Open Hartmann Procedure

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]

Complicated diverticulitis

Currently, the most common indication for an open Hartmann procedure is complicated diverticulitis (see the images below), ^[3] though there has been increasing interest in minimally invasive alternatives in this setting. ^{[4, 5, 6]} 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. ^[7]

The wide spectrum of symptoms associated with diverticulitis has led to the formation of the Hinchey classification system. ^[8]  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
• Stage IV - Diverticulitis with fecal 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 most recent attack.

The Hartmann procedure has generally been considered the preferred treatment for Hinchey stages III and IV. However, in a systematic review and meta-analysis comparing outcomes of the Hartmann procedure versus primary resection anastomosis (PRA) for the treatment of Hinchey III and IV diverticulitis, Halim et al found that PRA may be associated with a lower overall mortality, though not with any significant difference in wound infection rates. ^[9] Both surgical strategies appeared to be acceptable in this setting.

In a multicenter randomized open-label superiority trial that included 133 patients (age range, 18-85 y) presenting with clinical signs of general peritonitis and suspected perforated diverticulitis, Lambrichts et al compared the outcomes of the Hartmann procedure (n = 68) and sigmoidectomy with primary anastomosis (n = 65). ^[10] ​ They found that for hemodynamically stable immunocompetent patients younger than 85 years, primary anastomosis was preferable to the Hartmann procedure as a treatment for perforated diverticulitis (Hinchey III or Hinchey IV disease).

In a study assessing the Hartmann procedure (n = 4482) against primary anastomosis and diverting ileostomy (n = 642) for the treatment of perforated diverticulitis, Lee et al found no differences in in-hospital mortality or morbidity between the two operations but noted that the Hartmann procedure was associated with a shorter postoperative length of stay and a lower total admission cost. ^[3]

Rectosigmoid cancer

The next most common indication for a Hartmann procedure is rectosigmoid cancer. The following scenarios of rectosigmoid carcinoma may warrant performing the Hartmann procedure:

• Emergency - Management of obstruction, perforation, or bleeding
• Elective - Cure, palliation, or anticipation of impending obstruction

A multicenter nonrandomized prospective cohort study of 179 patients with low rectal cancer who were treated with either the Hartmann procedure or intersphincteric abdominoperineal excision (IAPE) found that overall complication rates were high with both procedures but that surgery-specific complication rates were not significantly different between the two. ^[11] ​ IAPE was associated with a higher incidence of serious medical complications (16% vs 5%) and poorer 90-day quality-of-life (QoL) scores.

Other indications

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, idiopathic myointimal hyperplasia of the mesenteric veins, ^[12] or pneumatosis cystoides. ^[13]

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:

• Hypotension
• Renal failure
• Diabetes
• Malnutrition
• Immune compromise
• Ascites

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.

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. ^[14]  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. ^[14]  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%.

Gentile et al studied 30 elderly patients with Hinchey grade II-III acute diverticulitis, of whom 14 (mean age, 62.6 y) underwent laparoscopic lavage and drainage (LLD) and 16 (mean age, 64.8 y) underwent the Hartmann procedure. ^[15] 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. ^[16]

Loire et al analyzed long-term (median, >9 y) outcomes and QoL in patients previously enrolled in the DIVERTI study, a prospective randomized trial that compared the Hartmann procedure with PRA for generalized peritonitis due to perforated diverticulitis. ^[17]  PRA was associated with fewer long-term complications and better QoL, and it significantly reduced the incisional hernia rate and the need for reoperation without jeopardizing long-term survival.

In a retrospective study that included 102 patients with sigmoid volvulus who were treated with either the Hartmann procedure (n = 56) or resection and primary anastomosis (n = 46), Kazem Shahmoradi et al found that postoperative complications and mortality did not differ significantly between the two treatment groups, though the Hartmann procedure was associated with a shorter duration of hospitalization. ^[18]