Hartmann’s procedure is an eponymous procedure named after Professor Henri Hartmann. It was first described for sigmoid cancer and consisted of a segmental resection of the sigmoid colon, closure of the rectal stump, and end colostomy using the distal descending colon. Now the operation is done in cases where a segmental resection of the left/sigmoid colon is needed and it is too risky to perform a primary anastomosis. Common indications include perforated sigmoid colon (due to diverticulitis, stercoral perforation, trauma, etc.), cases of colon obstruction due to left/sigmoid colon, or upper rectal lesions. It can be safely performed laparoscopically or open. However, the majority of these cases are done using the open approach due to several factors: dilated bowel loops can make the laparoscopic approach much more difficult due to lack of working space, these patients tend to be acutely ill needing the surgery to be expeditious, and unstable patients may also have a difficult time tolerating pneumoperitoneum. Additionally, the open approach makes a thorough washout easier to perform and saves time.
Hartman’s reversal after an abdominal catastrophe is challenging due to many factors. First, there will be lots of adhesions, which will make the initial laparoscopic access difficult, and occasionally unsafe. Second, dissection of the rectal stump can be challenging.
The timing of the operation is important. It is advisable that the decision to reverse the stoma after a major catastrophe in the abdomen is at least 6 months to 1 year, preferably the latter. This would allow more time for the adhesions to soften and make it more likely to complete the surgery in a minimally invasive fashion. The operation consists of multiple steps:
Colostomy takedown/accessing the abdomen and preparing the left colon.
Lysis of adhesions.
Mobilization of the left colon.
Mobilization and possible transection of the rectum.
Creation of colorectal anastomosis.
Flexible sigmoidoscopy to test the anastomosis.
Assess for the need of temporary diversion.
Ureteral stents placement should be considered preoperatively, to facilitate the identification of the both ureters, especially if the index surgery was difficult, if the patient has a history of ureteral injury, or if the rectal stump is short. In such cases, the scarring can be dense and the rectal dissection may be more extensive, and the ureters may be medialized due to the previous operation.
A pouchogram of the rectal stump can help in defining the length of the remaining rectum and its anatomy. If the patient has had a recent colonoscopy with visualization of the rectum and assessment of its length then no preoperative imaging is necessary. Most often these patients have imaging secondary to their primary pathology, namely cancer, and these can be used in preoperative planning, especially judging the need for takedown of the splenic ...