Hartmann's procedure was described in 1923 as a technique for the treatment of rectal cancer. It is now frequently performed when primary bowel reanastomosis is deemed unsafe, as in obstructing or perforated diverticular disease, some cases of colon cancer, inflammatory bowel disease, and colorectal trauma. In this procedure, the diseased sigmoid is resected, an end colostomy is created, and the rectal stump is closed off (Fig. 6.14). The Hartmann pouch is a blind segment, which is generally reattached to the proximal colon at a later date, usually within 3 to 6 months after the initial surgery. In some cases, reanastomosis is never performed; for example, it may be thought to be unsafe because of high surgical risk due to poor medical condition,
technical difficulty, or patient noncompliance. The classic pouch contains only the rectum, however in reality, the pouch may be substantially longer, and may include the entire sigmoid colon and may even extend to the transverse colon. If the pouch has been closed by stapling, the length of the pouch can be estimated by examination of the scout film of the abdomen. Generally, the pouch is "dropped" into peritoneal cavity, but it may be sutured to the anterior abdominal wall (Fig. 6.15).
Radiographic assessment after Hartmann's procedure may be necessary in the early postoperative period to assess for complications. In the early postoperative period, the most common complication
is breakdown and leakage from the rectal stump (Fig. 6.16). Leakage may be intraperitoneal or extraperitoneal, depending on the location of the stump. The reported leakage rate has ranged from 2 to 9% . Leakage from the rectal stump is the cause of the highest morbidity and mortality after the first stage of this procedure . Water-soluble contrast medium should be used to assess for leaks in the early postoperative period. When one is performing these studies, care must be taken not to inflate the balloon unless absolutely necessary, since high pressure may be produced in the rectum proximal to the balloon could lead to bowel perforation. CT imaging can identify a pelvic abscess as a further complication (Fig. 6.17). Routine contrast studies of the pouch and proximal colon via the colostomy are usually performed before
takedown of the colostomy and reanastomosis of bowel. The purpose of this is to assess the colonic anatomy and the length and integrity of the pouch. It is important to determine the length of the pouch and its relation to the colostomy, which will affect surgical planning. The pouch can slowly shorten over time, thereby changing its original relationship to the proximal diverted colon .
Complications involving the pouch in the later postoperative period include leakage, diversion colitis, stricture, fistula, pelvic adhesions, and recurrent carcinoma. Unexpected, asymptomatic leaks were identified in two patients, 3 and 7 months after creation of a Hartmann's pouch in one series of 84 patients . For this reason, Cherukuri et al. advocate the use of water-soluble contrast medium rather than barium for study of the pouch, even months after surgery .
Diversion colitis, which can occur in any portion of the colon diverted from the fecal stream, is discussed in the section on colostomy. Fistulas have been reported from the rectal stump to the ileum and anterior abdominal wall. Pelvic adhesions may cause deformity of the proximal end of the pouch, simulating a leak or stricture, or they may interfere with complete filling of the pouch and lead to the erroneous interpretation, namely, that the pouch is shorter than its actual size. In patients who have had surgery for carcinoma of the colon, recurrence tumor may be detected in the pouch or pelvis. Primary carcinoma may develop in the rectal stump in patients who have had surgery for benign disease [10,11]. Since this is an "unused" segment and the pouch is diverted from the fecal stream, such tumors may grow to a large size without producing symptoms. For this reason, routine study of the pouch in patients with long-term Hartmann's procedures is advocated. The blind pouch may also contain polyps, fecal debris, and inspissated mucus.
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