Open Hartmann Procedure Technique

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. ^[15]

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. ^[15]

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. ^{[16, 17]}

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. ^[18]

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 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. ^[15]

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
• Parastomal hernia ^[19]
• Skin irritation around the colostomy
• Paralytic ileus
• Wound dehiscence
• Ureteral injury
• 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. ^{[20, 21, 22]}