Hartmann's procedure

Henri Albert Hartmann was a French Surgeon of Paris (1860-1952)

Technique

• 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

• Diet only limited by ileus
• Digitate around day 4 if still no stool output to confirm no twist or fascial obstruction

Complications

• Rectal stump blow-out
• Deep-space infection
• Retracted colostomy
• Non-reversal of colostomy (>50%)
• Ureteric injury