Hartmann's procedure
Henri Albert Hartmann was a French Surgeon of Paris (1860-1952)
Technique
[edit | edit source]- Lithotomy with myself on patient's right
- Typically full laparotomy
- Explore abdomen
- Pack small bowel to RUQ
- Mobilise descending colon - lateral to medial, along white line of Toldt
- Identify and preserve ureter early, along with gonadal vessels. Close colonic dissection to avoid it, and expect to encounter it just medial to gonadal vessels.
- Lift sigmoid vertically and identify IMA pedicle medially, then join lateral and medial dissection planes
- Identify and divide vessels high, especially if disease is malignant
- Identify point of division (healthy descending colon) and carry mesenteric dissection up to this point
- Carry that dissection down to upper rectum
- Leave rectal stump as long as possible to facilitate reversal
- Staple across the rectum (contour or EndoGIA)
- Mark stump with Prolene tags
- Consider bringing stump out as mucus fistula
- Usually don't need to mobilise splenic flexure - only proximal mobilisation if needed to bring out a stoma
- Create stoma (see separate topic)
- Close wound
- Suture stoma in place
Post-op
[edit | edit source]- Diet only limited by ileus
- Digitate around day 4 if still no stool output to confirm no twist or fascial obstruction
Complications
[edit | edit source]- Rectal stump blow-out
- Deep-space infection
- Retracted colostomy
- Non-reversal of colostomy (>50%)
- Ureteric injury