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Adieu to Henri Hartmann?

A Hartmann’s procedure is no longer the operative strategy of choice in the majority of emergency situations. Improvements in both diagnostic and interventional radiology and anti-microbial therapy combined with advances in minimal access surgery have resulted in a move towards one stage surgery with a resultant decrease in its utility. Henri Hartmann first described the procedure that became eponymous with his name in a communication to the 30th congress of the French Surgical Association in 1921.He proposed this as a procedure for removal of cancers of the distal part of the sigmoid colon, an alternative to the commonly performed procedure for such cases at that time, the abdomino-perineal resection, which was associated with a mortality rate of 38%. Hartmann detailed dissection distal to the tumour to the level of the levator ani with ligation of the middle haemorrhoidal vessels laterally. Anteriorly he dissected to the level of the seminal vesicles. His communication to the French Surgical Association reported on two such patients. Subsequently he went on to describe the procedure in 34 patients, three of whom died [1], thus his operative mortality rate was only 8.8% .The Radical dissection distal to the disease process as initially described was subsequently recognized as unnecessary. Even in the setting of a poorly differentiated tumour a distal margin of 5 cm is sufficient. A modification of the original procedure became a routine and invaluable emergency operation. However the Hartmann’s operation as employed today is a misnomer as it differs substantially from the operation initially described. The most dreaded sequelae of diverticular disease remains generalized peritonitis because of perforated diverticulitis. In 1984 Krukowski et al. analysed 57 reports on treatment of acute diverticular disease and concluded that operative mortality rates following resectional surgery were less than half those from nonresectional approaches [2]. The Hartmann procedure (HP) was then adopted as the ‘gold standard’ in the setting of perforated diverticulitis. However morbidity and mortality rates following a HP are estimated at 20–30% and 10– 15% respectively. In addition the patient requires further surgery to restore intestinal continuity with its incumbent risks and up to 30% do not have their stomas reversed. Perhaps in part because of these figures further studies sought an alternative to the HP. Recent papers have compared resection and primary anastomosis (PRA) with and without proximal diversion to HP in this setting and concluded that PRA may be superior except in high risk patients [3]. It has long been realized that the majority of patients with diverticular peritonitis do not have faecal peritonitis. This led others to question whether nonresectional surgery was wrongly discarded [4,5]. Recent reports of laparoscopic peritoneal lavage for perforated diverticulitis have shown that this approach may be superior to existing resectional operations in the setting of nonfaeculant peritonitis, with morbidity and mortality rates of 4% and 3% respectively [6]. Current best practice should include imaging in the form of CT to objectively stratify patients with clinical evidence of peritonitis. Those with localized abscesses should be initially managed conservatively with antimicrobial therapy, intravenous fluids and the option of radiological drainage considered. Patients with evidence of free perforation should undergo laparoscopy to assess whether they have purulent or faecal peritonitis. Those with purulent peritonitis in whom there is evidence of a sealed perforation should undergo laparoscopic lavage. While its feasibility under these circumstances is beyond doubt caution may need to be applied to certain patient groups. This approach depends on the patients inherent counter inflammatory mechanisms to prevent uncontrolled pro-inflammatory cascades [7]. Patients demonstrating signs of cardiovascular and renal dysfunction may not be ideal candidates. Co-morbid conditions that predispose to development of systemic inflammatory response and its sequelae such as diabetes mellitus, malnutrition and respiratory impairment may be relative contra-indications. Immunosuppressive conditions and therapies are absolute contraindications. Dissection of the phlegmon to identify a perforation should be avoided; however those patients with purulent peritonitis and evidence of a continuing free perforation, who are not shocked, should undergo resectional surgery, in the form Correspondence to: E. Myers, Department of Surgery, Saint Vincent’s University Hospital, Dublin, Elm Park, Dublin 04, Ireland. E-mail: eddiemyers@eircom.net