Hartmann’s Procedure - A Surgical Approach for GI Issues

Introduction:

The closed-off region of the rectum and anus is sometimes referred to as Hartmann's pouch by doctors when discussing Hartmann's procedure. However, this Hartmann’s pouch is different from the Hartmann’s pouch in the gallbladder. It is shaped like a pouch since the anus side is open, the rectum side is sealed, and the remaining length is quite small. It serves no particular purpose, but clinicians may distinguish it from other body parts when checking for diseases or infections, particularly in patients undergoing Hartmann's pouch surgery to treat diverticulitis (development of small, bulged pouches in the digestive tract) or cancer.

What Is Hartmann Procedure?

Hartmann’s procedure, also known as proctosigmoidectomy, is surgery of the large intestine. It is a specialized colectomy in which only a part of the colon is removed. Henri Albert Hartmann introduced the Hartmann method for the first time in the year 1921. Hartmann created this technique in reaction to the abdominoperineal resection's high death rate. In Hartmann's surgery, the sigmoid colon, the last section of the colon that meets the rectum, is removed. The rectosigmoid colon is resected during the Hartmann surgery, and a colostomy (an opening in the colon created by performing surgery) is made in the process. Hartmann's procedure is used to remove the diseased or infected parts of the intestine.

Hartmann's procedure can be done either as a planned surgery or in an emergency. In order to remove an obstruction, a chronic infection, or cancer before it spreads, Hartmann's surgery is frequently performed in emergency situations. Under these circumstances, it is not possible to properly reattach the remaining portions of the bowel after removing a portion of it. It is very challenging or risky to attempt to reunite the portions during the same surgery due to infection, inflammation, and other causes. Moreover, the colon needs some time to heal. In order to accomplish this, Hartmann's procedure closes the residual rectum and directs the remaining colon to a new outlet known as a colostomy.

What Are the Parts of Hartmann’s Procedure?

There are two parts to Hartmann’s procedure:

1. In the first part, the last portion, or the lower portion of the bowel, is surgically removed.

2. The second part of the procedure involves redirecting the remaining part of the bowel into a colostomy.

What Are the Indications of Hartmann Procedure?

• The indications for the Hartmann procedure have evolved over time, despite the fact that it was first designed to treat distal colon cancer.

• Diverticulitis is complicated, particularly in stages III and IV, and involves peritonitis.

• Colorectal cancer, especially rectosigmoid cancer. If cancer results in obstruction, perforation, or bleeding, it can be necessary to perform emergency surgery.

• Large bowel obstruction caused by scar tissue.

• Inflammatory bowel disease complication.

• A complication of another bowel surgery.

• Rectal prolapse.

• Injury or trauma.

How Is Hatmann Procedure Done?

Hartmann’s procedure can be done via laparoscopic surgery or open surgery, depending on the patient's condition. In traditional open surgery, the abdominal cavity is opened in order to reach the organs. However, a more recent technique termed laparoscopic surgery makes smaller incisions with the help of a tiny camera known as a laparoscope. Although the laparoscopic approach is less invasive and requires a quicker recovery, not all conditions can be treated this way. Hartmann’s procedure is performed in the following ways:

Before the Procedure:

• Before the surgery, the patient is asked to fast for at least six to 12 hours. Fasting is important to maintain an empty stomach during the procedure; otherwise, the patient may vomit.

• The patient will undergo bowel preparation to clear up the colon if it is a planned surgery.

• An intravenous catheter is installed to keep the patient hydrated.

• Pain medication options are discussed with the patient in advance in case of planned surgery.

During the Procedure:

• The patient is generally put under general anesthesia.

• In laparoscopic surgery, the surgeon begins with a tiny incision. Through this incision, the laparoscope is introduced. The camera helps visualize organs on a screen. Then the surgeon makes a few more incisions to reach the colon.

• If the patient is undergoing open surgery, the surgeon makes a single large incision via the abdomen and opens the abdominal cavity.

• The surgeon will take out the colon to determine which part has to be removed.

• The diseased part of the colon is removed, and the rectal ends are sealed off.

• The surgeon creates a new opening called a stoma in the abdominal wall before attaching the other end of the colon to the abdominal wall.

• A colostomy bag is attached to the stoma (an opening in the abdomen that forms a connection to the digestive system or the urinary tract).

• The surgical wounds are closed.

After the Procedure:

• After the procedure, the patient is moved to a recovery room to rest for the next few hours.

• The patients will spend the following seven to ten days recovering in a hospital room till their condition stabilizes.

• The patient will be given antibiotics and pain medications to prevent infections and control pain.

• The medical staff will offer advice on utilizing the colostomy bag and taking care of the stoma.

Can Hartmann Procedure Be Reversed?

The patient may require the use of the colostomy bag permanently or only temporarily, depending on their condition. By removing the rectum's seal and releasing the end of the colon attached to the colostomy, the surgeon can reverse Hartmann's surgery. The surgeon will then join the two ends of the colon, allowing the patient to continue having regular bowel movements. The colostomy opening is stitched (sutured). It is advised that Hartmann's procedure reversal be carried out at least six months after the initial Hartmann's procedure.

What Are the Complications Associated With Hartmann Procedure?

Possible complications of Hartmann’s procedure are:

• Post-surgical infection.

• Pneumonia or chest infections.

• Hemorrhage or internal bleeding.

• Leaking colon.

• Hernia (organ protrusion through an unusual opening).

• Damage and infection in the surrounding organs.

• Scarring in the intestine may cause further obstruction.

What Are the Potential Adverse Effects of Hartmann Procedure?

Potential side-effects of Hartmann’s procedure are as follows:

• Temporary Ileus: After the procedure, the bowels could take a while to get back to normal. This condition is known as ileus or bowel paralysis. While the patient's bowels heal, they could require short-term IV (intravenous) fluids or nourishment.

• Anal Discharge: Patients may experience occasional anal discharge even though they will not be excreting from their anus.

• Sexual Dysfunction: A nerve associated with sexual functioning might occasionally get injured during rectal surgery. Therefore, this could make sex more painful or sensitive for women. In addition, it could make it difficult for males to ejaculate or keep an erection for a longer time.

Conclusion:

Hartmann’s procedure is done to treat conditions like colon cancer, colorectal cancer, diverticulitis, etc. The procedure can be done as a planned surgery or in emergency conditions. However, the procedure is generally quick and safe and has a good prognosis. The procedure is reversible, and reversal is usually performed after six to twelve months.