03 / Colorectal Surgery · open

Hartmann's procedure

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.

Part of Colorectal Surgery →4 stages4 complications to knowopen

Read the imaging first

On the tray for this operation

Test yourself on the tray

Stage

1 / 4

Laparotomy 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.

🔧 Scalpel 🔧 Richardson retractor 🔧 Yankauer suction

Watch for: Missed second perforation · Underestimated contamination

Why are we operating?

Hartmann's procedure resects the diseased sigmoid and deliberately does not restore continuity: the rectal stump is closed, the colon comes out as an end colostomy, and the join that would have leaked in a contaminated abdomen is never made. It is the operation of purulent and faeculent peritonitis, of obstruction in the unstable, and of the principle that continuity is a luxury bought with physiology.

Pulls toward surgery

Perforated diverticulitis with peritonitisObstructing sigmoid cancer in the unstableContaminated fields forbidding a joinPhysiology that cannot fund an anastomosis

Gives the team pause

The stable patient who could have a defended primary joinReversal realism: a third are never reversedStoma siting forgotten in the emergency

Shared foundations

Embryological planes & mesenteric envelopes

The idea that made colorectal cancer surgery an oncologic discipline: the gut grew inside mesenteric envelopes, and dissecting the bloodless plane around an intact envelope removes the cancer with its lymphatic field. Total mesorectal excision is this idea applied to the rectum; every colonic resection is the same idea at a different address.

Understand it once, in the specialty hub

Stomas: formation, function, life

Half the specialty's operations create, protect or reverse a stoma: what they are for, how they differ, and what living with one asks of a patient.

Understand it once, in the specialty hub

What the surgeon is thinking

Laparotomy and assessment
What is being decided during the first look?
The contamination's grade and the patient's reserve, because together they choose between Hartmann's, a defended join, and damage control: the operation's name is picked here, not in the theatre listing. Purulent versus faeculent peritonitis and the pressor requirement are the vocabulary of that decision.
Sigmoid resection
Why resect rather than simply wash and drain?
The perforated segment is the source, and source control is the operation's entire curative content: washing around a hole in the colon treats the symptom of contamination while the cause keeps publishing. The resection follows the same mesenteric logic as any sigmoid colectomy, abbreviated by urgency.
The rectal stump
What does the rectal stump need, and why is it a named step?
Secure closure and a recorded length: the stump's blow-out is a real early complication, and its identification is the hardest part of the eventual reversal. Some surgeons tag it with long sutures as a letter to the future operator, which is exactly the right way to think about it.
End colostomy
What makes a good end colostomy in an emergency?
Site, spout and supply: through the rectus at a site the patient can see and seal (marked pre-operatively whenever the emergency allowed), without tension, and pink at the mucosa. The stoma is the patient's daily experience of this operation for months or forever; five extra minutes here outvalue most other refinements.

Decision points

This patient has stabilised beautifully on the table. Convert the plan to resection with primary anastomosis?
- Stay with Hartmann's
  Faeculent contamination, immunosuppression or shaky physiology: the no-join decision stands even when the numbers flatter.
- Primary anastomosis with defunctioning stoma
  For genuine stability and limited contamination: spares the Hartmann's-reversal mountain, accepts a defended leak risk.
The intraoperative improvement is partly the resuscitation talking: the decision reads the whole story, including what the physiology looked like an hour ago. Both plans are defensible; drifting between them without a reason is not.
Months later: reverse the Hartmann's or leave it?
- Reversal
  A real operation with its own leak and complication rates, into a pelvis that remembers the peritonitis: for the fit and motivated.
- Leave the colostomy
  For the frail, the comorbid, or the content: a permanent stoma managed well is a legitimate outcome, not a failure.
About a third of Hartmann's stomas prove permanent, and the honest version of that statistic belongs in the first consent conversation: 'temporary' is a hope with a denominator, not a promise.

Leaving the OR

The handoff

Procedure: Hartmann's procedure for perforated sigmoid diverticulitis, purulent peritonitis
Stump: Stapled, oversewn, tagged; length recorded in the note
Stoma: End colostomy, left iliac fossa, spouted and pink
Physiology: Lactate falling, low-dose noradrenaline, washout completed
Watch for: Stoma viability first 48h, pressor trajectory, day 5 collection window

A fictional educational patient, handed over the way real ones are.

The postoperative course

POD 0-1ICU trajectory watching: the operation's success is read in lactate and pressors, and the stoma checked with a light, not a glance.
POD 2-4Stoma starts working; the teaching starts with it, since the patient goes home only when the bag holds no fear.
POD 5-7The collection window in a washed but once-contaminated abdomen: swinging fever means CT and usually a drain.
MonthsThe reversal conversation, held honestly against fitness and desire; colonoscopy of the remaining colon completes the cancer-exclusion housekeeping where diverticulitis was the diagnosis.

Watch it done

Hartmann's procedure explained
Sigmoid resection, rectal stump and end colostomy, and the reversal that may or may not follow.
Source: School of Surgery · Watch on YouTube
Diverticulitis: Hartmann's procedure, or is a washout all you need?
The evidence on laparoscopic lavage versus resection for perforated diverticulitis.
Source: SAGES · Watch on YouTube

Find Hartmann's procedure videos on YouTube

What can go wrong

Surgical-site infection Intra-abdominal abscess Postoperative ileus Postoperative bleeding

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