The utility of the Hartmann procedure

In 1923 the French surgeon Henri Hartmann described an operation for rectosigmoid cancer as an alternative to abdomino-perineal resection for high-risk patients. In the subsequent years, the indications for performing the Hartmann procedure have broadened to include complicated diverticulitis, ischemic bowel, iatrogenic perforations, volvulus, and colitis.

We have retrospectively reviewed our experience in 185 patients who underwent the Hartmann procedure from January 1981 to December 1995. Charts were reviewed for indications, morbidity, and mortality and to determine the outcome of patients who underwent the Hartmann procedure.

The main indications for performing the Hartmann procedure were complicated diverticulitis (including perforation, obstruction, and abscesses) in 108 patients, rectosigmoid cancer in 31 patients, and other indications in 46 patients. There were a total of 27 deaths for an in-hospital mortality of 14%. All complications occurred at a rate of less than 9%. Of the 158 surviving patients, 90 (57%) eventually underwent the second stage of the operation to restore bowel continuity. The average length of time between initial resection and reanastomosis was 149 days. There were no deaths associated with the second stage of the procedure and complications occurred at a rate less than 4%.

This is the largest reviewed series of the Hartmann procedure. Mortality is lower than in other reported series, and morbidity is low. Our data demonstrate that the second stage of the procedure, in properly selected individuals, is a procedure that can be performed with minimal morbidity and no mortality. This is different from other published reports. We conclude that the Hartmann procedure is a safe and efficacious option for the surgeon confronted with the complex pathology of the rectosigmoid area, with acceptable morbidity and mortality.