Hartmann's procedure

Why are we operating?

Resection of the diseased sigmoid with an end colostomy and a closed rectal stump: the operation for the perforated, obstructed or unstable left colon where an anastomosis would be a gamble.

Indication: Perforated diverticulitis with peritonitis, obstructing sigmoid cancer in an unstable patient, and sigmoid volvulus with compromised bowel.

The operation in 4 steps

1. 01Laparotomy and assessment

   Midline laparotomy, washout of contamination, and an honest assessment: the state of the sigmoid, the degree of peritonitis, and the physiology on the anaesthetist's screen.

2. 02Sigmoid resection

   The sigmoid is mobilised off the retroperitoneum, the mesentery taken with clamps and ties, and the diseased segment removed between proximal division and the upper rectum.

3. 03The rectal stump

   The upper rectum is closed with staples or sutures and left in the pelvis, sometimes with a marking suture for the surgeon who will one day reverse this.

4. 04End colostomy

   The proximal colon is brought out through the rectus at a site marked pre-operatively where possible, opened, and matured with sutures to the skin.

Danger zones

• Left ureter

  In inflammation or bleeding the retroperitoneal planes close up, and the ureter's peristalsis, its one identifying trick, is easy to miss in a hurried field.

Anatomy you need

The sigmoid and upper rectum this operation removes and closes; the left ureter crosses beneath exactly where the mesocolon is divided.

What can go wrong

• Surgical-site infection

  Wound erythema, warmth, discharge, and pain out of proportion, typically from postoperative day 4–7.

• Intra-abdominal abscess

  Swinging fevers, malaise, and localized pain from day 5 onward, classically after perforated appendicitis.

• Postoperative ileus

  Distension, absent flatus, intolerance of diet, and quiet bowel sounds in the days after abdominal surgery.

• Postoperative bleeding

  Tachycardia first, hypotension late; falling urine output; a distending abdomen or rising drain output.