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Utskriftsdato (20.9.2017)

Hartmann's Operation of colorectal cancer


Medical editor Stein G. Larsen MD
Gastroenterological Surgeon
Oslo University Hospital
Norway

General

Hartmann's operation is applied when the conditions are not suitable for anastomosis and simultaneously when it is not necessary to remove the pelvic floor with the anal canal. Hartmann's operation is also performed if the patient has poor anal sphincter function or if the patient's general status is too poor to tolerate a possible anastomosis leakage.

The procedure is rarely used in localized primary cancer, and is often of a secondary choice.

Indications 

  • cancer in the rectum
  • cancer in the sigmoideum

Goals

  • Curation
  • Avoid damage to the autonomic pelvic nerves
  • Reduce the operation time by not removing the anal canal
  • Avoid delayed healing in the perineum as in a rectal amputation
  • Palliation if the patient has a long expected survival despite metastases

Equipment

  • Laparotomy tray
  • Staple instrument: cross stapling  /closing/cutting
  • Surgery table with adjustable leg supports

Preparation

  • Placement of the stoma is marked on the skin.
  • Patients in which an anastomosis is planned should have a thorough bowel emptying procedure.
  • Thrombosis prophylaxis
  • Antibiotic prophylaxis
  • Epidural catheter is inserted for postoperative pain treatment.
  • A bladder catheter is inserted.
  • The patient lies horizontally on the operation table with legs supported to be lifted easily if an anastomosis is to be performed.
  • The operation is carried out under general anesthesia. 

Implementation

Dissection

The resection is performed similar to a mesorectal excision.

  • A mid-line incision from the symphysis is normally extended to the right of the navel.
  • The sigmoid colon is released laterally.
  • The inferior mesenteric vessels are identified and divided distal to the left colic vessels.
  • The upper resection level is identified and the bowel is divided with a staple/dividing instrument.
  • The peritoneum is split on both sides of the rectum. The perimesorectal plane is followed dorsallyi and laterally. In front the plane is behind the vesicles and prostate/vagina. The dissection is followed all the way to the pelvic floor if the tumor is less than 12 cm from the anal verge, or 5 cm below the tumor if it is higher than 12 cm.
  • The sympathetic hypogastric nerve is identified if possible on the pelvic wall.
  • The parasympathetic pelvic plexus is often difficult to identify on the pelvic wall.
  • If possible, the bowel is closed at least 1 cm below the tumor.
  • The distal end is rinsed with distilled water.
  • A new row of staples is set at the desired level and the bowel is split between the rows of staples.

Reconstruction

  • Sigmoideostomy is made in the marked area of the left rectal sheath.
  • Vacuum drain is put in the pelvis.
  • The abdomen is closed.

Follow-up

  • The patient may be mobilized as early as possible.
  • The patient may begin to drink and eat on the first postoperative day.
  • The drain is removed when there is no longer fresh blood - usually on the 2nd–3rd day.
  • The bladder catheter is removed as soon as possible. Because the surgery often causes temporary bladder paralysis it may have to stay for about one week.  
  • The epidural catheter is removed usually after 2–3 days and the patient obtains an oral analgesic.

Complications from surgery

Early

  • Cardiopulmonary complications depend on patient general health status, the duration of the surgery, and extent.
  • Complications from stoma may occur.
  • Possible infection in the pelvis can perforate the rectal stump, and empty through the stump.

Damage to the autonomous nerves in the pelvis may cause:

  • bladder paralysis—often temporary
  • erection and ejaculation problems
  • vaginal dryness

Delayed

  • Ventral hernia in the abdominal incision and peristomal hernias may occur.
  • Postoperative ileus occurs in about 5% regardless of radiation treatment.
  • Stomal prolapse occurs relatively rarely.