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iSSN 2413-6077. iJMMr 2022 Vol. 8 issue 1

DOI 10.11603/ijmmr.2413-6077.2022.1.13043

CLINICAL OUTCOMES OF REVERSAL OF HARTMANN’S PROCEDURE

I. Ya. Dzyubanovskyy, A. D. Bedeniuk, *S. Y. Grytsenko 
I. HORBACHEVSKY TERNOPIL NATIONAL MEDICAL UNIVERSITY, TERNOPIL, UKRAINE. 

Background. Reversal of Hartmann’s procedure (HP) is one of the most complex surgical interven-
tions in abdominal surgery with high morbidity rates of up to 58% in the patients after HP and mortality of up 
to 3.6%.

Objective. This was a retrospective observational study to analyze the Hartmann’s reversal (HR) outcomes.
Methods. The study involved 31 patients (16 males and 15 females), average age 59.6±10.31 (range 26-80), 

who underwent HR at Ternopil Regional Hospital in 2010 - 2021. The reasons for the HP were: cancer in 20 (64.5%) 
cases, perforation of the diverticulum – 6 (19.3%), traumatic rupture – 3 (9.7%) and Crohn’s disease - 2 (6.4%) cases.

Results. Median time from Hartmann’s procedure to reversal was 11.13±9.24 months (interval 3-38). 
Intraoperative time was 210.33±56.91 minutes (range 120-330). HR was performed in 30 (96.8 %) patients. Dense 
pelvic adhesions of the stump of the rectum was diagnosed in 13 (41.9%) patients. Hand-sewn anastomosis was 
performed for 22 (71%) patients, stapler anastomosis – 4 (12.9%), pull-through technique – 3 (9.7%) patients. AL 
occurred in 3 (9.7%) patients on the 15th, 23rd and 35th postoperative days. pseudomembranous colitis was 
diagnosed in 2 (6.4%) patients with AL. The mortality rate was 1 (3.3%) as a result of septic complications due to 
AL; this case was not operated by a colorectal surgeon due to administrative issue in the hospital.

Conclusions. Hartmann’s reversal is still one of the most difficult operations in colorectal surgery with high 
incidence of postoperative complications. Sound selection of patients with low comorbidity and in suitable time 
period is crucial for successful HR.

KEYWORDS: Hartmann’s procedure; reversal; anastomotic leakage.

*Corresponding author: Stepan Grytsenko, Assistant Professor, 
I. Horbachevsky Ternopil National Medical University, Ternopil, 
46000, Ukraine. 
E-mail: grytsenko_s@tdmu.edu.ua

International Journal of Medicine and Medical Research 
2022, Volume 8, Issue 1, p. 44-47
copyright © 2022, TNMU, All Rights Reserved

Introduction
A century has passed since Henry Hartmann 

firstly performed the widely known operation, 
but it has not lost its relevance and is fre-
quently used around the world to pre vent 
anastomotic leakage (AL), which remains an 
eternal problem in colorectal surgery [1]. 
Reversal of Hartmann’s procedure (HP) is one 
of the most complex surgical interven-
tions in abdominal surgery with high morbidity 
rates of up to 58% in the patients after HP and 
mortality of up to 3.6% [6, 8]. Multifactorial 
technical difficulties particular to reversal 
include dense pelvic adhesions, pelvic infection, 
adhesions, difficulty in identification of rectal 
stump and perfoming of colorectal anastomosis 
with short rectal stump [1, 7]. As a result, more 
than two-thirds of patients remain with a 
permanent stoma following Hartmann’s pro-
cedure, either due to inability to perform 
reversal or due to anastomotic leak and stoma 

restoration [1, 6, 7]. The majority of ostomy 
patients become socially and psychologically 
maladapted need to manage the physical and 
psychological challenges associated with 
a stoma [7]. 

Methods
This was a retrospective observational 

study to analyze the Hartmann’s reversal (HR) 
outcomes. The study involved thirty-one pa-
tients (16 males and 15 females) of average 
age 59.6±10.31 (range 26-80), who underwent 
HR at Ternopil Regional Hospital in 2010-2021. 
The median BMI was 25.2 (range 18-39). Most 
of the patients (80.6 %) had an ASA score 3-4. 
Median time from Hartmann’s procedure to 
reversal was 11.13±9.24 months (interval 3-38). 
Intraoperative time was 210.33±56.91 minutes 
(range 120-330). Blood loss was 331.67±191.4 ml 
(range 150-1000). The reasons for the HP 
were: cancer in 20 (64.5%) cases, perforation of 
the diverticulum – 6 (19.3%), traumatic rupture – 
3 (9.7%) and Crohn’s disease – 2 cases (6.4%) 
(Table 1). 

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iSSN 2413-6077. iJMMr 2022 Vol. 8 issue 1 I. Ya. Dzyubanovskyy et al.

Quantitative variables were calculated with 
the median. All calculations were performed 
using the Statistica 64 software.

Results
HR was performed for 30 (96.8 %) patients. 

Mobilization of the splenic flexure was per­
formed for 5 (16.1%) patients. Dense pelvic 
adhesions of the stump of the rectum was 
diagnosed in 13 (41.9%) patients. Hand-sewn 
anastomosis was performed for 22 (71%) 
patients, stapler anastomosis – 4 (12.9%), 
reduction – 3 (9.7%) patients. paracolostomy 
hernia was diagnosed in 7 (22.6%) patients. The 
mean hospital stay was 14.03±11.3 days 
(interval 7-62).

AL developed in 3 (9.7%) patients on the 
15th, 23rd and 35th postoperative days (Table 2). 
pseudomembranous colitis was diagnosed in 
2 (6.4%) patients with AL. 1 patient after HR was 
affected with Covid-19 on the 12th postoperative 
day, probably it was one of the major favorable 
factors of AL development which was diagnosed 
on the 35th postoperative day due to systemic 
infection and reducing the reactivity of the 
immune system. The mortality rate was 1 (3.3%) 
as a result of both sepsis and purulent peritonitis 
due to AL; this case was not operated by a 
colorectal surgeon due to administrative issue 
in the hospital.

Discussion
Adequate patient selection and preoperative 

planning are extremely important for HR pro-

cedures to reduce the risk of postoperative 
complications [1]. Patients with a benign 
disease, aged under 69 years old and with low 
comorbidity are more likely of undergoing HR 
[6, 8]. In our study AL was diagnosed in 3 (9.7%) 
patients aged 63-80 years old and ASA score 
3-4.

Chronic infection (cured abscess and in-
fected pelvis infiltratis) is one of the major 
factors influencing HR outcome and usually 
creates technical difficulties during surgery in 
the form of dense pelvic adhesions [4, 7]. These 
challenges made performing HR impossible in 
one patient in our study. 

One of the important factors is the optimal 
interval between HP and HR. According to the 
literature the best time to perform HR is at least 
6 months after the surgery [5, 7]. In our study 
t h e  i n t e r v a l  b e t w e e n  H P  a n d  H R  w a s 
11.13±9.24 months (interval 3-38), however, 
such results were obtained by inclusion of 
3  patients, who underwent HR at 36-38 months 
after HP. Other authors show that timing of 
surgery (more than 6 months) do not affect 
surgical complications rate or severity or the 
length of hospital stay [5]. In the study 
paracolostomy hernia was evidenced in 7 
(22.6%) patients, nevertheless at the same time 
it did not increase the complication rate.

Laparoscopic HR has significant privilege 
under open HR with less short-term comp-
lications regarding the overall morbidity, less 
frequency of wound infection and postoperative 
ileus [2, 3].

Table 1. Indications for Hartmann’s procedure

Indications for Hartmann’s procedure n %
Colorectal cancer 20 64.5
Perforation of the diverticulum 6 19.3
Traumatic rupture 3 9.7
Crohn’s disease 2 6.7

Table 2. Analasis of patients with AL

Clinical data/patients 1 2 3
Age 80 63 69
Sex female female female
Indications for HP perforation colorectal cancer perforation
Months between HP and HR 4 14 13
Relaparotomy + + +
AL on … postoperative day 15 23 37
Hand-sewn anastomosis + + +
Pseudomembranous colitis – + +
Covid-19 – – +
Hospital discharge/death 19(death) 42 56



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iSSN 2413-6077. iJMMr 2022 Vol. 8 issue 1

Conclusions 
Hartmann’s reversal is still one of the most 

difficult operations in colorectal surgery with a 
high incidence of postoperative complications. 
Sound selection of patients with low comorbidity 
and in period of 6-12 months after HP is crucial 
for successful HR.

Conflict of Interests
Authors declare no conflict of interest.
Authors’ Contributions.
Ihor Dzyubanovsky – conceptualization, 

writing – reviewing and editing; Anatoliy Be-
deniuk – methodoly, formal analysis; Stepan 
Grytsenko – investigation, data curation, wri­
ting – original draft.

КЛІНІЧНІ РЕЗУЛЬТАТИ ЗАКРИТТЯ СТОМИ ПІСЛЯ ОПЕРАЦІЇ ГАРТМАНА 

і. Я. Дзюбановський, а. Д. Беденюк, с. Й. Гриценко
ТЕРНОПІЛЬСЬКИЙ НАЦІОНАЛЬНИЙ МЕДИЧНИЙ УНІВЕРСИТЕТ ІМЕНІ І. Я. ГОРБАЧЕВСЬКОГО МОЗ УКРАЇНИ, 

ТЕРНОПІЛЬ, УКРАЇНА
 
Вступ. Закриття стоми після операції Гартмана є однією з найскладніших хірургічних втручань в 

абдомінальній хірургії з високим рівнем захворюваності до 58% і смертністю до 3,6%.
Мета. Це ретроспективне обсерваційне дослідження з метою аналізу клінічних результатів 

закриття стоми після операції Гартмана.
Методи. Тридцять один пацієнт (16 чоловіків та 15 жінок) із середнім віком 59,6±10,31 років (діапазон 

26-80), які проходили курс лікування у Тернопільській обласній лікарні з 2010 по 2021 рік. Причинами 
операції Гармана були: рак у 20 (64, 5%) випадків, перфорація дивертикула – 6 (19,3%), травматичний 
розрив – 3 (9,7%) та хвороба Крона – 2 (6,4%).

Результати. Середній час між операцією Гартмана та реконструктивно-відновною операцією 
становив 11,13±9,24 місяця (інтервал 3-38). Інтраопераційний час становив 210,33±56,91 хв (діапазон 
120-330). Реконструктивно-віднову операцією виконано у 30 (96,8 %) пацієнтів. Щільні тазові спайки 
кукси прямої кишки діагностовано у 13 (41,9%) хворих. 22 (71%) пацієнтам накладено ручний анастомоз, 
степлерний анастомоз у 4 (12,9%), низведення у 3 (9,7%). Неспроможність анастомозу виникла у 3 (9,7%) 
пацієнтів на 15, 23 та 35 добу після операції. У 2 (6,4%) хворих з неспроможністю анастомозу 
діагностовано псевдомембранозний коліт. Летальність у 1 (3,3%) випадку внаслідок септичних 
ускладнень зумовлених неспроможністю анастомозу, цей випадок неоперований колоректальним 
хірургом.

Висновки. Закриття стоми після операції Гартмана залишається однією з найскладніших операцій 
в колоректальної хірургії з високим відсотком післяопераційних ускладнень. Правильний відбір пацієнтів 
з низьким рівнем супутньої патології та в правильний період часу є важливим ключем до успішного 
виконання реконструктивно-відновної операції.

КЛЮчоВі сЛоВа: операція Гартмана; закриття стоми; неспроможність анастомозу.

Information about the authors 
Ihor Dzyubanovsky, Professor, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine. 
https://orcid.org/0000­0001­8852­3938, e­mail: dzubanovsky@tdmu.edu.ua
Anatoliy Bedeniuk, Professor, I. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine. 
https://orcid.org/0000­0003­1649­7886, e­mail: bedenyuk@tdmu.edu.ua
Stepan Grytsenko, Assistant Professor, I. Horbachevsky Ternopil National Medical University, Ternopil, 

Ukraine. 
https://orcid.org/0000­0002­6422­093X, e­mail: grytsenko_s@tdmu.edu.ua

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References
1. Alberto Bitran, Roberto Rasslan, Fabio de 

Oliveira Ferreira, Edivaldo Massazo Utiyama, Samir 
Rasslan. Hartmann’s reversal as a safe procedure 
for selected patients: analysis of 199 patients at a 
high-volume center in Sao Paulo. Surg Today. 2020; 
50(8):855­62. 

https://doi.org/10.1007/s00595­020­01957­0.
2. Chen Z, Nair N, Hanif U. Outcomes of lapa-

roscopic vs. open reversal of Hartmann’s pro cedure: 
a single centre experience. Cureus. 2021;13(8): 
e17242. 

https://doi.org/10.7759/cureus.17242.
3. Chavrier D, Alves A, Menahem B. Is laparoscopy 

a reliable alternative to laparotomy in Hartmann’s 
reversal? An updated meta-analysis. Tech Coloproctol. 
2022;26(4):239­52. 

https://doi.org/10.1007/s10151­021­02560­2.
4. Hess GF, Schäfer J, Rosenthal R, Kettelhack C, 

Oertli D. Reversal after Hartmann’s procedure in 
patients with complicated sigmoid diverticulitis. 
Colorectal Dis. 2017;19(6):582­8. 

https://doi.org/10.1111/codi.13553.

5. Horesh N, Lessing Y, Rudnicki Y, Kent I, 
Kammar H, Ben-Yaacov A et al. Timing of colostomy 
reversal following Hartmann’s procedure for 
perforated diverticulitis. J Visc Surg. 2020;157(5):395­
400. 

https://doi.org/10.1016/j.jviscsurg.2020.01.005.
6. Horesh N, Rudnicki Y, Dreznik Y, Zbar AP, 

Gutman M, Zmora O et al. Reversal of Hartmann’s 
procedure: still a complicated operation. Tech 
Coloproctol. 2018;22(2):81­7. 

https://doi.org/10.1007/s10151­017­1735­4.
7. Nir Horesh, Yonatan Lessing, Yaron Rudnicki, 

Ilan Kent, Haguy Kammar, Almog Ben-Yaacov et al. 
Considerations for Hartmann’s reversal and Hart-
mann’s reversal outcomes-a multicenter study. Int 
J Colorectal Dis. 2017;32(11):1577­82. 

https://doi.org/10.1007/s00384­017­2897­2.
8. Hallam S, Mothe BS, Tirumulaju RMR. Hart-

mann’s procedure, reversal and rate of stoma-free 
survival. Ann R Coll Surg Engl. 2018;100:301–7. 

https://doi.org/10.1308/rcsann.2018.0006.

Received 19 May 2022; revised 29 May 2022;  
accepted 14 June 2022.

This is open access article distributed under the Creative Com-
mons Attribution License, which permits unrestricted use, 
distribution, and reproduction in any medium, provided the 
original work is properly cited.

I. Ya. Dzyubanovskyy et al.