Hartmann's Procedure Explained

Hartmann’s procedure is an operation in which a diseased or damaged section of the left colon (usually the sigmoid) is removed, an end colostomy is formed, and the remaining rectum is closed as a stump. It is most often used in an emergency, when joining the bowel immediately would be unsafe. The colostomy may be temporary or lifelong, depending on later reversal.

What Hartmann’s procedure involves

The operation has three essential steps. The surgeon removes the diseased segment of bowel — most often the sigmoid colon and upper rectum. The remaining rectum (or distal colon) is closed and left in the pelvis; this blind-ending pouch is called the rectal stump, or Hartmann’s pouch. The healthy cut end of the proximal colon is brought out through the abdominal wall as an end colostomy.

It may be performed through a conventional open incision or, in selected people, with a laparoscopic (keyhole) approach. In a true emergency an open operation is still common, because the abdomen may contain pus or faeces and the tissues can be inflamed and fragile.

The procedure is named after the French surgeon Henri Hartmann, who described it in 1921 as a treatment for rectal cancer. Its modern role is broader. It is now used far more often for emergency left-sided colonic disease than as a planned cancer operation.

Why surgeons choose it

Joining two ends of bowel (an anastomosis) is unsafe when the person is very unwell, the bowel is unprepared, or the tissues are swollen, infected or poorly perfused. A leak from a new join in those circumstances can be life-threatening. Hartmann’s procedure avoids an anastomosis altogether: intestinal waste leaves through the colostomy, and the closed stump is left to heal.

Typical reasons include perforated or obstructing diverticulitis of the sigmoid colon; obstructing or perforated left-sided colorectal cancer when an immediate join is judged too risky; ischaemic (poorly blood-supplied) bowel; trauma, volvulus, or an anastomotic leak from a previous operation; and, occasionally, complex inflammatory bowel disease affecting the left colon.

Elective (planned) Hartmann’s procedures are less common. They may be chosen when a person is frail, has severe other illness, or has a very low tumour where sphincter-preserving surgery is not appropriate and a permanent colostomy is already expected.

Evidence comparing emergency Hartmann’s procedure with resection plus primary anastomosis (sometimes protected by a temporary loop ileostomy) is mixed. Randomised trials in selected, more stable patients with perforated diverticulitis have suggested that primary anastomosis can be safe in experienced hands and may leave more people stoma-free later. In everyday emergency practice, Hartmann’s procedure remains widely used, particularly for the sickest patients. The choice is individual and should be explained by the operating team.

The colostomy and the rectal stump

After Hartmann’s procedure the person has an end colostomy, usually sited in the left lower abdomen. Stool is typically formed or semi-formed, because most of the colon remains in circuit. Output and pouch routine vary. A stoma care nurse will teach pouch changing, skin care and how to recognise problems such as leakage, retraction or a parastomal hernia.

Readers should consult their stoma care nurse or clinician for personal advice about siting, appliances and any change in output — generic descriptions cannot replace that assessment.

Mucus from the anus

The rectal stump still produces mucus. Many people notice a small amount of mucus, and sometimes old blood, passed from the anus in the weeks after surgery. This is expected. If mucus builds up or irritates the skin, the clinical team may discuss options for managing the stump. There is no single home method that suits everyone, and nothing should be introduced into the rectum without advice. Ask your stoma care nurse or colorectal team first.

A condition called diversion colitis can develop in the unused stump: inflammation related to the lack of the usual faecal stream. It may cause discharge, spotting or discomfort. Treatment, if needed, is guided by a clinician.

Is the stoma temporary?

Hartmann’s procedure is often described as creating a “temporary” colostomy, but that language can mislead. Reversal is a second major operation and is not automatic. Published series show that a substantial proportion of people — especially older adults, those with major other illness, or those treated for advanced cancer — never have the stoma reversed. Whether reversal is offered depends on recovery, remaining bowel length and quality, pelvic scarring, cancer staging and the person’s own wishes.

Recovery after surgery

Emergency Hartmann’s procedure is major abdominal surgery, often undertaken when the person already has sepsis or obstruction. A hospital stay of one to two weeks is common, and longer if there has been peritonitis or a period in intensive care. Pain control, early mobilisation, breathing exercises and a gradual return to eating are the usual pattern of care.

The stoma may not work immediately. When it does, output can be loose at first. Hydration and a stepwise diet are guided by the ward team and stoma care nurse. Before discharge, most people should be confident with emptying and changing their pouch, and should know whom to contact if the stoma becomes high-output, the skin breaks down, or they develop abdominal pain, fever or vomiting.

At home, recovery continues over weeks to months. Heavy lifting is usually restricted while the abdominal wall heals, to reduce hernia risk. Driving, work and sex can resume when the person feels well and their clinician agrees — there is no single timetable. Follow-up includes wound and stoma review and, where cancer was the indication, discussion of histology and any further oncological treatment.

Seek urgent medical help for severe abdominal pain, high fever, persistent vomiting, a dusky or sunken stoma, or heavy rectal bleeding.

Reversal of Hartmann’s procedure

Reversal (restoration of bowel continuity) reconnects the remaining colon to the rectal stump and closes the colostomy. It may be open or laparoscopic. Timing is typically several months after the original operation, once inflammation has settled, nutrition has improved and, in cancer, once any adjuvant treatment is complete. Imaging or endoscopy of the stump is often done first to confirm it is suitable.

Reversal carries the risks of any major bowel operation, including anastomotic leak, ileus, infection, bleeding and a further stoma if a join cannot be safely completed. Some people are left with altered bowel habit — frequency, urgency or clustering of stools — because part of the colon and a length of rectum have been lost. Pelvic nerve effects on bladder and sexual function are possible, as they are after the original pelvic dissection.

Not everyone is a candidate. Frailty, metastatic cancer, a very short or damaged stump, dense adhesions, or a preference for keeping a well-functioning colostomy are common reasons to leave the stoma as it is. A well-sited, well-managed colostomy can support a full life. The decision is a balance of risk and benefit, not a test of courage. Discuss it with the colorectal surgeon and stoma care nurse.

Living well in the meantime

Most people with an end colostomy after Hartmann’s procedure return to a varied diet, bathing, swimming and social life. A few practical points are worth knowing.

Flatus and odour are managed with a well-fitted pouch and filters; diet tweaks help some people but are individual. Parastomal hernia is relatively common after emergency stomas; support garments may be advised, and surgical repair is a separate decision. Medicines, including some painkillers, can constipate or loosen output — check with a pharmacist or nurse rather than stopping prescribed treatment. If cancer was the indication, surveillance of remaining bowel still applies.

Psychological adjustment after emergency surgery and a stoma can be substantial. Many hospitals can signpost counselling or peer support. Feeling low, especially in the first months, is not a personal failure.

Always involve your stoma care nurse or clinician in decisions about the stoma, the stump, reversal and any new symptom. They know your operation and your other health conditions.

The bottom line

Hartmann’s procedure removes diseased left colon, creates an end colostomy and closes the rectal stump. It is a well-established emergency operation when an immediate bowel join would be unsafe. The stoma may later be reversed, but many people live long term with a colostomy and do well. Outcomes depend on the original illness, surgical recovery and personal circumstances. Questions about your own operation, reversal and stoma care should be directed to your colorectal team and stoma care nurse.