Hartmann’s Procedure

Patient information - General Surgery

General Surgery
Hartmann’s
Procedure

Introduction
This booklet provides information about your operation. Please do not hesitate to ask
any questions that you or your family/whanau may have. This booklet also provides
information on support networks, services provided within the hospital and what to
expect following treatment. There is a space at the end of this booklet to write down
any questions that you may have.

What is the Large Bowel (Colon) and Rectum?

The large bowel (colon) and rectum is a muscular tube, approximately 1.5 meters long
and is divided into 7 sections; the caecum, the ascending colon, the transverse colon,
the descending colon, the sigmoid colon, the rectum and the anus.

After food has been swallowed, it passes down through the gullet and stomach into the
small bowel. As food passes through the small bowel it is digested and the body
absorbs essential vitamins and nutrients. From here the food passes into the large
bowel (colon).
 The main functions of the large bowel are
 To absorb water and salt back into the body
 To store waste (faeces or stool)
 To secrete mucous which acts as a lubricant

Ref: 3049 Authorised by: CD, Dept Surgery April 2015

Types of Surgery
Open Surgery
Some patients will have open surgery, which is an incision (cut) in the abdomen called a laparotomy.

Laparoscopic Surgery
This is a relatively new approach to bowel surgery in which the operation is done through small incisions
using specialized equipment. Some advantages of this can be early recovery and return to work,
reduced scarring of the abdomen and fewer respiratory problems. Your surgeon will offer laparoscopic
surgery if it is suitable for you.

Hartmann’s Procedure
A Hartmann’s procedure is usually performed in an acute
(emergency) situation for diseases of the sigmoid colon or rectum
including
 Cancer
 Diverticulitis
It is usually performed by open surgery (see above). The diseased
area is removed and the bowel is not re-joined. A temporary or
permanent bag (colostomy) is required. If this is a temporary bag,
you may require one or two more operations to return your bowel
function to normal.

What is a Colostomy?
A colostomy is an opening on your abdomen where the large bowel is brought up through the muscle
layers to the abdominal wall and stitched to the skin. A bag is placed over this opening to allow your
bowel motion to be collected. You will be seen by a stomal therapist prior to your surgery if appropriate.
They will provide you with information and support. A mark will be placed on your abdomen which will
identify a suitable site for the stoma. Whilst in hospital you will be seen regularly by the stomal therapist
to teach you how to care for your stoma. Initially on discharge from the hospital the stomal therapist will
visit you at home to provide on-going support, education and bags. You will then be followed up at their
clinic. If you live outside of the Canterbury region you will be followed up by your local stomal therapy
service. Following this operation you may still pass mucous or discoloured fluid through your anus. The
frequency may vary from once to several times, but this is not uncommon. If you have concerns about
this please discuss them with your GP or surgeon. Once you have recovered from your surgery you will
need to have a colonoscopy (flexible telescope test) to examine your bowel. This will determine whether
it is possible to reconnect the bowel together again. This is done at an outpatient clinic appointment in
the gastroenterology department.

Stage 2 – Closure of Colostomy

The colostomy closure is done as a second operation usually twelve months after your first operation
(please refer to Reversal of Hartmann’s Procedure pamphlet). Occasionally a different bag (ileostomy)
is required as part of this operation to allow the new join in the bowel to heal. If this occurs you will need
a third operation to join your bowel together again. You will have an x-ray to check how well the join has
healed approximately three to six months after you have left hospital after the second operation. This is
done at an outpatient clinic appointment in the x-ray department.

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Stage 3 – Closure of Ileostomy
The ileostomy closure is done as a third operation usually within six to twelve months after your
second operation (please refer to Closure of Ileostomy pamphlet).

Preparing for Surgery

A Hartmann’s procedure is often performed as an emergency operation therefore there is little time to
plan and prepare you for your surgery.

Complications of Surgery
About one in three people having bowel surgery will have a complication related to their operation.
Most of these are very minor but some are more significant and may be life threatening.
Complications can be divided into those related to the anaesthetic and those related to the surgery.
Your anaesthetist will discuss the anaesthetic with you. If you have any further concerns please
discuss them with your surgeon or his/her team. Some of the significant complications are discussed
below.

Bleeding
Bleeding can occur during surgery or even up to a few days later. If this happens, you may need a
blood transfusion but this is only given with your consent. Occasionally we use radiological techniques
(x-ray) to stop the bleeding and rarely surgery is required.

Infection
Infection can occur in a number of sites including inside the abdomen, the lungs, the bladder and in
the wound. A number of techniques are used to prevent infection. These include antibiotics, sterile
wound dressings and isolation of patients with bad infections. It is an expectation of the surgical team
that you begin mobilising either the day of your operation or the day after to reduce the risk of this
complication.

Bowel Obstruction
This is usually caused by internal scarring. It can occur after any abdominal operation, sometimes
years later. Mostly it is treated with intravenous fluids (a drip), pain relief and sometimes a drainage
tube, which is inserted through your nose and passed down into the stomach (nasogastric tube).
Mostly it does not require another operation and will settle with the above treatment. The symptoms of
a bowel obstruction are a combination of
 Not passing wind or a bowel motion
 Abdominal pain or cramps
 Vomiting

Death
The chance of dying as a result of your surgery is very low (less than one per cent), but this risk
increases as you get older (>80 years), or if you are very unwell at the time of your surgery (for
example people having emergency surgery for a bowel obstruction or bowel perforation).

Wound Hernia
Like some bowel obstructions this is a late complication and may take some years to present. Hernias
are a weakness in the abdominal wall and are more common in obese patients, smokers and after
wound infections. Sometimes they require surgical repair.

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Deep Vein Thrombosis (DVT/Leg Clots)
This is the same as “travellers’ clots” seen in long flight airline passengers and is due to reduced
mobility for long periods of time (such as when you are anaesthetised during your operation). Being
overweight, having cancer surgery, smoking, and not moving after surgery all increase the risk of
clotting. The chance of this happening can be reduced by the use of anti-clotting agents (small injection
under the abdominal skin), specialised stockings and getting you up and mobile as soon as possible.

Planning for Your Discharge from Hospital

It is very important to consider how you will manage your care once you are discharged from hospital
and discuss this with your family. You need to consider this before you come in for your surgery.
The following options may be discussed with you and should be considered.
 Organising to stay with family and friends or arranging someone to stay with you for at least 48
hours after your discharge from hospital.
 Going home with extra supports, for example, assistance with personal cares and domestic
assistance. Please note: domestic assistance is free only if you fit the criteria which are:
a) have a community services card
b) you live alone.
 A short period of rehabilitation may be required at The Princess Margaret Hospital. This will be
assessed during your recovery.
 Convalescence care should be discussed prior to your admission. There are limited
convalescence beds available in the Canterbury area, which you may be eligible to access. A
referral to a social worker will be made if this is an option. You will be responsible for travelling to
and from these facilities.
 Convalescence into a rest home can incur a payment for service. This is based on certain criteria,
which may apply. A referral to a social worker will be made if this is an option.
The earlier we are aware of the need for convalescence care, the more likely you are to secure a bed in
the facility of your choice.
If you have any concerns about how you will manage at home after your surgery, please discuss these
with your family and the nurse caring for you.

Leaving Hospital
You will be able to return home once your doctor feels you are safe from any complications.
Please see your GP for medical advice if you become unwell after your discharge from hospital or you
develop any of the following
 Chest pain
 Shortness of breath
 Fever or chills
 Calf pain
 Nausea or vomiting
 Diarrhoea / Constipation
 Excessive Bleeding
 Increasing Abdominal Pain
 Increasing Abdominal Pain

IN THE EVENT OF AN EMERGENCY CALL AN AMBULANCE IMMEDIATELY

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Helping Yourself
Getting back to normal can take some time. It can sometimes take up to a year following bowel surgery
to return back to your normal level of function, so don’t get discouraged.

Rest and Activity

It is important to gradually increase your activity after your surgery so that you return to your normal
ability / mobility levels. Building up the distance you walk will improve your fitness and strength and
may help to prevent chest infections. Over 4-5 weeks aim to build up to 30-40 minutes walking at a
pace that just starts to make you breathe a little harder than at rest. Please avoid lifting any heavy
objects for at least six weeks following your surgery as your abdominal muscles will be weak and this
will reduce the risk of developing a hernia.
Pain Relief
Continue taking regular pain relief as discussed prior to your discharge.

Wound Care
If your abdominal wound becomes red, painful or has a discharge, please see your GP for advice. If
you have clips or sutures in your wound you will need to make an appointment with your GP to have
these removed. You will be given a clip remover prior to your discharge from hospital.

Dietary Advice
You will be provided with advice about diet from a dietician while in hospital. It is important to make
some changes to your diet with a colostomy and this will be reinforced by both stomal therapists and
nursing staff.

Bowel Function
Your bowel motion through your colostomy may also take up to a year to settle down because your
bowel has been shortened, however some people never have the same consistency of bowel motion
after this type of operation.
It is not uncommon following this type of bowel surgery to experience:
 Loose bowel motions through the colostomy as the bowel length has been shortened by the
surgery and therefore less fluid is absorbed from the bowel motion
 More frequent bowel motions into the colostomy
 Increased wind through the colostomy
 Abdominal bloating
 Please discuss this with your healthcare provider as a combination of the following may help to
improve your bowel function
 Diet
 Fibre and fibre supplements
 Medications

Returning to Work
This depends on your occupation and how you feel physically and emotionally. You can be issued with
a medical certificate if required. Please discuss with the medical staff prior to discharge.

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Driving
You may commence driving when you can put your foot on the brake in an emergency situation with-
out discomfort. This is usually about 6 weeks after, if you had open surgery but is generally a shorter
timeframe if you had laparoscopic surgery. Some pain relief can cause drowsiness and may alter your
normal driving responses. Some insurance agencies may not cover you in an accident for up to 6
weeks following surgery. It is your responsibility to check this with your insurance company.

Sexual Activity
It is usually safe to engage in sexual intercourse approximately six weeks after surgery unless you
have been advised otherwise. It is not uncommon for sexual desire to be reduced following surgery but
this should only be temporary.

What are the Results from my Surgery (histology)?

Histology reports are available for your surgeon seven to ten days after surgery and include infor-
mation about the type of disease you have and how complex it may be. If you do not receive the re-
sults of your surgery while you are in hospital these will be given to you at an outpatient appointment.
Please try to bring a support person with you to your outpatient appointment.

Follow Up
Initial follow up after your surgery will be with your surgeon or a member of their team approximately
two to six weeks after discharge from hospital. Further follow up will be determined depending on the
results from this operation.

Contacts
Colorectal Nurse Specialist Nurse Maude
Department of Surgery Stoma Advisory Service
Christchurch Hospital
24 McDougall Avenue
Phone: 364 1687
Merivale
Pager: 8095
Christchurch
Phone: 375 4200

Useful Websites
The value of the internet is widely recognised, however, not all the information available may be accu-
rate and up to date. For this reason, we have selected some key sites that people might find useful.
Beat Bowel Cancer Aotearoa www.beatbowelcancer.org.nz
Cancer Society of New Zealand www.cancernz.org.nz
Colorectal Surgical Society of Australia and NZ www.cssa.org.au
Macmillan Cancer Support www.macmillan.org.uk
The Mayo Clinic www.mayoclinic.com/health/diverticulitis

Acknowledgements
Thank you to all those who were involved in the development of this booklet, including patients, their
families, hospital staff and Nurse Maude Stomal Therapists.

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Questions/Notes
Please make a note of any questions you would like to ask:
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For more information about:

 your health and medication, go to www.healthinfo.org.nz
 hospital and specialist services, go to www.cdhb.health.nz

Ref: 3049 Authorised by: CD, Dept Surgery April 2015