Emergency left colonic resection with end colostomy

(Hartmann procedure)
B. Brac, C. Sabbagh, J.M. Regimbeau

To cite this version:

B. Brac, C. Sabbagh, J.M. Regimbeau. Emergency left colonic resection with end
colostomy (Hartmann procedure). Journal of Visceral Surgery, 2020, 157, pp.329 - 333.
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Version of Record: https://www.sciencedirect.com/science/article/pii/S1878788620301727
Manuscript_1e18a7449b4e76f2eedd8f34fd90dc22

Emergency left colonic resection with end colostomy (Hartmann procedure)

Brac B1,2,3, Sabbagh C1,2,3, Regimbeau JM1,2,3

1. Department of Digestive Surgery, Amiens University Hospital, 80054 Amiens cedex 1,

France

2. Picardie-Jules-Verne University, Picardie, Amiens, France

3. Unité de Recherche BQR SSPC « Simplification des Soins des Patients Complexes »
– Université de Picardie Jules Verne

Les auteurs déclarent ne pas avoir de conflit d’intérêt.

Correspondant :
Professor JM Regimbeau, MD, PhD
Department of Digestive Surgery
Amiens University Hospital
1 rond-point du Professeur Christian Cabrol
F-80054 Amiens cedex 01, France
E-mail: regimbeau.jean-marc@chu-amiens.fr

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© 2020 published by Elsevier. This manuscript is made available under the CC BY NC user license
https://creativecommons.org/licenses/by-nc/4.0/
Introduction

Described in 1921 by Henri Albert Hartmann to treat colorectal cancer, the so-called
« Hartmann procedure» is a rapid and simple surgical technique intended to
decrease peri-operative morbidity and mortality. This technique is often performed
by young surgeons (1). Indeed, end-colostomy may be necessary in situations where
restoration of continuity is risky, either because of unfavorable local conditions
(Hinchey IV peritonitis) or because a more definitive resection must be aborted due to
hemodynamic instability. More rarely, the Hartmann procedure is performed
electively in patients who are particularly vulnerable to the risk of post-operative
complications or anal incontinence. Depending on the underlying disease and
general status of patients, the Hartmann operation is generally performed with the
intention of ulterior restoration of continuity. However, the literature reports a 32 to
85% rate of non-reversal. This risk of non-reversal makes it imperative to create a
stoma of good quality (2). We therefore describe the essential technical points of the
Hartmann procedure with precision, in order to decrease post-operative morbidity,
ideally after pre-operative stoma site marking. Moreover, the patient must be
informed, and prepared for either permanent colostomy or reversal.

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 1- Patient position

A two-team approach is recommended: the patient is supine with arms abducted to

90° allowing use of self-retaining retractors (Olivier or Gosset abdominal retractor, for
example) to obtain adequate exposure of the splenic flexure and the pelvic cavity.
Adequate exposure is indispensable to facilitate and shorten the operation; without a
self-retraining retractor, the assisting surgeon would be immobilized and of little help
for the operation. The two-team approach also provides access to the rectum in order
to lavage the rectal stump at the end of the operation and to test for air-tightness in
case of difficult stapling. A double ringed wall protector should decrease the risk of
parietal contamination and surgical site infection. Of note, it is important to mark the
stoma site pre-operatively with the patient in sitting position; when the patient is on
the operating table, the skin landmarks are less obvious, making it difficult to locate
the best site for the stoma.

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 2- Incision and prevention of splenic decapsulation

The operation is conducted most often via a long midline xipho-pubic laparotomy,
facilitating, if necessary, splenic flexure mobilization. First the omentum is detached
from the colon; the spleen is inspected to determine whether any peri-splenic
adhesions must be taken down (to avoid the possibility of traction-related capsular
tear).

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 3- Splenic flexure mobilization

Splenic flexure mobilization is not mandatory. Nevertheless, it should be entertained

if the stoma cannot be brought out to the skin correctly; this helps prevent stoma
retraction/disinsertion, the main complication of the Hartmann procedure (2). Splenic
flexure mobilization is recommended when the operating surgeon is young.
Mobilization is performed from lateral to medial. Should splenic flexure mobilization
as described above, fail to provide adequate mobility, the inferior mesenteric vein
and/or the inferior mesenteric artery should be divided at its origin.

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 4- Mobilization of the left colon, identification of the ureter
The left colon is mobilized from lateral to medial. The retroperitoneal mobilization
should allow the colon to be brought medially in case of benign disease but should
also be complete enough to allow lymph node dissection at the origin of the inferior
mesenteric artery in case of malignancy. Visualization of the ureter is recommended
but not mandatory, notably during one’s learning curve or in case of inflammation
associated with mesocolic retraction. Moreover, visualization of the ureter is a
safeguard that the plane of dissection is correct.

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 5- Division of the left mesocolon, control and division of the rectum

The left mesocolon is divided just below the rectosigmoid juncture while the
mesorectum is divided beneath the sacral promontory (Figure 5A). Division and
closure of the rectum is an important step because the second most frequent
complication related to the Hartmann procedure is stump leakage (1). Rectal division
should be performed just below the rectosigmoid juncture, after completely stripping
the mesorectum from the rectum, thus ensuring accurate stapling. For the stapling,
one can use a laparoscopic linear stapling device (for example the EndoGIA®
(Medtronic, Boston, USA)) (Figure 5B). The staple line is then oversewn with a
running absorbable suture to complete hemostasis. The suture ends are left long to
facilitate identification when continuity is restored at a second stage (Figure 5C).
After stapled closure, the rectal stump should be washed out followed by insertion of
an intra-rectal drain. If adequate rectal stump closure is impossible, a Mikulicz type
drainage system should be inserted.

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 6- Confection of the end colostomy

Colostomy construction warrants particular attention to decrease the morbidity and

ensure patient quality of life, especially because the colostomy can sometimes be
permanent (2,3). Whenever possible, the stoma site should be marked pre-
operatively, with the patient in sitting position, by an enterostomal therapist, in order
to avoid bringing the stoma out in a skin fold. The stomal skin incision should be large
enough to allow the colon and mesocolon to be brought out according to patient
morphotype. The incision should be neither too small, nor too large, to avoid stricture
or peri-stomal hernia. The stoma should be tracted through the abdomen in its
« closed » position, that is to say, with a straight skin/subcutaneous fat/fascial
trajectory to avoid the bayonet effect. In the obese, the subcutaneous, fascial and
peritoneal layers should be incised vertically. This incision can be partially closed to
avoid parastomal herniation. Again, particularly for the obese, if the stoma site was
not marked pre-operatively, the stoma site should be situated higher (more cranial)
than usual in order to avoid stomal disinsertion when the patient is upright (when the
abdominal panniculus drops) (4).

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Conclusion

Abdominal drainage is not necessary after Hartmann’s procedure (5). Intra-rectal

drainage, associated with stump wash-out, should help overcome the sphincteric
obstacle, enhance rectal emptying, and thus decrease the risk of stump leakage. It is
useless to leave a drainage in contact with the staple line, with the hope of draining
an eventual stump leak. If this occurs, it can be drained either by endoscopic or
interventional radiology insertion of a double pig-tail stent (6,7).
The Hartmann procedure is by definition a simplified operation that is often performed
in the emergency setting, in patients with major co-morbidity and/or by young
surgeons. Each step of the operation should be performed with the ulterior incentive
of reducing the post-operative morbi-mortality and the intention of reversal to ensure
the best possible quality of life. Hartmann reversal is usually performed six months
after the initial operation and can be performed via laparotomy or laparoscopy (8).

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References:

1. Desai DC, Brennan EJ, Reilly JF, Smink RD. The utility of the Hartmann
procedure. Am J Surg,1998; 175: 152-4.

2. Dumont F, Vibert E, Duval H, Manaouil D, Sredic A, Alfahel N, et al. [Morbi-

mortality after Hartmann procedure for peritonitis complicating sigmoid
diverticulitis. A retrospective analysis of 85 cases]. Ann Chir, 2005; 130: 391-9.

3. Mariani A, Moszkowicz D, Trésallet C, Koskas F, Chiche L, Lupinacci R, et al.

Restoration of intestinal continuity after colectomy for non-occlusive ischemic
colitis. Tech Coloproctology, 2014; 18: 623-7.

4. Sabbagh C, Rebibo L, Hariz H, Regimbeau JM. Stomal construction: Technical

tricks for difficult situations, prevention and treatment of post-operative
complications. J Visc Surg 2018;155: 41-9.

5. Rebibo L, Ebosse I, Iederan C, Mahjoub Y, Dupont H, Cosse C, et al. Does

drainage of the peritoneal cavity have an impact on the post-operative course of
community-acquired, secondary, lower gastrointestinal tract peritonitis? Am J
Surg, 2017; 214: 29-36.

6. Sabbagh C, Maggiori L, Panis Y. Management of failed low colorectal and

coloanal anastomosis. J Visc Surg 2013; 150: 181-7.

7. Robert B, Yzet T, Regimbeau JM. Radiologic drainage of post-operative

collections and abscesses. J Visc Surg, 2013; 150: S11-18.

8. Blot C, Sabbagh C, Rebibo L, Brazier F, Chivot C, Fumery M, et al. Use of

transanastomotic double-pigtail stents in the management of grade B colorectal
leakage: a pilot feasibility study. Surg Endosc 2016; 30: 1869-75.

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Figure 1

Patient position
Figure 2
Incision and prevention of splenic decapsulation
Figure 3
Splenic flexure mobilization
Figure 4
Mobilization of the left colon, identification of the ureter
(Figure 5ABC).

Division of the left mesocolon, control and division of the rectum

Figure 6
Confection of the end colostomy