Reversal of Hartmann's procedure: effect of timing and technique on ease and safety

The optimal time for reversal of Hartmann's procedure is controversial. Significant operative difficulty and morbidity have been reported for Hartmann's reversal. The purpose of this study was to examine 11 years' experience with Hartmann's reversal, with particular attention to rate of reversibility, operative difficulty, and timing of reversal.

Case records of all patients undergoing either Hartmann's procedure or Hartmann's reversal at St. Vincent's Hospital between 1981 and 1991 were examined. Patients having Hartmann's reversal were divided into an early group (before 15 weeks) and a late group (after 15 weeks). These groups were compared in terms of morbidity and mortality, bed stay, and operative difficulty.

Hartmann's procedure was performed on 111 patients, mostly for advanced cancer and complicated diverticular disease. Of 96 patients who survived, 50 (52 percent) underwent reversal. Of those with diverticular disease, 40 of 48 (83 percent) underwent reversal. Mortality for Hartmann reversal was 2 percent; anastomotic leak rate 4 percent; and overall complication rate 26 percent. Early reversal was performed in 13 patients and late reversal in 37 patients. There was no difference between these groups in mortality, morbidity, or anastomotic leakage. However, bed stay was longer in the early group and graded operative difficulty greater. In particular, cases in which adhesion density was most severe and in which accidental enterotomy occurred were more common in the early group (P = 0.02, Miettinen's modification of Fisher's exact test).

Hartmann's reversal can be performed with an acceptable morbidity and mortality in most survivors of complicated diverticular disease. Operative difficulty appears to be less after a delay of 15 weeks.