Intraoperative Decision-Making for Hartmann’s Procedure in Rectal Cancer Surgery

Overview

This retrospective multicenter study analyzed 1,141 rectal cancer patients in Sweden to identify factors influencing the selection of Hartmann’s procedure (HP) versus anterior resection (AR) or abdominoperineal resection (APR). HP was performed in 24% of cases, often in older patients with more comorbidities, and intraoperative decisions to switch from AR to HP were documented with specific clinical reasons.

Background

Anterior resection (AR) with total mesorectal excision is standard for middle and upper rectal cancers, while abdominoperineal resection (APR) is recommended for tumors ≤5 cm from the anal verge. Hartmann’s procedure (HP), originally described in 1921, is an alternative for patients at high risk of anastomotic leak or with adverse intraoperative events. Although HP was previously questioned due to pelvic sepsis risk, recent data suggest it is a safe option. However, indications for HP vary widely, and intraoperative changes from AR to HP are not well studied.

Data Highlights

Key Findings

• HP patients were significantly older and had higher ASA scores compared to AR and APR groups (p < 0.001).
• HP patients more frequently had cardiovascular disease and diabetes.
• 19 patients registered as AR and 2 as APR actually underwent HP, indicating intraoperative changes in surgical plan.
• HP was chosen intraoperatively due to adverse events or high risk of anastomotic complications.
• HP accounted for 24% of surgeries in this cohort, reflecting its role as an alternative to AR and APR in selected patients.

Clinical Implications

Surgeons should consider HP as a viable option in older rectal cancer patients with significant comorbidities or when intraoperative findings suggest high risk for anastomotic leak. Awareness of factors predicting the need for intraoperative conversion to HP can improve surgical planning and patient counseling. HP may reduce postoperative complications in high-risk patients without compromising oncological outcomes.

Conclusion

Hartmann’s procedure remains an important surgical option for rectal cancer patients with specific risk profiles or intraoperative challenges. This study highlights the patient factors and intraoperative considerations influencing the choice of HP, supporting its continued use in appropriate clinical scenarios.

References

1. Swedish National Guidelines 2020 -- Rectal Cancer Treatment Recommendations
2. Hartmann HA 1921 -- Original Description of Hartmann’s Procedure
3. Swedish ColoRectal Cancer Registry 1996-2017 -- Registry Data Source