A Hartmann procedure is a surgery that removes a diseased section of the lower colon, closes off the remaining rectal stump, and brings the healthy end of the colon through the abdominal wall to create a colostomy. First performed in 1921 by French surgeon Henri Hartmann, it remains one of the most common emergency operations for serious colon problems. The procedure is typically done in two stages: the initial surgery to remove the diseased bowel, and a second surgery months later to reconnect the intestine, if possible.
What Happens During the Surgery
The operation focuses on the sigmoid colon and upper rectum, the section of the large intestine just before the rectum. The surgeon removes the segment that is infected, perforated, or blocked. The cut end of the rectum is then stapled or sutured shut and left inside the abdomen. This sealed pouch is called the rectal stump.
The healthy upstream portion of the colon is brought through a small opening in the abdominal wall, usually on the left side, creating what’s called an end colostomy. Stool exits the body through this opening (called a stoma) into an external pouch rather than passing through the rectum. The stoma itself is a small, round piece of pink intestinal tissue that sits flush with or slightly above the skin surface.
Why Surgeons Choose This Procedure
The Hartmann procedure is most often performed as an emergency operation when the colon has perforated or become severely infected. The most common reason is complicated diverticulitis, where small pouches in the colon wall become inflamed and eventually burst, spilling intestinal contents into the abdominal cavity. Surgeons classify the severity of this contamination using a grading system (Hinchey stages I through IV), and the Hartmann procedure is a standard choice for the most severe stages: III (generalized pus throughout the abdomen) and IV (widespread fecal contamination).
It’s also used for obstructing colon cancer, traumatic colon injuries, and other situations where the bowel needs to be removed urgently but reconnecting it immediately would be too risky. The core logic is straightforward: eliminating the source of contamination and controlling infection take priority over restoring normal bowel function.
Surgeons tend to reserve this procedure for patients who are the sickest. Studies consistently show that the Hartmann procedure group includes a higher proportion of elderly, frail patients and those with severe sepsis compared to patients selected for immediate reconnection. Roughly 67% of Hartmann patients in comparative studies had significant underlying health problems, versus about 40% of patients who received a primary reconnection. When someone is hemodynamically unstable or has heavy fecal contamination, a Hartmann procedure is considered the safer, faster option.
Open vs. Laparoscopic Approaches
The surgery can be performed through a large abdominal incision (open) or through several small incisions using a camera and specialized instruments (laparoscopic). In emergency settings, open surgery is more common because it provides faster access. However, when laparoscopic surgery is feasible, patients benefit from shorter hospital stays. One study found an average hospitalization of about 5 days for the laparoscopic approach compared to 12 days for open surgery. Complication rates between the two approaches are similar, but recovery milestones like eating solid food happen sooner with laparoscopic surgery.
Recovery After the Initial Surgery
Hospital stays after an open Hartmann procedure typically range from 10 to 15 days, though this varies with the severity of the original problem and the patient’s overall health. Most people operated on in emergency situations are already in poor condition, which extends recovery.
One of the more significant early complications involves the rectal stump. In about 17% of cases, the sealed end of the rectal stump can break open (called a “blowout”) within the first 90 days, most commonly around 12 days after surgery. Nearly half of these blowouts occur at the staple or suture line. This is a serious complication that may require additional intervention. The reported incidence in the medical literature ranges from 3% to 33%, depending on the patient population studied.
Adjusting to life with a colostomy is one of the biggest challenges during recovery. Many patients report that stoma management significantly affects their quality of life. Learning to properly fit, empty, and change the colostomy pouch takes practice and usually involves guidance from a specialized stoma nurse. Skin irritation around the stoma is common early on but usually improves as patients develop a routine.
The Reversal Surgery
The Hartmann procedure is often described as temporary, but the reality is more complicated. Only 35% to 60% of patients ever undergo the second surgery to reverse the colostomy and reconnect the bowel. Many patients are too frail, develop new health problems, or simply choose not to go through another major operation.
For those who do proceed, the reversal typically happens about seven to eight months after the initial surgery, though the timing ranges widely from a few weeks to over two years. The reversal involves reopening the abdomen, freeing the colon from any scar tissue, locating and opening the rectal stump, and reconnecting the two ends. This is a significant operation in its own right, with complication rates of around 16% and a small but real mortality risk of roughly 3.6%. Leaking at the reconnection site occurs in about 3.6% of reversal patients.
When the reversal is done laparoscopically rather than through an open incision, patients tend to recover faster. One comparative study found the laparoscopic group returned to eating solid food in about 5 days versus 8 days for open reversal, and their hospital stay averaged 11.5 days compared to 15 days. Complication rates were statistically similar between the two approaches, though incisional hernias were the most common late complication regardless of technique, affecting about 24% of all reversal patients.
Living With a Permanent Colostomy
For the 40% to 65% of patients whose colostomy is never reversed, the stoma becomes a permanent part of daily life. This is not necessarily a medical failure. In many cases, the initial surgery saved the person’s life during a critical emergency, and the ongoing health risks of a reversal surgery simply outweigh the benefits, particularly for older patients or those with other serious conditions.
People with permanent colostomies can return to most normal activities, including work, exercise, travel, and social life. The adjustment period is real, though, and many patients benefit from support groups and ongoing follow-up with stoma care specialists. Modern pouching systems are discreet, odor-controlled, and designed for active lifestyles.