Journal of Visceral Surgery (2016) 153, 31—38

Available online at

ScienceDirect
www.sciencedirect.com

REVIEW

Current indications for the Hartmann

procedure
J. Barbieux ∗, F. Plumereau , A. Hamy

Service de chirurgie viscérale et endocrinienne, CHU d’Angers, 4, rue Larrey,

49100 Angers cedex 1, France

Available online 8 February 2016

KEYWORDS Summary The Hartmann procedure is used in the case of left-sided colonic disease, especially
Hartmann procedure; in the setting of emergency where intraoperative conditions contraindicate completion of an
Peritonitis; anastomosis. This procedure has been initially described for the management of colorectal
Restoration of cancer and is based on a sigmoïdectomy without restoration of intestinal continuity, including a
intestinal continuity left-sided iliac terminal stoma and closure of the rectal stump. Both procedure and underlying
risk factors explain high rates of mortality and morbidity, around 15 and 50% respectively, and a
low overall rate of subsequent restoration of internal continuity, less than 50%. The purpose of
this review was to evaluate the value of the Hartmann procedure and its equivalents in colonic
surgery, according to its indications: colorectal cancer, peritonitis from diverticular disease,
anastomotic complications, ischemic colitis, left-sided colonic volvulus and abdominal trauma.
© 2016 Elsevier Masson SAS. All rights reserved.

Introduction
The Hartmann procedure was first described in 1923 by Henri Albert Hartmann (1869—1952)
for the management of colorectal cancer [1]. It consists of a sigmoid colectomy without
restoration of intestinal continuity; an end colostomy is brought out in the left lower
quadrant and the rectal stump is closed. The objective of the Hartmann procedure was to
reduce the morbidity and mortality of sigmoid colectomy for cancer, especially by avoiding
colorectal anastomosis [2]. By extension, this use has gradually been extended to other
left colon pathologies, especially in the emergency setting, where perioperative condi-
tions contraindicate the performance of a colorectal anastomosis. This procedure is fast,
simple and effective, and preserves the possibility of an eventual restoration of intesti-
nal continuity. It is most often performed in the emergency setting when patient condition
(hypotensive shock, need for damage-control laparotomy, ASA IV patients) or the condition

∗ Corresponding author.
E-mail address: julienbarbieux@hotmail.com (J. Barbieux).

http://dx.doi.org/10.1016/j.jviscsurg.2016.01.002
1878-7886/© 2016 Elsevier Masson SAS. All rights reserved.
32
of intestinal tissue (severe inflammation, colonic obstruc-
tion with distension) makes the intervention difficult and
increases the risk of postoperative complications [3]. In
practice, the rate of restoration of intestinal continuity after
Hartmann procedure remains low at less than 50% [2]. In
fact, restoration of continuity has its own morbidity, which
limits the indications; the mortality rate is close to 2% and
morbidity is about 30% [4]. The objective of this review is
to clarify the place of the Hartmann procedure in current
practice of colonic surgery, based on a comprehensive lit-
erature search of the term, ‘‘Hartmann procedure’’, and
analyzing all the series published in the last 20 years that
included more than 10 patients, according to the surgical
indications.
Hartmann Procedure for Colorectal Cancer
The Hartmann procedure was first described for the treat-
ment of colorectal cancer with obstruction [1]. Since then,
its indication for cancer has become limited (Table 1).
For scheduled cancer surgery, the use of the Hartmann
procedure has become rare. Its indications are now well
defined: cases of cancer of the colon and upper rectum with
stricture or preocclusion but without signs of complication
(perforation, parietal guarding, small bowel incarceration),
palliative situations in patients with serious comorbidities or
preexisting anal incontinence (with the alternative of endo-
scopic placement of an endoprosthesis for this indication)
[5].
In the management of left colon obstruction, the role of
the Hartmann procedure remains controversial. The French
recommendations propose an initial diverting stoma allow-
ing completion of diagnostic work-up, followed by early
single-stage resection and anastomosis [6]. The recom-
mendations of the ‘‘World Society of Emergency Surgery’’
advocate the Hartmann procedure for high-risk patients (as
an alternative to diverting colostomy), citing the advantage
of a shorter overall hospitalization period [7]. The study by
Krstic et al., comparing the Hartmann procedure vs. divert-
ing colostomy, found that the only significant difference
was a longer hospital stay after diverting colostomy with
second-stage resection/anastomosis during the same hospi-
talization [8]. Chéreau et al. reported more complications in
patients treated with the Hartmann procedure, despite ASA
scores similar to those of patients treated with diverting
colostomy. However, in this series, the Hartmann procedure
was preferred for cases of complicated colonic obstruction
with perforation, which can constitute a significant bias [9].
The registry study by Kube et al. highlighted that resec-
tion/anastomosis with a proximal protective stoma had the
same spectrum of complications as the Hartmann proce-
dure, with a trend to more frequent systemic complications
after Hartmann procedure, and a comparable rate of early
reintervention [10].
The choice of therapeutic strategy should also take into
account the prospect of adjuvant chemotherapy, particu-
larly in patients with synchronous liver metastases. The
choice of surgical intervention should not delay this systemic
management [9].
Overall, poor general condition (hypotensive shock at the
time of surgery, severe comorbidity, and advanced age (mak-
ing the likelihood of any eventual reoperation for colectomy
unlikely), or local complications (associated peritonitis) may
contribute to making the Hartmann procedure the preferred
or necessary surgical choice. Among the other options,
J. Barbieux et al.
initial decompressive colostomy followed by second-stage
resection/anastomosis, or resection/anastomosis with a
protective proximal stoma may be applicable to obstructed
colorectal cancer when conditions are more favorable
although each option has its own specific advantages and
disadvantages [11].
When colorectal cancer is treated by the Hartmann pro-
cedure, restoration of intestinal continuity seems to be
infrequent: in the series by Chéreau et al., fewer than 40% of
patients with obstructed left colon cancer eventually under-
went reversal and reanastomosis, but this series included
only 11 patients [9]; other series in the literature are silent
on this point [8,10].
Hartmann Procedure for perforated
diverticulitis with peritonitis
The management of peritonitis associated with sigmoid
diverticulitis has recently evolved, particularly since the
advent of laparoscopy. The Hartmann procedure remains
the simplest but most radical intervention; other options
have been described such as resection/anastomosis with or
without protective stoma [3], or laparoscopic lavage and
drainage [12]. The meta-analysis by Cirocchi et al. pub-
lished in 2013 noted the heterogeneity of management
strategies despite a large literature on the subject, mak-
ing it difficult to create a decision tree [13]. Laparoscopic
lavage and drainage for complicated diverticulitis was first
described by O’Sullivan et al. in 1996 [12]. This approach is
contra-indicated in cases of fecal peritonitis, hemodynamic
instability, or demonstration of uncontained perforation at
surgery [3,13]. When confronted with these clinical find-
ings, conversion to open laparotomy with performance of
a Hartmann procedure is recommended [3]. In a Dutch
meta-analysis published in 2010, the rate of failure for
lavage and drainage was 4.3% [14]; mortality and morbid-
ity of this procedure were 0—7.7%, and 2—11% respectively
[14,15].
Laparoscopic lavage and drainage has been considered
an appropriate option for Hinchey II complicated diver-
ticular disease that is not amenable to radiology-guided
drainage or for Hinchey III peritonitis in a hemody-
namically stable patient [16]. However, these indications
for laparoscopic lavage and drainage are controversial
because of the significantly higher rate of reopera-
tion (20%) during the initial hospitalization compared to
immediately sigmoidectomy [17,18]. Overall, Hartmann’s
intervention would be most appropriate for Hinchey II
disease that is not amenable to radiologic drainage or
for Hinchey III peritonitis in a hemodynamically stable
patient.
For purulent peritonitis, the possibility of single-stage
resection/anastomosis has also been supported. The meta-
analysis by Cirocchi et al. showed that the overall mortality
rate was significantly lower after resection/anastomosis vs.
the Hartmann procedure [13]; however, in terms of reopera-
tion for complications, no significant difference was found
between the two techniques [13]. Mueller et al. concluded
that anastomotic leakage after initial resection/anastomosis
was more often associated with a high ASA score than with
the Hinchey stage per se [19].
In addition to the Hinchey classification, the choice of
surgical technique must take into account the patient’s
general comorbidities. Currently, the World Society of
Current indications for the Hartmann procedure 33

Table 1 Rates of morbidity, mortality and restoration of intestinal continuity from the principal series of Hartmann
procedures, classified according to the operative indications.
Indication Authors—Year [ref] Number of % Morbidity % Mortality % Rate of
for surgery interventions (number of (number of restoration of
patients) patients) continuity
(number of
patients)
Cancer
Chereau et al. — 2013 11 55% (6) 27% (3) 36% (4)
[9]
Krstic et al. — 2014 [8] 46 23% (11) — —
Kube et al. — 2014 [10] 226 36% (82) 7% (16) —
Diverticular
peritoni-
tis
Angenete et al. — 2014 36 53% (19) 11% (4) —
[15]
Binda et al. — 2012 [22] 56 46% (26) 11% (6) 61% (34)
Cirocchi et al. — 2013 246 — 22% (54) —
[13]
Dumont et al. — 2005 85 51% (43) 14% (12) 77% (54)
[25]
Gentile et al. — 2014 16 31% (5) 25% (4) 63% (10)
[16]
Jaffergi et al. — 2014 74 — 31% (23) —
[21]
Mueller et al. — 2011 26 46% (12)a 27% (7) —
[19]
Oberkofler et al. — 30 57% (17)a 13% (4) 57% (17)
2012 [23]
Trenti et al. — 2011[27] 60 87% (52) 45% (27) 27% (9)
Anastomotic
leak
Maggiori et al.—2011 3 — — 0% (0)
[31]
Parc et al. — 2000 [35] 22 — 13% (3) 42% (8)
Ischemic
colitis
Moszkowicz et al. — 81 — — 33% (27)
2013 [41]
O’Neil et al. — 2012[39] 11 — — 72% (8)
Sigmoid
volvulus
Raveenthiran et al. — — 25—50% — —
2010 [51]
Abdominal
trauma
Demetriades et al. — 100 27% (27) 4% (4) —
2001 [53]
a Major complications only.

Emergency Surgery recommends the Hartmann proce-
dure for diverticulitis with purulent or fecal peritonitis
or in patients with a poor prognosis, whereas resec-
tion/anastomosis or lavage/drainage is recommended for
patients without poor prognostic factors [20]. Advancing
age leads to a decrease in immune function and therefore
could increase the risk of sepsis [21]. This accounts for the
reluctance of surgeons to perform anastomosis in elderly
patients with peritonitis. The overall general condition is
also important because, patients with numerous or severe
comorbidities are exposed to an increased risk of anastomo-
tic leakage [19].
In patients with Hinchey III or IV peritonitis, the
Hartmann procedure has been compared to initial resec-
tion/anastomosis with a protective ileostomy [22,23]. Binda
et al. conducted a randomized trial that has included the
largest number of patients (n = 90) to date [22]. Initial results
found no difference in mortality and morbidity between the
two procedures. However, this study could not be completed
because a lack of inclusions, making its findings statistically
34
non-significant due to a lack of power. Oberkofler et al. con-
ducted a similar study [23]: after the initial intervention,
there was no statistically significant difference in mortality
or morbidity, but when results of the second intervention
to restore continuity were included, there were fewer seri-
ous complications (Dindo-Clavien IIIb or IV) and a higher
recovery rate for the resection/anastomosis with protective
ileostomy arm compared to the Hartmann procedure arm
[23]. Of note, these results have been strongly criticized
from a methodological point of view [24].
Finally for patients with diverticulitis and Hinchey III
peritonitis, initial resection/anastomosis is preferable if the
patient’s hemodynamic status and comorbidities allow. For
Hinchey IV peritonitis, anastomosis/resection with protec-
tive ileostomy for patients without comorbidity is more
debatable. In this setting, the Hartmann procedure remains
a simple, fast technique that is within the technical mastery
of all surgeons. Indeed, the professional experience of the
surgeon performing colorectal surgery also influences the
frequency of protected resection/anastomosis vs. Hartmann
procedure [21].
The mortality following a Hartmann procedure for peri-
tonitis due to diverticulitis remains high (Table 1). In a
retrospective descriptive study of patients operated on
between 1992 and 2002, Dumont et al. reported a 14% mor-
tality rate [25], with an early morbidity of 51%, 28% of which
were from surgical complications (abscess — 14%, stomal
complications — 6%) and 33% from medical complications.
Late posthospitalization morbidity was also high: 29%, 12%
of which were stomal complications and 7% bowel obstruc-
tion. In this retrospective study, the only significant risk
factor for morbidity by multivariate analysis was an ASA
score ≥ 3. The clinical picture (age and comorbidities) con-
tributes to or causes any or all of these complications. The
role of the surgical approach has not been extensively stud-
ied since laparotomy is almost the universal approach in the
emergency setting. However, Turley et al. recently proposed
laparoscopic Hartmann procedure for diverticular peritoni-
tis. Using a propensity score, they could not identify any
difference in morbidity or mortality between laparoscopy
and laparotomy [26].
The rate of restoration of continuity after Hartmann pro-
cedure for peritonitis due to diverticulitis is rather low
(Table 1). In the study by Trenti et al., it was only 27% after a
mean follow-up of 76 months [27]. The study by Binda et al.,
the general morbidity rate for surgery to restore continuity
was almost significantly higher (P = 0.058) after Hartmann
procedure (24%) than when closing a protective ileostomy
(5%) [22]. In this study, there was no significant difference in
terms of stomal closure rate and anastomotic leakage rate.
In contrast, for Oberkofler et al., there was a significant
difference in stomal closure rate (P = 0.012) favoring the
performance of initial colectomy/anastomosis protected by
ileostomy (90%) vs. the Hartmann procedure (58%) [23]. The
French series by Dumont et al. found a 77% rate of restora-
tion of continuity with an overall hospital morbidity of 13%
[25]; in this study, age > 75 years and an ASA score ≥ 3 at
the first intervention were predictors of non-restoration of
intestinal continuity [25].
In sum, for peritonitis due to perforated diverti-
culitis, the Hartmann procedure is recommended for
Hinchey stage IV peritonitis [28]. For Hinchey III peritoni-
tis, literature studies favor performance of a Hartmann
procedure in patients who have severe life-threatening
sepsis, and for patients with severe comorbidities that
increase the risk of anastomotic leakage [20]. The
J. Barbieux et al.
expected rate of restoration of continuity approaches 70%
[16,22,23,25].
Hartmann procedure and anastomotic
complications
The Hartmann procedure may also be indicated to treat
postoperative complications of colorectal anastomoses: this
indication ranks second in the series by Garber et al. [4] and
fourth in the series by Seah et al. [29]). In elective rectal
surgery, the rate of anastomotic leakage has been esti-
mated to range from 1 to 24% [30,31]. Several studies have
reported a lower rate of symptomatic anastomotic leakage
when a protective stoma was present, allowing avoidance of
a Hartmann procedure in most cases of anastomotic leakage
[32—34]. However, in case of full anastomotic disruption or
ischemia of the mobilized left colon, the Hartmann proce-
dure remains the only possibility.
It is preferable to conserve the anastomosis if local and
general conditions permit, since restoration of continuity
after reoperative rectal surgery can be difficult (Table 1)
[35]. Maggiori et al. reported a series of 11 patients with
anastomotic leakage following low colorectal or coloanal
anastomosis who required reoperation. [31]. Three of these
11 reoperated patients underwent a Hartmann procedure
and none have had restoration of continuity. The height of
the initial anastomosis also seems to influence the rate of
restoration of continuity. Parc et al. have published a series
of 19 patients who had undergone a Hartmann procedure
following anastomotic leakage with peritonitis; restoration
of continuity was not possible in eight of these patients.
Seven of these eight patients had had undergone a low ante-
rior rectal resection [35]. Overall, following anastomotic
fistula complicating rectal surgery, 3—19% of patients did
not undergo restoration of continuity [36,37].
In case of chronic fistula or colovaginal fistula that per-
sists despite creation of a protective stoma, surgical options
are takedown of the anastomosis and performance of the
equivalent of a Hartmann procedure or alternatively, perfor-
mance of an anastomotic repair using the Beaulieu or Soave
technique [38]. The overall clinical picture and the func-
tional outcome of this reintervention must be considered
when deciding on the therapeutic strategy. The Hartmann
procedure is faster and its postoperative sequelae are sim-
pler while protecting the patient from recurrent fistula or
complications of incontinence.
Hartmann procedure and ischemic colitis
For patients with ischemic colitis in the emergency setting,
the Hartmann procedure is an alternative for management,
but the indications for this procedure are not exclusive.
The depth of extension of ischemia, the extent of colonic
involvement, and also the impact on the patient’s general
condition should be considered when choosing a medical or
surgical therapeutic strategy. Indeed, medical treatment is
sufficient in 80% of cases [39]. When signs of irreversible
colon ischemia (portal venous air, pneumatosis intestinalis)
or complications (pneumoperitoneum) are present on the
initial imaging study, surgery is indicated. Endoscopic assess-
ment showing a Favier Class 3 or a Favier Class 2 with
failure of medical treatment should lead to surgery [40,41].
There is no agreement regarding the time interval between
the inception of medical treatment and the evaluation
Current indications for the Hartmann procedure
of its effectiveness: Virdis et al. have proposed an inter-
val of 48—72 h for Favier Class 2 to prevent worsening to
Class 3, which increases the risk of postoperative morbid-
ity and mortality [42]. During surgery, it is fundamental to
explore the entire colon with palpation of mesenteric arte-
rial pulses, wherever possible. Thus, any colonic segment
that is edematous, purplish, thickened or otherwise atonic
must be treated by resection. A serosa that is macroscop-
ically healthy-appearing does not necessarily equate to a
well-vascularized colonic segment. Indeed, ischemia can be
far more advanced at the mucosal level than is apparent
from the appearance of the serosa; for this reason, the per-
formance of an anastomosis is contra-indicated [43]. The
goal of the resection is to divide the bowel at a level where
there is healthy arterial supply with good submucosal bleed-
ing. There is no simple way to assess the colonic tissue
vascularization [41,44] in this urgent setting. In cases of
ischemic colitis, Moszkowicz et al. in 2014 identified two
risk factors for mortality by multivariate analysis: age > 75
years and the presence of multiple organ failure [45]. Note
that a cholecystectomy should also be performed to pre-
vent the risk of acute acalculous cholecystitis that might
require a second surgery in a frail, unstable patient, increas-
ing the already considerable perioperative risk [46]. When
surgery is indicated for ischemic colitis, the prognosis is
poor with a mortality rate of approximately 40% (Table 1)
[39].
The rate of restoration of continuity after Hartmann pro-
cedure for ischemic colitis is estimated at 40%; the series of
Mariani et al. could identify no predictive factor [47].
In their series, the mortality was zero but the morbid-
ity was 45% (mainly due to medical or cardiopulmonary
problems) (11/24 patients). Restoration of continuity was
achieved at a mean interval of eight months (range 0.2 to 35)
after the initial intervention. In comparison to restoration
of continuity after Hartmann procedure for other etiolo-
gies, this longer interval is partly explained by the need
for concurrent management of cardiovascular comorbidities
in these patients. The 5-year recurrence rate of ischemic
colitis is estimated at 10% [41].
In conclusion, when confronted with Favier Class 3
ischemic colitis or Class 2 with unfavorable progression,
the Hartmann procedure is indicated and colonic resection
should include all hypovascularized colonic segments.
Hartmann procedure and sigmoid volvulus
Colonic volvulus is the third leading cause of colonic obstruc-
tion, most frequently involving the sigmoid colon [48]. The
probability of spontaneous detorsion is estimated at only 3%
[49]. The current management therefore usually includes
an initial attempt at detorsion followed by a procedure to
prevent recurrent volvulus. Detorsion is performed endo-
scopically, followed by placement of a large-bore rectal
tube to prevent early recurrence. Endoscopic detorsion is
successful in an estimated 79% of cases [49] with, how-
ever, a 40—90% risk of recurrent volvulus [50]. Emergency
surgery is recommended in case of shock, if perforation
is suspected, if endoscopic detorsion fails or reveals pro-
found ischemia. When surgery is indicated, the two options
are resection/anastomosis or a Hartmann procedure. The
Hartmann procedure is indicated for colonic ischemia with
fecal peritonitis, or when the patient’s general condition is
poor with hemodynamic instability [49]. Currently, resec-
tion/anastomosis is feasible in most cases [51]. Liang et al.
35
showed that a laparoscopic intervention is feasible once
laparoscopic colonic decompression has controlled abdom-
inal distension and minimized the risk of intestinal injury
[52]. To our knowledge, there are no studies comparing
surgical techniques for treatment of sigmoid volvulus. The
overall mortality of surgery for sigmoid volvulus is estimated
at 10% [50]. When surgery can be performed electively to
prevent recurrence after detorsion, resection with anasto-
mosis is indicated. Sigmoidopexy and meso-sigmoidoplasty
are no longer performed since they are associated
with recurrence rate as high as 80% in the literature
[49].
The Hartmann procedure, therefore, has only a limited
place in the management of uncomplicated sigmoid volvu-
lus. If a Hartmann procedure is performed, restoration
of continuity should be decided on a case-by-case basis
depending on the overall patient condition and postopera-
tive course. The literature does not allow specific analysis
of the results of restoration of continuity after Hartmann
procedure for sigmoid volvulus.
Hartmann procedure and abdominal
trauma
Abdominal and perineal trauma, whether civilian or military,
may give rise to situations where the Hartmann procedure
could be indicated. This is an uncommon etiology accounting
for less than 1% of indications [29]. Demetriades et al., com-
pared immediate restoration of continuity vs. the Hartmann
procedure for left colon trauma, and could find no signif-
icant difference in terms of postoperative complications
[53]. Fecal contamination, transfusion ≥ 4 units of red blood
cells during the first 24 h and antibiotic monotherapy were
independent risk factors for complications in this study.
The authors therefore concluded that one-stage resec-
tion/anastomosis was preferable to the Hartmann procedure
[53].
In the management of severe abdominal and perineal
trauma, ‘‘damage control’’ should be a priority. If necessary,
sigmoid resection can be performed at a first laparotomy
with performance of a definitive diverting ostomy as a sec-
ond surgical step, once the patient’s condition is stabilized
[54]. A study by Ott et al. showed that the open abdomen
was a significant independent risk factor for anastomotic
leakage [55]. Only the etiology of trauma, and whether the
patient’s condition is stable or unstable define the choice of
therapeutic action in case of abdominal or perineal trauma.
Surgery, according to the principles of ‘‘damage control’’
laparotomy should minimize the delay before full resuscita-
tion and reanimation can proceed to correct the patient’s
instability.
The Hartmann procedure and restoration
of intestinal continuity
The median rate for restoration of continuity after a Hart-
mann procedure is 44% for all etiologies combined (19—71%)
[2]. Median time interval to restoration of continuity is
5—7 months [2,4,25]. In a British cohort, this period was
more heterogeneous and even shorter in case of benign
initial conditions (9.2 months versus 12.6 months for can-
cer), but the cancer patient’s need to undergo postoperative
adjuvant systemic chemotherapy often leads to delay in the
second-stage restorative surgery [56].
36
The choice of interval is a major dilemma. Indeed,
extending the deadline allows tissues to heal after the ini-
tial intervention and for underlying inflammation to subside
in sigmoid diverticulitis, but also allows the rectal stump
to atrophy making it more difficult to localize and dissect
out during the second intervention, thereby increasing the
risk of injury during the pelvic dissection [57]. It may be
necessary to freshly divide the rectal stump when local
inflammation makes surgical approach difficult. A fresh divi-
sion of the rectal stump may be necessary if rectal stricture
prevents insertion of the circular stapler from below or
when the stump is injured during dissection. Antolovic et al.
found a 3% risk of ‘‘technical’’ intraoperative complications
(ureteral and bladder lesions) [58]. On the other hand, too
short an interval may lead to an intervention in an inflam-
matory setting with increased risk of visceral injury due to
tissue fragility and adhesions as well as increased blood loss
and transfusion needs. To facilitate eventual reanastomosis
after diverticulitis with peritonitis, Garancini et al. proposed
suspending the rectal stump, by placing two tension-free
sutures of non-absorbable suture into the presacral fascia
next to the sacral promontory and leaving the suture ends
long [59]. During surgery to restore continuity, this should
help prevent atrophy of the stump and retraction down
into the pelvis, thereby minimizing the risk of urinary tract
injury during dissection. Moreover, transanal dilators can be
inserted and the bladder can be distended with saline to
facilitate identification of the rectal stump.
The main difficulty regarding restoration of continuity is
careful weighing of the indications. Factors favoring a choice
not to restore continuity are an elevated ASA score ≥ III,
age > 75 years, the presence of metastatic cancer, patient
refusal, and technical impossibility of accessing the rec-
tal stump [2,25]. David et al. showed that the restoration
rate was higher for patients who had undergone emergency
surgery rather than elective surgery (85 vs. 15%); this makes
sense since the elective Hartmann procedure is often a
deliberate choice linked to locoregional progression of can-
cer or the reflection of very poor patient condition [56].
Since 1990, the choice of surgical approach for restora-
tion of continuity has evolved with the advent of
laparoscopy. In a registry study, Cellini et al. sought to iden-
tify risk factors for complications based on whether the
intervention was performed by laparoscopy or laparotomy
in a homogeneous group of patients who had previously
undergone a Hartmann procedure [60]. Among 2567 restora-
tions of continuity in this study, the majority (87%) was
performed by laparotomy. However, the results were sig-
nificantly and independently in favor of the laparoscopic
approach, which resulted in fewer major complications
(multiorgan failure, reoperation), infections (sepsis, septic
shock, intra-abdominal abscess) and parietal complications
with a statistically shorter median duration of hospitaliza-
tion (1.5 days) [60].
In a review of the literature, De Wall et al. showed that
operative time was not influenced by the surgical approach
[2]. The 13% conversion rate (range 7—22%) was related pri-
marily to inability to identify the rectal stump (80% of cases)
due to dense adhesions, to a perforation of the rectal stump
(7% of cases), to persistent infection of the stump (5%), and
to tumor infiltration of the stump (3%). Mortality was simi-
lar with the two surgical approaches but hospital stay was
shorter after laparoscopy, with a mean gain of 6.9 days. Mor-
bidity was lower after laparoscopy than after laparotomy
(12% vs. 20%), especially for parietal infections, cardiopul-
monary complications, and anastomotic leaks (1.2 vs. 5.1%).
J. Barbieux et al.
However, this literature suffers from a significant selec-
tion bias since the patients undergoing laparoscopy were
younger, recovered faster, and underwent surgery for diver-
ticulitis or cancer less often than the group operated by
laparotomy, even though there was no difference in terms
of ASA score. These younger patients preferentially under-
went laparoscopic procedures for inflammatory diseases,
volvulus, ischemic lesions or traumatic injuries. This study
also detailed anastomotic complications related to restora-
tion of continuity: anastomotic leakage in 5%, postoperative
bleeding in 3%, and anastomotic stricture in 6% [2]. These
anastomotic complications required a second operation and
resulted in up to 50% incidence of permanent stoma; for the
entire series, 6% of patients required a permanent stoma.
Conclusion
The Hartmann procedure is associated with high morbidity
and mortality, which are related not to the surgical proce-
dure in itself, but rather to the clinical context in which it
is performed and to patient comorbidities. The Hartmann
procedure can be performed by any surgeon; it is faster and
easier than resection/anastomosis albeit with a low rate of
restoration of continuity. Table 1 summarizes the results of
major recent series of Hartmann procedure, in terms of mor-
tality, morbidity and restoration of continuity as they relate
to the surgical indication. At the present time, this pro-
cedure remains indicated for colonic conditions with fecal
contamination of the abdominal cavity, shock, ischemic col-
itis, or in patients with multiple comorbidities.
Key points
• The Hartmann procedure is a quick and simple
technique that can provide the best solution for
patients with an unfavorable initial prognosis.
• The Hartmann procedure is associated with high
rates of severe complications, with a mortality of
about 15% and a morbidity of about 50%.
• The high morbidity and mortality are not related to
the surgical procedure per se, but to the clinical
context that indicates this surgery and to patient
comorbidities.
• The rate of restoration of intestinal continuity after
a Hartmann procedure is around 45% with a 2%
mortality rate and about a 30% morbidity rate.
• The risk of non-restoration of intestinal continuity
after Hartmann procedure is high and there is a need
to find an alternative to this procedure whenever
possible.
• In sum, the indications for the Hartmann procedure
are fecal contamination of the abdominal cavity,
shock, ischemic colitis, or the presence of numerous
comorbidities.
Disclosure of interest
The authors declare that they have no competing interest.
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