Hartmann’s Procedure: Everything You Need to Know

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Hartmann’s procedure (clinically referred to as proctosigmoidectomy) is a surgery that takes on inflammatory conditions and cancer of the colon. It’s most often used to treat complicated cases of diverticulitis, an infection of the outpouchings (diverticula) in the lining of the colon, and colon cancer.

The aim of this surgery is to remove problematic tissue and connect the healthy portion of the colon to a colostomy bag. Patients that are healthy enough to undergo it may have a second procedure, called “reversal,” which involves reconnecting the healthy portions of the colon and restoring normal function.  

This complicated treatment requires significant preparation, a lengthy hospital stay, as well as lifestyle changes afterward. It’s important to understand the basics of how Hartmann’s procedure works, how to prepare, and what life looks like after this procedure.           

What Is Hartmann’s Procedure?

Whether taking on diverticulitis, colon cancer, or other conditions, the goal of Hartmann’s procedure is the same—to get rid of problematic colon tissue. This prevents the infection or cancer from spreading, while also removing obstructions from this part of the body. In cancer cases, this procedure is most often an emergency surgery.

For diverticulitis, however, this surgery is not a first-line treatment. The healthcare provider may first prescribe antibiotics and recommend lifestyle adjustments to treat the condition before indicating surgery.

Both open and less-invasive laparoscopic techniques can be used to perform Hartmann’s procedure. While you’re asleep on general anesthesia, surgeons locate and remove the cancerous or inflamed portion of the colon, sealing off the healthy parts.

They then re-route the healthy portion of the digestive tract to an opening (called a “stoma”) in the abdomen that is connected to a colostomy bag. Finally, the healthy portions of the colon are stabilized, and the incisions are stitched shut. Once the incision (for open surgery) or multiple incisions (for laparoscopy) are stitched shut.

Contraindications

As with all major surgeries, Hartmann’s procedure may not be the best option for some patients. Particular concern surrounds patients over the age of 70 years of age; while the procedure can be safe for this group, the presence of other medical conditions can complicate matters.

A history of any of the conditions may contraindicate surgery for this population:

In addition, a number of other factors have been associated with higher complication rates, including:

  • Previous abdominal surgery significantly increases the chances of complications after the operation, making it a potentially poor option.
  • Obesity also leads to an increased risk of problems, including higher rates of surgical infection and incisional hernia (essentially a hole or weakness in the colon wall).
  • Nutrition status can also impact treatment decision-making, as those experiencing malnutrition have a higher rate of complications.
  • Type II diabetes may also contraindicate this surgery in some cases.

While the above aren’t necessarily outright contraindications, they are factors that the healthcare provider will have to weigh as they decide on a treatment plan.

Potential Risks

As hard as surgeons work to ensure that Hartmann’s procedure is safe and effective, there’s always a chance of complications. What can happen? Here’s a breakdown:

  • Infection in the incision(s)
  • Leaking colon
  • Hernia
  • Paralysis of intestinal muscles
  • Internal bleeding
  • Damage to organs or tissues in the area
  • Deep vein thrombosis (blood clot in the leg)
  • Pulmonary embolism (blood clot in the lung)

Purpose of Hartmann’s Procedure

Primarily, this surgery is called for in cases of severe inflammation, infection, or cancer growth in the colon. These arise due to several conditions:

  • Diverticulitis: As noted above, the most common indication for Hartmann’s procedure is diverticulitis, in which pockets in the lining of the colon become infected. While this case is very common and often asymptomatic, more complicated cases require surgery.
  • Colon cancer: Cancerous growths in the colon can also lead to diverticulitis symptoms. Surgery offers a chance to remove malignant cells, preventing further spread of cancer.
  • Colon injury: Trauma or surgical misadventure can lead to injury and inflammation in the colon. Sometimes, Hartmann’s procedure is used to correct the issue.
  • Crohn’s disease: This condition is characterized by chronic diarrhea, abdominal pain, cramping, blood in the stool, and other symptoms. Though Hartmann’s procedure is not a first-line treatment for this condition, it may sometimes be indicated.
  • Ulcerative colitis: Surgery may considered in cases of this type of inflammatory bowel disease, characterized by bloody diarrhea and abdominal pain, among other signs. 
  • Radiation damage: In rare cases, imaging using X-ray or radiation can cause scarring and inflammation in the colon.

Critical to the success of Hartman’s procedure is proper testing and diagnosis. Here’s a breakdown of what may be done:

  • Physical examination: Initially, the healthcare provider will need to assess your report of symptoms as well as your medical history.
  • Lab tests: To get a better sense of the cause of the problem, the healthcare provider will order the collection of blood samples for lab testing. These can be particularly helpful in determining the level of inflammation in the area, the relative health of the liver and kidneys, as well as the presence of cancer.
  • Electrocardiogram (ECG): Some patients will have abnormally low blood pressure (hypotension) or a history of heart problems. ECG monitors heart activity and helps surgeons determine if any cardiac conditions make surgery too risky.
  • Computerized tomography (CT) scan: Imaging will be necessary for the surgeon to fully assess the colon and diagnose the issue. The standard for practice these days is the CT scan, which employs multiple X-rays to create a composite, three-dimensional computer map of the affected area.
  • Radiography: In some cases, healthcare providers will also use X-ray, magnetic resonance imaging (MRI) or other imaging methods to confirm a diagnosis.  

 

How to Prepare

Proper preparation for Hartmann’s procedure, as with any major surgery, is as essential for the patient as it is for the medical team. Since this treatment impacts the lower-digestive system, it requires a number of significant pre-operative lifestyle changes, and, since a hospital stay is needed afterwards, you have to plan ahead.

While you’ll get a good deal of guidance from your surgeon and medical staff, it’s important to have an understanding of what you can expect and how to get ready. 

Location

Whether performed as an open surgery or laparoscopically, Hartmann’s procedure is performed in the surgery ward of a hospital. Here’s a quick rundown of what you can expect to find there:

  • Operating table will be where the surgery occurs as you lie flat on your back.
  • Monitors for vital signs, including heart rate, oxygen levels, blood pressure, etc., are needed throughout the procedure.
  • A ventilator or ventilating tube will help you breathe while you’re under general anesthesia
  • Laparoscope is the retractable, adjustable camera used to transmit live video of the affected area for the surgeon. 
  • Surgery tray containing the necessary equipment will be within reach of the surgeon.
  • Foley catheter is a tube inserted into the bladder for urination.
  • Surgical staples or sutures will also be necessary to complete the procedure.

What to Wear

On the day of surgery, aim to dress comfortably. You’ll get pre-operative instructions from your surgeon, but here are some guidelines:

  • You’ll wear a hospital gown during the procedure and throughout recovery.
  • Wear comfortable, loose-fitting clothes that don’t constrict your abdomen in any way.
  • Skip contact lenses if you need vision correction and wear glasses instead.
  • Don’t wear jewelry, including body piercings.
  • Go scent-free and don’t wear perfumes, cologne, deodorant, or any kind of scented skin product. 
  • Wear a pad instead of using a tampon if you’re menstruating.
  • Shoes with laces should be worn; sometimes swelling occurs in the feet, so be ready to adjust the fit.

Food and Drink

Given that Hartmann’s procedure impacts the digestive system, there are many dietary changes that need to be made to prepare you for the surgery. Here are some keys to the pre-operative diet:

  • Healthy diet: To help assure a good outcome, in the month or so leading up to your surgery, you may be counseled on how to improve your diet. Generally speaking, you should emphasize lean proteins and fresh fruits and vegetables, while steering clear of excess sugar or salt.
  • Clear liquids: You also may have to adhere to a clear liquid diet starting the final day before the procedure. This means only water or juices that are clear, as well as broth for protein: no solid foods. Coffee, tea, and clear juices like apple or cranberry are OK during this time.
  • What to avoid: Along with solid foods, in the final 24 hours before surgery you should steer clear of all alcoholic drinks, milk or cream, juices with pulps, and most sweets. Jello, hard candies, and flavored ice are acceptable snacks.  

Medications

In preparation for Hartmann’s procedure, your surgeon may ask you to do a bowel prep regimen, aimed at healthily and safely emptying your bowels the day before surgery. Specific instructions vary, and not every surgeon will ask you to do this, but here’s what you can expect:

  • Antibiotics: To help prevent infection as you prepare, you’ll be prescribed antibiotics to take as you undergo bowel prep.
  • Dulcolax tablets: Your surgeon will give you exact instructions about using this laxative, but typically four doses should be taken by 3 p.m. the day before surgery.
  • Miralax (polyethyl glycol): This over-the-counter, liquid laxative should be taken as directed until a 238-gram bottle is finished. It’s best mixed with a 64-ounce Gatorade bottle around 5 p.m., and taken in 8-ounce increments every 15 minutes until the mixture is finished.
  • 4% chlorohexidine gluconate (CHG) solution: In the days before surgery, you’ll be asked to bathe with this special, antiseptic soap. 
  • Preop mixture: Sometimes, the surgeon will formulate a special bowel prep mixture that you’ll need to take two hours before surgery.

To avoid the risk of excessive bleeding or other unintended effects, your surgeon will need to go through the prescribed and over-the-counter medications, vitamins, and herbal supplements that are part of your regimen. In particular, let your healthcare provider know if you’re taking any of the following as dosages may need to be adjusted or temporarily cut off:

  • Non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, Advil or Motrin (ibuprofen), and Aleve (naproxen) should not be taken for at least 48 hours prior to surgery. Some healthcare providers recommend you stop as soon as a week in advance.
  • Vitamin E supplements should also be avoided in preparation as they can increase bleeding.
  • Antiplatelet medications, such as Ecotrin (enteric-coated aspirin), and Plavix (clopidogrel), can also be problematic for surgery.
  • Anticoagulants like Coumadin (warfarin), heparin, and Eliquis (apixaban) may also require adjustments to dosage or temporary cessation.
  • Some herbal supplements, such as ginkgo biloba, garlic or ginger tablets, fish oil, and St. John’s wort, among others, should be avoided for at least two days before surgery.

It’s absolutely essential that you give your healthcare provider a full accounting of what you’ve been prescribed and what you’re taking. 

What to Bring

So what do you need to bring along as you prepare for your stay in the hospital? Don’t forget the following:

  • Insurance information
  • Photo ID
  • List of all medications you’re taking
  • List of supplements or herbs that are part of your routine
  • List of current allergies
  • Advance directives (living will/healthcare proxy)
  • Toiletries (toothbrush, toothpaste, soap, etc.)
  • Slippers and bathrobe
  • Books, magazines, e-reader, tablet, or other reading material

 

Pre-Op Lifestyle Changes

Aside from the liquid diet mentioned above, there will also be a couple of lifestyle changes needed to ensure good outcomes. These include:

  • Quit smoking: Tobacco and nicotine products can impact recovery from surgery. If you’re a smoker, talk to your healthcare provider about your options; even just three days off before surgery can significantly boost outcomes.
  • Boost exercise: Getting a little aerobic exercise every day will make recovery quicker and reduce the chance of complications. If fitness isn’t part of your routine, start easy by walking, biking, or swimming.
  • Eat healthy: Until the point at which you need to switch to an all-liquid diet, it’s a good idea to ensure you’re getting proper nutrition. Make sure you’re drinking enough water, and emphasize lean proteins and fresh fruits and vegetables in your meals.
  • Avoid alcohol: Alcohol consumption can impact recovery and success of the procedure. Be honest with your healthcare provider about how much you drink and let them know if you have a dependency.

Your surgeon may have specific instructions for you; be sure to follow their recommendations closely.

What to Expect on the Day of Surgery

On the day of surgery, a great deal happens. Not only does Hartmann’s procedure, itself, have to be performed, but the medical team also needs to check that you’re ready for surgery, and make sure your in-hospital recovery is going well.

Before the Surgery

Your first stop will be the pre-op room, where you’ll change into a hospital gown and have a final medical evaluation and consultation. Here’s what happens:

  • Pre-op assessment: A quick assessment of important health signs, such as heart rate, blood pressure, and temperature, is performed.
  • Assessment of medications: The medical staff will also ask you about the medications and supplements you’re taking.
  • Pre-operative medications: Patients are given antibiotics and medications to prevent blood clots to prevent complications.
  • Consultation with the anesthesiologist: You’ll also meet the anesthesiologist, who’ll determine the right dosage to put you to sleep safely.
  • Connection to IV: Either just after arriving in the operating room, or while in pre-op, you’ll be connected to an IV that delivers anesthesia.

During the Surgery

Hartmann’s procedure takes anywhere from two to four hours. Specific techniques vary between laparoscopic and open surgery approaches, with the former becoming the more frequently preferred option. Here’s a quick breakdown of the first stage:

  • Staging: Once you’re brought into the operating room, you’ll be put to sleep, connected to a respirator, and hooked to monitoring machines. The surgeon will first mark out the space for the stoma, which will be where the colostomy bag joins the body, as well as the incision sites.  
  • Incision: In open surgery, an incision is made in the abdomen, near the navel; whereas, laparoscopy relies on multiple smaller ports, to allow the laparoscope and instruments access the area.
  • Identification: The cancerous or inflamed portion is located, and its blood supply is split off from healthy tissues.
  • Removal: The surgeon carefully cuts off and extracts inflamed or cancerous tissues, and seals off the rectal side of the colon.
  • Creating the stoma: An incision is made in the abdomen to create the stoma.
  • Connecting the colostomy bag: The portion of the colon coming from the stomach is routed to the stoma and connected to the colostomy bag. Feces and gas will be passed into it as you heal.
  • Stabilization: The colon is stabilized using surgical staples or sutures.
  • Closing incisions: Once everything is in place, the incisions are sutured or stapled shut.

Typically, you’ll wake up in the operating room, and once the surgeon is sure you’re stable, you’ll be taken to a post-operative recovery room.

After the Surgery

Hartmann’s procedure is a major surgery and requires up to 10 days of in-hospital recovery. As you recover from surgery, nurses will be checking in with you to ensure there are no complications or problems. What can you expect? Here’s a quick rundown:

  • In the recovery room: Patients spend two to three hours in the recovery room and are monitored for vital signs. You’ll be connected to IVs delivering pain medication and antibiotics, which you’ll keep in for the next three to seven days. Once your condition has stabilized, you’ll be transferred to recover in your hospital room.
  • Consultation and screening: Members of the medical team will monitor your progress and provide consultation about how to use your colostomy bag, manage pain, and other aspects of recovery.
  • Diet: Solid foods will have to be gradually reintroduced as you recover, and you’ll be on an all-liquid diet for the first day. You may be connected to an IV delivering fluids in the earlier going to ensure you remain hydrated.
  • Laxatives: Constipation often follows this surgery, so you may be prescribed laxatives.
  • Breathing exercises: You’ll be encouraged to use a device called an incentive spirometer to help exercise your lungs, which is an essential aspect of recovery. The medical team will instruct you on how to use it.

Physical activity: Within 12 hours of surgery, you’ll be asked to stand up with assistance; this helps prevent the formation of blood clots. As you recover, you’ll need to gradually increase activity, taking

When can you go home? To be discharged, your surgeon needs to see:

  • Stable vital signs (blood pressure, heart rate, temperature, and others)
  • Pain managed with oral medication
  • Ability to have a bowel movement or pass gas into the colostomy bag
  • Ability to get out of bed with little assistance

Recovery

Depending on the case, it can take anywhere from three months to one year to see complete recovery from Hartmann’s procedure. Typically, the first follow-up appointment is one to three weeks after surgery, with additional appointments scheduled as needed.

If surgical staples were used in the procedure, you’ll come in to have those removed. In cases of colon cancer, you’ll also need a biopsy or other tests as directed by your surgeon.

What’s the recovery timeline look like? When can you resume your normal activities? Here’s what you need to keep in mind:

  • Driving: As long as you’re on prescribed pain medications, you cannot drive. You’ll need clearance from the surgeon before you can take the wheel.
  • Return to work: Very much depends on the kind of work you do. If you do manual labor, you need at least six weeks—usually more—before you punch in. Office workers may be able to return sooner.
  • Diet: In some cases, your healthcare provider may ask you to follow a gastrointestinal (GI) soft diet, of low-fiber and easy to digest foods as you recover. For four to six weeks, this means avoiding meat with casings, nuts, fresh fruits, pulpy juices, raw vegetables, corn, mushrooms, and some breads, among others. After that, you’ll slowly reintroduce other foods.
  • Bathing or swimming: While showers can be taken, avoid submerging in water until you get clearance from your surgeon.
  • Physical activity: While you are encouraged to incorporate light exercise, such as walking, into your routine, there are many restrictions. Don’t lift anything heavier than 10 pounds for the first six weeks after surgery, and sit out contact sports (football, martial arts, etc.) and strenuous exercise (tennis, running) until you have your healthcare provider’s approval.

As you recover at home, you’ll also need to manage common side-effects of treatment, including:

  • Pain: Follow your surgeon’s orders carefully when it comes to your prescribed pain medications. The idea will be to taper off of these; as you reduce dosage, you can use NSAIDs like Advil (ibuprofen) or Tylenol (acetaminophen).
  • Constipation: Difficulty passing stools is common following surgery, and you’ll get guidance for managing constipation. It helps to try to use the bathroom as you would normally, drink plenty of fluids, and stay active.
  • Colostomy: Following Hartmann’s procedure, you’ll use a colostomy bag to defecate. Hospital staff will educate you on use and care, and tell you about your options. 

Healing

Making sure your incisions heal properly is another important aspect of recovery from Hartmann’s procedure. Here are some tips to care for them: 

  • Watch for signs of infection, including increasing pain, heat, redness, swelling, and drainage from the incision, and fever above 100.5 F.
  • Showering daily is recommended and can help ease pain. Remove bandages, and gently clean your incisions using scentless, liquid soap. Don’t use a washcloth and pat, rather than rub. When you’re finished, pat them dry, and only dress them if there’s still drainage.
  • Don’t take baths or go swimming while your incisions are healing.

Coping With Recovery

The impact of a surgery like Hartmann’s procedure goes beyond the body; it can also affect your mental health. Multiple studies have found post-operative patients of colorectal surgeries were found to have higher rates of depression and anxiety. Recovery is challenging, exhausting, and you’re far from alone if you’re struggling. 

That said, there are some strategies to take on mental health challenges after surgery:

  • Seek out a support network: The support of family and friends can make a huge difference, so don’t be afraid to reach out to loved ones. Be as open and communicative as you can, and don’t be afraid to accept help.
  • Mental health counseling: Post-surgical counseling with a professional who specializes in this work can be crucial for taking on depression, anxiety, or other issues.
  • Support groups: Knowing that others have undergone surgery and having a space to share your feelings can also be of great help, especially for cancer survivors. Seeking out support groups or online forums can help remind you that you’re not alone in this.      

Possible Future Surgeries

While Hartmann’s procedure does often lead to terminal use of the colostomy bag, some patients may be able to have revision surgery. In this procedure, performed under general anesthesia, the surgeon reconnects the healthy portions of the colon, and closes the stoma. In addition, the surgeon may use mesh to reinforce the walls.

This procedure occurs three to six months after the first as the surgeon needs to ensure that everything has healed completely. You and your healthcare provider will talk about your options.     

Lifestyle Adjustments

Over the longer term after Hartmann’s procedure, a number of broader lifestyle changes can be made to maintain positive results. These include:

  • Stay hydrated: Ensuring that you’re getting enough fluids—usually about 64 ounces a day—helps keep the colon healthy.
  • Eat well: Keeping to a solid, well-rounded diet that emphasizes vitamins and proteins. Keep track of how food is making you feel, so that your diet nourishes you.
  • Get exercise: Keeping active helps promote digestion, among many other health benefits. Ensuring that you’re getting enough activity or going to the gym will help keep you on the right track.

As intense as recovery from Hartmann's procedure can be, it can be an opportunity to make positive changes in your life.

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