A Hartmann’s procedure is a surgery that removes a diseased section of the lower colon, closes off the remaining rectal stump, and reroutes the bowel to an opening in the abdomen called a colostomy. It’s most often performed as an emergency operation when part of the colon has perforated or become obstructed, and reconnecting the bowel immediately would be too risky. About 83% of these surgeries are done on an urgent basis.
How the Surgery Works
The operation targets the sigmoid colon and upper rectum, the section of large intestine on the lower left side of your abdomen. The surgeon removes the damaged portion, then divides the remaining anatomy into two separate ends. The downstream end, the rectal stump, is stapled or sutured closed and left inside the pelvis. The upstream end of healthy colon is brought through the abdominal wall to create an end colostomy, a small opening where stool exits the body into an external pouch.
This two-part approach is the defining feature of a Hartmann’s procedure. By not reconnecting the bowel right away, the surgeon avoids the risk of a new connection (called an anastomosis) breaking down in a patient whose body is already under severe stress from infection, inflammation, or trauma. Henri Hartmann first described the technique in 1921 as a way to reduce the high death rates that occurred when surgeons tried to rejoin the colon immediately after removing cancerous blockages.
Why It’s Performed
The most common reason is complicated diverticular disease, accounting for about 44% of cases. This typically means diverticulitis that has caused the colon wall to perforate, leading to infection spreading into the abdominal cavity. The second most common indication is colorectal cancer causing obstruction, at roughly 32%. The remaining cases involve a mix of conditions: reduced blood flow to the colon (ischemia), a twisted bowel (volvulus), or traumatic injury.
The procedure is generally chosen when the situation is too dangerous for a single-stage operation. A patient with widespread infection in the abdomen, unstable vital signs, or a weakened immune system is far more likely to have a bowel reconnection fail. In those circumstances, getting the diseased tissue out and diverting the stool stream through a colostomy is the safer path.
Recovery After Surgery
Expect to spend roughly seven to ten days in the hospital after the procedure. During that time, you’ll gradually move from IV fluids to clear liquids to solid food as your digestive system wakes back up. A stoma nurse will teach you how to care for your new colostomy before you go home.
Once home, most people need four to six weeks before they can return to manual labor or vigorous exercise. Full physical recovery, the point where you genuinely feel like yourself again, typically takes three to six months. Fatigue is common for several weeks, and you should avoid heavy lifting for at least six weeks to reduce the risk of a hernia at the surgical site.
Living with a Colostomy
After a Hartmann’s procedure, stool exits through the colostomy into an adhesive pouching system worn against the skin. You’ll learn to empty and change the pouch, usually on a predictable schedule since output from a colostomy tends to be more formed than from other types of stomas. Most people adapt to the routine within the first few weeks at home.
Diet matters, especially early on. For the first several weeks, stick to bland, low-fiber foods that are easy to digest: peeled fruits, canned fruits, soft melons, ripe bananas, and cooked vegetables. Avoid raw fruits with skin (like apples, strawberries, and grapes), carbonated drinks, and high-fiber foods until your system has had time to adjust. Introduce new foods one at a time so you can identify anything that causes gas, bloating, or discomfort. Some food intolerances that appear after surgery resolve as the colon heals.
Possible Complications
One complication specific to this surgery is rectal stump blowout, where the closed-off rectal stump leaks or develops an abscess in the pelvis. This occurs in roughly 17% of patients within the first 90 days, with a median onset around 12 days after surgery. About half of these cases involve a visible defect in the closure line, while the other half present as a pelvic abscess detected on imaging. Symptoms can include pelvic pain, fever, or discharge from the rectum.
A population-based study comparing Hartmann’s procedure to other rectal surgeries found it carries a higher risk of intra-abdominal infection but does not significantly increase the rates of reoperation, readmission, or 30-day mortality compared to alternative approaches. For patients who aren’t candidates for a more complex reconstruction, the overall complication profile is considered acceptable.
Can the Colostomy Be Reversed?
Yes, but not always. Reversal is a second surgery where the surgeon reopens the abdomen, frees the colostomy from the abdominal wall, locates the closed rectal stump, and reconnects the two ends of bowel. Younger patients, those in better overall health, and those whose original surgery was for a non-cancerous condition are the most likely candidates for reversal. Patients who had an emergency Hartmann’s procedure are actually about five and a half times more likely to undergo reversal than those who had elective surgery, likely because the emergency group tends to be healthier people who encountered an acute problem rather than patients with advanced cancer or multiple chronic conditions.
Reversal surgery usually requires a hospital stay ranging from one day to about a week, depending on complexity. Full recovery follows a similar timeline: fatigue for several weeks, no heavy lifting for about six weeks, and a return to normal activities within roughly six weeks for most people.
Not everyone gets reversed. Some patients have cancer that requires ongoing treatment, are too frail for another operation, or simply adapt to the colostomy and choose not to undergo a second surgery.
How It Compares to Primary Anastomosis
For perforated diverticulitis specifically, there’s an important alternative: removing the diseased segment and immediately reconnecting the bowel in a single operation, sometimes with a temporary small-bowel stoma to protect the new connection. A randomized trial (the LADIES trial) compared the two approaches in patients with severe diverticulitis who had pus or stool leaking into the abdominal cavity.
The results favored primary anastomosis. At 12 months, 95% of patients in the reconnection group were living without a stoma, compared to 72% in the Hartmann’s group. Short-term complication and mortality rates were similar between the two groups. Based on these findings, primary anastomosis is now preferred for hemodynamically stable patients under 85 who don’t have immune system problems. A Hartmann’s procedure remains the go-to choice for patients who are too unstable or too sick to tolerate the longer, more technically demanding reconnection surgery.