Is Hartmann still alive?

There is still an important controversy about the optimal management of colonic diverticular disease, complicated by peritonitis. Most surgeons have always been reluctant to perform a primary anastomosis in the presence of diffuse peritonitis, and were mostly in favour of the Hartmann's procedure. Some even preferred the three stage procedure. However for some considerable time feasibility studies about primary resection with primary anastomosis were published. Those studies demonstrated that this technique was safe. The last years some authors tried to compare the primary anastomosis with the Hartmann's procedure, by reviewing the literature. It is obvious that their conclusions are debatable because of the selection bias, but nevertheless there is evidence that in selected patients primary anastomosis is at least as good as the Hartmann's procedure if the surgeon is experienced enough. By doing so, a risky restoring of the continuity after Hartmann's procedure can be avoided. Actually, there is a tendency to advocate the primary anastomosis, covered by a defunctioning ileostoma for patients with Hinchey stages I to III (abscess or purulent but not faecal peritonitis). However nothing is really proven and a randomized, controlled trial is required to show if primary anastomosis is as safe or even superior compared to Hartmann's procedure.