Open Hartmann Procedure
- Author: Angel Mario Morales Gonzalez, MD; Chief Editor: Kurt E Roberts, MD more...
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.”
Although the Hartmann procedure was initially developed for the treatment of distal colonic adenocarcinoma, the indications have progressed with the times.
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.
The wide spectrum of symptoms associated with diverticulitis has led to the formation of the Hinchey classification system. In this system, complicated diverticulitis is staged as follows:
Stage I - Diverticulitis with a paracolic abscess (see the image below)
Stage II - Diverticulitis with a more distant abscess (pelvic or retroperitoneal)
Stage III - Diverticulitis with purulent peritonitis
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 last 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:
Emergency - Management of obstruction, perforation, or bleeding
Elective - Cure, palliation, or anticipation of impending obstruction
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 
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. 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.
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. 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. 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%.
The following equipment is needed to perform a Hartmann procedure:
Standard exploratory laparotomy tray
Sterile gloves and gowns
Skin preparation solution (the authors prefer ChloraPrep [CareFusion, San Diego, CA], which consists of 2% chlorhexidine gluconate and 70% isopropyl alcohol)
No. 10 blade
Bookwalter retractor (Codman & Shurtleff, Raynham, MA) or other self-retaining retractor
Fiberoptic retractor to facilitate visualization of the pelvic structures
Several types of sutures and ties, including chromic, polyglactin, polypropylene, and polydioxanone
Sterile sponges and laparotomy pads
Sterile irrigation solution (water and normal saline)
Linear cutting staplers of various sizes (30 mm, 60 mm, 90 mm)
Drain (sometimes used; the authors prefer the Jackson-Pratt)
Ostomy wafer and bag
General anesthesia is required for a Hartmann procedure. Once the patient is asleep and the endotracheal tube is in place, the patient can be positioned. The supine position is employed. Often, the patient can be placed in a mild Trendelenburg position to facilitate visualization of the pelvic structures and retraction of the small bowel.
To ensure correct anatomic positioning, the patient's arms should be tucked at the sides, with the palms facing toward the thigh and the thumb facing in a relaxed upward position. The hands must be completely and securely encased in the wrap. To avoid compromising perfusion to the fingertips, care should be taken not to wrap the hands too tightly.
Next, a warming blanket, such as the Bair Hugger (Arizant, Eden Prairie, MN), is placed at the nipple line on the top portion of the patient. The patient’s feet must be uncrossed. A blanket is placed on the patient from the midthighs to the toes and secured with a patient safety belt. It is important to ensure that the patient does not come into contact with metal at any time.
Open approach to Hartmann procedure
An open Hartmann procedure is performed as follows.
Incision and inspection of abdomen
With the patient in the supine position, a midline incision is made with a No. 10 blade. Sometimes, turning the blade around the umbilicus results in an irregular and cosmetically displeasing incision. This problem can be avoided by retracting the umbilicus laterally after grasping it with tissue forceps, then making a straight incision. Once the umbilicus is released, the incision will curve smoothly around the umbilicus.
Another way of avoiding this problem is to make the incision through the umbilicus. Doing so will produce a straight line, as opposed to a curvilinear one, and this will be a more cosmetically pleasing result. The umbilicus can be reconstructed later, during skin closure. This method is the authors’ preference.
The incision is then carried down to the fascia with the blade or the Bovie electrocautery. In obese patients with a large amount of subcutaneous tissue, the midline may be difficult to find. To make it easier to find the midline, the surgeon and the assistant should each place a large laparotomy pad on either side of the incision and exert strong lateral traction (see the images below); this will cause a relatively avascular plane to open up in the midline.
After access to the peritoneal cavity is gained, the abdomen is examined to confirm the diagnosis. A large self-retaining retractor (the authors prefer the Bookwalter retractor) is then placed. Care must be taken to pad the abdominal wall when placing the retractor.
Exposure of sigmoid colon and pelvis
Next, the patient is placed in a mild Trendelenburg position to facilitate exposure of the sigmoid colon and the pelvis. The small bowel is retracted upward and placed in the right upper quadrant to keep it out of the way. This is accomplished by wrapping the small bowel in a warm, moist towel and retracting it with one of the Bookwalter retractor blades.
The sigmoid colon is then mobilized. With the colon held in the surgeon’s left hand, the lateral peritoneal reflection (the white line of Toldt) is incised, and dissection is carried out proximal and distal to the affected area. To produce a tension-free colostomy, it is usually necessary to mobilize the descending colon and the sigmoid colon; the splenic flexure is not routinely mobilized.
In situations involving severe inflammation (eg, perforated diverticulitis), it is easier to start this maneuver in an area that is not inflamed and then move to the affected area. If visualization of adjacent structures is a problem, careful blunt finger dissection can usually be employed to separate the colon from the retroperitoneal structures safely.
At this point, the ureter must be identified. It can usually be found as it crosses over the aortic bifurcation. The gonadal vessels can be a helpful landmark: once they are identified, the ureter can usually be found slightly medial and deep to them. To confirm that the structure is the ureter, gently press on it with a pair of forceps; the ureter exhibits peristalsis when this is done. If the ureter is injured, every attempt should be made to identify and repair it intraoperatively. In most instances, this involves consultation with a urologist.
In a hostile abdomen, the ureter can be very difficult to identify. Ureteral stents can be placed to facilitate identification in such situations. Although it is clear that stent placement makes it easier to identify the ureter, whether this measure prevents injury remains controversial. Many surgeons place stents if the patient has previously undergone pelvic surgery, if the cancer is invading the retroperitoneum, or if the patient has severe diverticulitis.
Transection of bowel
Once the sigmoid colon and the descending colon are completely mobilized, the proximal point of bowel transection is selected. Usually, this point lies at the junction between the descending colon and the sigmoid colon, which can be identified by visualizing the ascending branch of the left colic artery.
In patients with a thickened colonic mesentery, such visualization may not be possible. In such instances, care must be taken to remove the sigmoid colon entirely and fashion the colostomy with the descending colon. Failure to do so may put the patient at risk for recurrent diverticulitis in the remaining segment of sigmoid colon.
The descending colon is then divided with a linear cutting stapler. The sigmoid vessels are divided up to the rectosigmoid junction. The rectum is identified and differentiated from the sigmoid colon by the loss of the taeniae coli. The rectum is then similarly divided through healthy tissue with a linear stapler.
The most common cause of recurrent diverticulitis after sigmoidectomy is incomplete resection of the sigmoid colon at its proximal or distal margin. Once again, every attempt should be made to identify the rectum and make sure that the distal transection is done at this level.[8, 9, 10]
Creation of colostomy
The next step is to create the colostomy. Only about 50-60% of colostomies are taken down at a later date. Accordingly, care must be taken in the creation of the colostomy. The colostomy must function optimally and must be capable of remaining in place for a long time without giving rise to complications.
Colonic mobilization at this point should be sufficient to allow bringing up a segment of descending colon about 2-3 cm above the skin, without any tension. More extensive mobilization is not desirable, because it may result in a redundant stoma and an increased risk of prolapse or parastomal hernia.
At the authors' institution, the preferred technique is to place a Kocher clamp in the fascia and another one in the dermis at the level of the colostomy site, which ideally has been marked preoperatively. The surgeon, holding a folded laparotomy sponge in the palm of the nondominant hand, presses the sponge against the parietal peritoneum at this level and retracts the skin by holding the Kocher clamps with the same hand.
A 3-cm circular disk of skin is then removed at the colostomy site. Next, a longitudinal incision is made through the subcutaneous fat to expose the rectus sheath. The rectus sheath is incised longitudinally, and the muscle is bluntly split to expose the posterior sheath and peritoneum. At this point, the laparotomy sponge is visible under the peritoneum.
The peritoneum is opened with the electrocautery; the laparotomy sponge prevents injury to the abdominal contents. The defect created should be large enough to accommodate two fingers. A Babcock clamp is advanced through the skin incision and into the abdominal cavity, then used to grasp the stapled proximal bowel. The stapled bowel is brought out through the abdominal wall, with care taken to ensure that it is not twisted or under tension.
Closure and stoma maturation
The midline incision must be closed before the colostomy is matured. The fascia is closed with a looped polydioxanone suture. The ideal ratio of suture length to wound length ratio is 4:1; smaller ratios may result in failed closure. A good way to ensure having enough suture is to use two sutures, one starting from the superior portion of the wound and the other from the inferior aspect. The two sutures meet in the middle of the wound, ensuring adequate length and avoiding the use of a short suture at the distal end of the incision.
The midline incision is then protected with a towel or laparotomy pad while the stoma is matured. The staple line is excised from the stoma. Four stitches are placed, one at each aspect of the stoma (superior, inferior, lateral, and medial). The stitches consist of a full-thickness bite of bowel and a full-thickness bite of skin. The objective in creating a colostomy, as opposed to an ileostomy, is not to evert the bowel but to leave it flush against the skin. The skin is then closed with skin staples, and an ostomy appliance is placed over the colostomy.
Although a Hartmann procedure is a relatively low-risk operation, complications are inevitable. Potential complications include the following:
Wound infection (most common)
Rectal stump leak
Abscesses around the rectal stump
Fistula from the rectal stump to the bowel
Retraction of the colostomy
Skin irritation around the colostomy
General consequences that may occur with any operation (eg, bleeding, damage to surrounding structures, and cardiopulmonary complications)
Mortality is estimated to be about 13% if purulent peritonitis is present and may be as high as 43% if feculent peritonitis is present.[12, 13, 14]
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