Hartmann's procedure

Hartmann's procedure is an operation in which:

• A section of the sigmoid colon or upper rectum is removed (this is usually the part that has been causing the problem — perforated, obstructed, or otherwise damaged)
• The upper end of the remaining bowel is brought out through the abdominal wall as an end colostomy (a stoma — a small opening on the abdomen where stool collects in a bag)
• The remaining lower part — the rectal stump — is closed and left inside the abdomen

The reason for not rejoining the bowel at the time is safety. When the bowel is inflamed, infected, contaminated, or the patient is unwell, a new join (anastomosis) has a high risk of leaking — which would be a serious complication. Hartmann's avoids that risk by deferring the rejoining to a later, planned, safer operation.

Hartmann's is most commonly performed in emergency situations:

• Perforated diverticulitis with peritonitis — when an infected diverticular pocket has burst (see Surgery for Diverticular Disease for the broader picture)
• Obstructing or perforated sigmoid or rectosigmoid cancer in a patient who is too unwell for a primary join (see the Bowel Cancer Surgery hub)
• Large bowel obstruction where colonic stenting is not appropriate or has failed
• Severe colonic ischaemia (damaged blood supply to the bowel)
• Iatrogenic perforation at colonoscopy in conditions that prevent a safe primary repair

The decision is usually made in the operating theatre, based on what is found and how the patient is coping. Sometimes the alternative — a primary join with a defunctioning loop ileostomy — is possible; sometimes Hartmann's is the safer choice.

• Avoids the risk of an anastomotic leak at a time when a leak would be very dangerous
• Provides a definitive surgical solution that works even when conditions are far from ideal
• Allows you to recover from the acute illness and stabilise, with the option of reversal later when things are calmer

Hartmann's is a major operation, usually performed in difficult circumstances. The main considerations:

• The stoma is not always reversed. Around 40–50% of patients do not proceed to reversal, either because they are not well enough for further major surgery, the rectum is unsuitable, or because they decide against further surgery once they are better. This is worth knowing honestly from the start.
• Wound infection is relatively common given the contamination at the original operation.
• Intra-abdominal collection (a pocket of fluid or infection inside the abdomen) can occur and may need drainage.
• Stoma complications — retraction, prolapse, or a parastomal hernia — can develop over time.
• Incisional hernia at the operation wound is a recognised long-term risk.
• Long-term effects of the retained rectal stump — occasional bleeding, mucus discharge, or diversion proctitis (inflammation of the unused rectum). These are usually minor.

Most Hartmann's procedures are emergencies, so detailed pre-operative planning is not always possible. Where there is time, the team will: confirm the diagnosis on CT, give fluids and antibiotics, optimise blood and clotting, and have a stoma nurse mark the best position on the abdomen for the stoma (taking into account your clothing line and where the stoma will sit clear of skin folds).

Consent covers the possibility of stoma formation — even in scenarios where it was not the planned approach.

The operation is performed at Warringal Private Hospital or Epworth Eastern under general anaesthetic, usually taking 2–4 hours. The diseased segment of bowel is removed, any contamination is cleaned out, the upper end of the bowel is brought through the abdominal wall as an end colostomy, and the rectal stump is closed inside. A laparoscopic (keyhole) approach is used where the patient's condition allows; otherwise it is performed open through a midline abdominal incision.

Recovery from an emergency Hartmann's is significant — both because of the operation itself and because most patients were unwell going in. Typical recovery looks like:

• Hospital stay: 5–10 days, sometimes longer for patients who were critically unwell pre-operatively
• Pain management: epidural or patient-controlled analgesia initially, transitioning to oral medications
• Mobilising: getting out of bed and walking from day 1 — important to reduce clot risk and help bowel function return
• Eating and drinking: gradual reintroduction starting with fluids, then a light diet, as your bowel wakes up
• Stoma education: the stoma nurse will spend time with you teaching you appliance changes, skin care, hydration, and recognising signs of dehydration — see the Stoma Care guide

Full recovery to feeling yourself again usually takes 6–12 weeks. The bowel surgery aftercare guide covers the practicalities — see the Bowel Surgery Aftercare guide.

A post-operative review is arranged within 2–6 weeks of discharge. This review is provided at no charge.

Reversal of a Hartmann's is a planned operation that rejoins the colon to the rectal stump deep in the pelvis. It is more involved than reversing a loop stoma because it involves dissecting through scar tissue from the first operation.

Reversal is offered when:

• You have fully recovered from the first operation (usually 6–12 months later)
• The rectum is suitable — confirmed on a contrast study or sigmoidoscopy
• You are fit enough for further major surgery
• You actively want it

Reversal is itself a substantial operation with its own risks, including the risk of an anastomotic leak (around 5–10%). What reversal involves is discussed in detail closer to the time. Around 50–60% of suitable patients eventually proceed to reversal.

In an emergency setting, the decision between Hartmann's and a primary join with a defunctioning loop ileostomy is made carefully based on the patient's stability and what is found at operation. Where it is safe to join the bowel with a protecting ileostomy, that is often the preferred option — because reversing a loop ileostomy is simpler than reversing a Hartmann's.

When Hartmann's is the safer choice, the conversation about reversal — including the honest acknowledgement that not everyone proceeds to it — happens as soon as the patient is well enough to have it.

Have questions about this procedure?

If you have questions or would like to be seen, Mr Nguyen consults at his rooms in Heidelberg and operates at Warringal Private and Epworth Eastern. A GP or specialist referral is needed to make an appointment.

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