Hartmann operation

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Schematic representation of a Hartmann situation after Hartmann operation. A: Surgically removed section of the intestine. B: rectum blindly closed by suturing. C: Artificial anus drained through the abdominal wall (terminal colostoma )

The Hartmann operation (discontinuity resection according to Hartmann ) describes an operation on the large intestine on the sigmoid colon , in which the continuity of the intestine is interrupted after a resection . Here, the rectum is closed blindly and the upper oral end is diverted from the abdominal wall as an artificial anus. Indications for a Hartmann operation are inflammatory processes in the abdomen, acute peritonitis or a generally poor condition of the patient such as sepsis , severe trauma or palliative situations . Compared to a reanastomosing surgical technique, the Hartmann operation offers the advantage of a faster and therefore more patient-friendly surgical technique. The so-called Hartmann situation created by the Hartmann operation with blind closure of the rectum and the colostoma diverted through the abdominal wall can in principle be remedied in a further operation by reanastomosis after the acute disease has healed.

indication

The primary indication for Hartmann's operation is acute sigmoid diverticulitis or large intestinal perforations with accompanying purulent or fecal peritonitis. Further indications are sepsis with circulatory instability , severe abdominal trauma with intestinal perforation and necessary segment resection, rectal perforations , unsafe reanastomosis situations after removal of tumors, stenosing rectal carcinoma with accompanying ileus , pre-existing fecal incontinence and the general need for care of the patient.

All indications have in common that they aim to be patient-friendly by shortening the operation time in critical patients or reducing postoperative complications such as anastomotic leakage in high-risk patients.

Surgical procedure

In the Hartmann operation, a distinction is made between a two-stage and a three-stage procedure. In the three-stage procedure, the first step is the creation of a terminal colostomy, the blind closure of the anal stump and the creation of a drainage in the area of ​​the abdominal inflammation. In the second procedure, after the patient has stabilized, the affected section of the intestine is resected. After complete healing, a third operation is used to restore the continuity of the intestine and relocate the artificial anus. With the two-stage procedure, the first two steps are carried out in one operation. The three-stage procedure is associated with a significantly higher mortality than the two-stage procedure. While up to 44% of the patients die with the three-stage procedure, it is only up to 14% with the two-stage procedure. Current studies show that with the help of modern intensive therapy and gentle surgical technology, mortality in a one-step procedure with direct reanastomosis of the intestinal ends after resection can be superior to Hartmann's surgery. However, Hartmann surgery is still recommended for high-risk patients and those with massive peritonitis.

The operation can be performed both minimally invasive using laparoscopy and open surgery.

Alternatives

For patients without pronounced peritonitis or sepsis, an early surgical procedure is recommended, in which the large intestine is anastomosed again after the diseased section has been removed and a temporary double-barreled ileostomy is created as an artificial anus to protect and relieve the suture for healing . After the colon suture has healed, this can be moved back in an uncomplicated small operation.

Aftercare

After healing, a Hartmann situation can be surgically relocated about 2 to 6 months after the first operation. In 20% to 50% of patients with a Hartmann situation, this cannot be moved back. An artificial anus is to be left here for life.

Risks and Complications

In contrast to continuity-maintaining operations, the Hartmann operation has the advantage that the risk of anastomotic leakage is avoided. Suture insufficiency on the rectal stump is a possible risk. A later repositioning operation in a Hartmann situation is also afflicted with a significantly higher morbidity than in repositioning a double-barreled ileostomy. After the operation, some patients may experience problems with the artificial anus, such as prolapse or circulatory disorders. Other possible complications are hernias next to the stoma and stenoses or skin damage in the area of ​​the stoma.

history

In 1921, the French surgeon Henri Albert Hartmann presented two cases of patients at the 30th surgeon congress of the Association Française de Chirurgie in Strasbourg, in whom he had deviated from the then usual surgical procedure for colon tumors. Both patients had stenosing sigmoid carcinomas . Hartmann operated on both patients and removed the tumors and the accompanying lymph nodes with a sufficient safety margin . In contrast to the usual procedure at the time, however, he did not perform an anorectal amputation, but sutured the anal stump and left it in the patient. The patients recovered much faster from this gentle surgical method and were free of recurrences 9 and 10 months after the operation .

literature

  • Christian Ferdinand Jurowich Perioperative Management in Visceral and Thoracic Surgery Deutscher Ärzteverlag, 2003 ISBN 9783769104059
  • Michael Korenkov, Christoph-Thomas Germer, Hauke ​​Lang Gastrointestinal operations and technical variants: Surgical techniques of the experts Springer, 2013 ISBN 9783642322594
  • Asher Hirshberg, Kenneth L. Mattox Top Knife: Arts and Crafts of Trauma Surgery Springer, 2006 ISBN 9783211329184
  • Margret Liehn, Lutz Steinmüller, Roger Döhler Surgical Manual: Basics, Instruments, Surgical Procedure Springer, 2011 ISBN 9783642168451
  • Thomas Carus Operational Atlas Laparoscopic Surgery: Indications - Operational Procedure - Variants - Complications Springer 2014 ISBN 9783642312465
  • Wolfgang F. Caspary, Manfred Kist, Jürgen Stein Infectiology of the gastrointestinal tract , Springer, 2006 ISBN 9783540413592
  • Volker Schumpelick, Reinhard Kasperk, Michael Stumpf Surgery Atlas, Georg Thieme Verlag, 2013 ISBN 9783131537348

Web links

Individual evidence

  1. ↑ a b c Christian Ferdinand Jurowich Perioperative Management in Visceral and Thoracic Surgery , p. 193
  2. ↑ a b c d Michael Korenkov, Christoph-Thomas Germer, Hauke ​​Lang Gastrointestinal operations and technical variants: Surgical techniques of the experts , p. 276
  3. ↑ Asher Hirshberg, Kenneth L. Mattox Top Knife: Art and Craft of Trauma Surgery, p. 80
  4. ↑ a b Margret Liehn, Lutz Steinmüller, Roger Döhler OP manual: Basics, instruments, operating procedure , p. 158.
  5. ↑ Thomas Carus Operational Atlas of Laparoscopic Surgery: Indications - Procedure - Variants - Complications p. 270
  6. ↑ a b c d Wolfgang F. Caspary, Manfred Kist, Jürgen Stein Infectiology of the gastrointestinal tract p. 298
  7. ↑ a b c d e Alex Hotouras Henri Hartmann and his operation Grand Rounds Vol 8 pages L1 – L3 doi : 10.1102 / 1470-5206.2008.9001 (currently unavailable) ( online ), ( PDF 52.5KB)
  8. ↑ Volker Schumpelick, Reinhard Kasperk, Michael Stumpf Surgery Atlas , p. 315
  9. ↑ Henri Hartmann Nouveau procédé d'ablation of cancers de la partie du terminal colon publication on the 30th Surgery Congress of the Association Française de Chirurgie , Strasbourg 1921 ( PDF 25,4KB)