomosis in a contaminated or unstable operative field. The classic indication is Hinchey III (purulent peritonitis) or IV (feculent peritonitis) complicated diverticulitis, where creating an anastomosis in a contaminated abdomen is dangerous. It is also used for obstructing left-sided colon cancer in an unstable patient or in the damage control setting. The examiner should know that Hartmann's reversal is a technically challenging operation with 30–50% morbidity and that many patients never undergo reversal.
Key Examiner Focus Points
- Sigmoid resection with end colostomy and rectal stump closure (Hartmann's pouch)
- Indicated for complicated diverticulitis (Hinchey III/IV), obstructing sigmoid cancer in unstable patient
- Avoids anastomosis in contaminated or unstable setting
- Hartmann's reversal is a major operation with significant morbidity — many are never reversed
- Alternative: resection with primary anastomosis and diverting loop ileostomy
Common Curveballs
The patient is a healthy 45-year-old with Hinchey III diverticulitis — should you still do a Hartmann's?
In a young, otherwise healthy patient, consider resection with primary colorectal anastomosis and proximal diverting loop ileostomy instead. The DIVERTI and LADIES trials showed that primary anastomosis with diversion has comparable outcomes to Hartmann's and avoids the morbidity of a Hartmann's reversal. Reserve Hartmann's for unstable, elderly, or immunocompromised patients.
During Hartmann's reversal, you cannot find the rectal stump
This is common. Place a rigid proctoscope or flexible endoscope transanally with transillumination to identify the stump. It may be deep in the pelvis, adherent to pelvic structures. Careful sharp dissection is required. A preoperative Gastrografin enema can help delineate the stump.
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