Overview
Damage control when the colon cannot be safely rejoined.
The Hartmann procedure resects the sigmoid colon (and a portion of the upper rectum when needed), brings the proximal colon to the skin as an end colostomy, and closes the rectal stump below. No anastomosis is created — the proximal and distal ends are kept separate. The operation is chosen when reconnecting the colon at the same operation would carry an unacceptably high risk of leak, sepsis, or death. The original Hartmann was described in 1921 by Henri Hartmann for rectal cancer; today it is most often used for emergency diverticulitis.
The decision to do a Hartmann instead of a primary anastomosis (with or without a protective loop ileostomy) is judgment. We consider the degree of contamination, hemodynamic stability, nutrition, steroid use, the quality of the bowel wall, and the patient's overall reserve. When the situation is bad enough that an anastomosis would be reckless, the Hartmann buys time — control the source, get out, fix the next thing in stages. Reversal to restore continuity can be considered 3–6 months later in selected patients.
Who is a candidate?
Most Hartmann procedures are done in patients presenting urgently. Perforated diverticulitis with feculent peritonitis, obstructing left-sided colon cancer with proximal distention, anastomotic leak after prior colorectal surgery, severe rectosigmoid trauma, and sigmoid volvulus with non-viable bowel are typical scenarios. Less common but valid indications include the planned management of severe refractory diverticulitis in patients on chronic immunosuppression, where the surgeon judges that a primary anastomosis carries unacceptable risk. The decision is always individualized — we never default to a Hartmann when a safe primary anastomosis is possible.
How we perform it
Under general anesthesia, with the patient in lithotomy position, we enter the abdomen — laparoscopically when the patient is stable and contamination is limited, open through a midline incision when not. Adhesions are taken down. The colon is mobilized along the left paracolic gutter and the splenic flexure is taken down if needed to bring the proximal colon to the skin tension-free. The mesentery is divided, ureters are protected, and the diseased sigmoid is resected with staplers proximally and distally. The peritoneal cavity is irrigated thoroughly. The proximal colon end is brought through a separate skin incision (ideally a pre-marked stoma site) and matured to the skin. The rectal stump is closed with a stapler and oversewn. We leave a closed-suction drain when contamination has been heavy. Total operative time is 90 to 180 minutes.
Recovery
Most patients stay 5–10 days — longer for sicker presentations. A wound and ostomy nurse begins stoma teaching immediately. You will learn appliance changes, skin care, output management, and what's normal versus what to call about. Pain is controlled with a multimodal regimen. Diet advances as bowel function returns. Walking starts the day of surgery. We see you in clinic at 2 weeks and 6 weeks, and at the 6-week visit we begin discussing whether reversal is on the table. Full activity returns at 4–6 weeks. Long-term, with an end colostomy you can do nearly everything you did before — work, exercise, swim, travel — with appliance management as a part of the routine.
Reversal — what to know
Hartmann reversal restores intestinal continuity by reconnecting the colostomy to the rectal stump. It is typically planned 3–6 months after the index operation, once adhesions have softened and the patient has recovered nutritionally. About half of Hartmann colostomies are ultimately reversed — the others remain permanent because of age, frailty, advanced cancer, dense adhesions, or patient preference. The reversal itself is a major operation with risk of anastomotic leak (the rectal stump is often shortened and inflamed) and frequently requires a temporary loop ileostomy to protect the new anastomosis. We discuss reversal candidacy honestly and individually.
Why Florida Surgical
Hartmann procedures are usually emergencies, and the surgeon who does the index operation matters — for the technical decisions that prevent further complications, and for the continuity that gets a patient through stoma teaching, recovery, and reversal evaluation. Both Dr. Shaw and Dr. Decio cover acute care surgery at HCA Florida Northwest, HCA Florida Westside Regional, HCA Florida Woodmont, HCA Florida University, and Florida Medical Center, and we manage the entire course including reversal candidacy and operation when appropriate.
Frequently asked questions
When is a Hartmann procedure done?
The Hartmann procedure is most often done as an emergency operation for perforated diverticulitis with feculent or purulent peritonitis, obstructing left-sided colon cancer, severe rectosigmoid trauma, or anastomotic leak from a prior surgery. It is chosen when the colon cannot safely be reconnected at the index operation — usually because of contamination, hemodynamic instability, malnutrition, or tissue inflammation.
Is the colostomy permanent?
Not always. The colostomy is intended to be temporary in most cases — a reversal operation can restore intestinal continuity 3–6 months later. However, only about half of Hartmann colostomies are ultimately reversed. The reversal is itself a major operation, and patients who are elderly, frail, have advanced cancer, or have significant pelvic adhesions may not be reversal candidates. We discuss this realistically before and after surgery.
Can the Hartmann be done laparoscopically?
Yes — in select cases. A stable patient with perforated diverticulitis without massive contamination, an obstructing tumor without distended bowel, or a planned Hartmann for refractory diverticulitis can often be done laparoscopically. Emergency cases with feculent peritonitis, hemodynamic instability, or massive distention generally require an open approach for adequate exposure and washout.
What is recovery like?
Most patients stay 5–10 days — longer if they came in septic. Stoma teaching begins before discharge. You will work with a wound and ostomy nurse to learn appliance changes, skin care, and managing output. Pain is well controlled with a multimodal regimen. Activity gradually returns over 4–6 weeks. We see you in clinic at 2 weeks and 6 weeks.
What does the reversal involve?
Hartmann reversal reconnects the colostomy to the rectal stump, restoring continuity. It is typically done 3–6 months after the index operation, once adhesions have softened and the patient has recovered nutritionally. The operation can sometimes be done laparoscopically; an open approach is needed for hostile abdomens. Stay is typically 4–6 days. Risks include anastomotic leak (the rectal stump is often shortened and inflamed) and the possibility of needing a temporary loop ileostomy to protect the new anastomosis.