Hartmann Procedure

Hartmanns Procedure
Herry Rahardjo, MD 20-5-2010
5/20/2010
rahardjoherry@yahoo.com
POKOK BAHASAN / SUB POKOK BAHASAN 1. 2.
3. 4. 5. 6.
Anatomi, tofografi kolon dan rektum Etiologi, macam, diagnosis dan rencana pengelolaan kelainan atau karsinoma kolon dan rektum Indikasi operasi Hartman Teknik operaasi Hartmann dan komplikasinya Work-up penderita dengan kelainan Perawatan penderita pasca operasi Hartmann
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INTRODUCTION
Hartmanns procedure, first described by the French surgeon Henri Albert Hartmann in 1921, is one of the most commonly performed operations. Henri Albert Hartmann was born in Paris on 16th June 1860 as the only son of an Alsatian family The procedure is described in detail in his book, Chirurgie du Rectum, which was published in 1931 and constituted volume 8 of
[4]
He attended medical school at the University of Paris after which he did his surgical training under Felix Terrier who was considered one of the most prominent French surgeons at the time and was renowned for performing the first hysterectomies in France[1].
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Hartmann joined Terrier at the Hospital Bichat around 1882 and in 1892 he was appointed lecturer in surgery, Assistant Professor in 1895, Assistant Director of Surgery in 1898 and Professor and Chairman of Surgery in 1909.
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In 1914, Hartmann accepted the position of Chief of Surgery at lHotel-Dieu, the oldest and most famous hospital in Paris and he stayed there for many years until his retirement in 1930
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He first described the operation that became eponymous with his name at the 30th Congress of the French Surgical Association in 1921[1,2]. He reported on two patients with obstructive sigmoid carcinoma who were treated with proximal colostomy, sigmoid resection and closure of the rectal stump via an abdominal approach.
In particular, he cut across the sigmoid, well above the tumour and then dissected downward to the levator ani. He ligated the middle haemorrhoidal vessels laterally. Anteriorly, he dissected to the level of the seminal vesicles and cut across the rectum at least 3 cm below the tumour. He then closed the rectal stump in two layers, closed the pelvic peritoneum, and brought out the sigmoid colon as an end
Embryology
The embryonic gastrointestinal tract begins developing during the fourth week of gestation. The primitive gut is derived from the endoderm and divided into three segments: foregut, midgut, and hindgut. Both midgut and hindgut contribute to the colon, rectum, and anus.
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The midgut develops into the small intestine, ascending colon, and proximal transverse colon, and receives blood supply from the superior mesenteric artery. During the sixth week of gestation, the midgut herniates out of the abdominal cavity, and then rotates 270 degrees counterclockwise around the superior mesenteric artery to return to its final position inside the abdominal cavity during the tenth
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The hindgut develops into the distal transverse colon, descending colon, rectum, and proximal anus, all of which receive their blood supply from the inferior mesenteric artery. During the sixth week of gestation, the distal-most end of the hindgut, the cloaca, is divided by the urorectal septum into the urogenital sinus and the rectum.
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The distal anal canal is derived from ectoderm and receives its blood supply from the internal pudendal artery. The dentate line divides the endodermal hindgut from the ectodermal distal anal canal.
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Anatomy
The large intestine extends from the ileocecal valve to the anus. It is divided anatomically and functionally into the colon, rectum, and anal canal. The wall of the colon and rectum comprise five distinct layers: mucosa, submucosa, inner circular muscle, outer longitudinal muscle, and serosa.
In the colon, the outer longitudinal muscle is separated into three teniae coli, which converge proximally at the appendix and distally at the rectum, where the outer longitudinal muscle layer is circumferential. In the distal rectum, the inner smooth-muscle layer coalesces to form the internal anal sphincter. The intraperitoneal colon and proximal one third of the rectum are covered by serosa; the mid and lower rectum lack serosa.
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Colon Landmarks
The colon begins at the junction of the terminal ileum and cecum and extends 3 to 5 feet to the rectum. The rectosigmoid junction is found at approximately the level of the sacral promontory and is arbitrarily described as the point at which the three teniae coli coalesce to form the outer longitudinal smooth muscle layer
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The cecum is the widest diameter portion of the colon (normally 7.5 to 8.5 cm) and has the thinnest muscular wall. As a result, the cecum is most vulnerable to perforation and least vulnerable to obstruction. The ascending colon is usually fixed to the retroperitoneum. The hepatic flexure marks the transition to the transverse colon.
The intraperitoneal transverse colon is relatively mobile, but is tethered by the gastrocolic ligament and colonic mesentery. The greater omentum is attached to the anterior/superior edge of the transverse colon.
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These attachments explain the characteristic triangular appearance of the transverse colon observed during colonoscopy. The splenic flexure marks the transition from the transverse colon to the descending colon. The attachments between the splenic flexure and the spleen (the lienocolic ligament) can be short and dense, making mobilization of this flexure during colectomy challenging.
The descending colon is relatively fixed to the retroperitoneum. The sigmoid colon is the narrowest part of the large intestine and is extremely mobile. Although the sigmoid colon is usually located in the left lower quadrant, redundancy and mobility can result in a portion of the sigmoid colon residing in the
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This mobility explains why volvulus is most common in the sigmoid colon and why diseases affecting the sigmoid colon, such as diverticulitis, may occasionally present as right-sided abdominal pain. The narrow caliber of the sigmoid colon makes this segment of the large intestine the most vulnerable to
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COLON
Colon
from ileum until rectum. Colon including :

caecum appendix vermiformis colon ascenden colon transversum colon descenden colon sigmoideum
Vasculary
Artery
sources from the arterial rectalis inferior branch from the arterial pudenda interna . from anus to kava and branch of the Iliaca vein to vein of the rectalis inferior until vein of the pudenda interna.
Vein
Artery of the colon
Vein of the colon
Distribution of the nodes
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Nodes and Nerve of the rectum

From
canalis analis to inguinal nodes Nn anales branch from the Nn pudendus , pleksus sacralis S2 S4.
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TOPOGRAPHY
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Position topography
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Quadrant of the abdomen side
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FISIOLOGI
Absorpsi
Water : 1,5 2L 100 200ml Natrium Klorida Fatty acid short chain, substansi nitrogen
Secretion
Kalium Bikarbonat
MOTILITY Colon asenden dan transversum Segmental contractility Motion from proximal to distal, remove fecal material GAS 100 200ML Sources : Mouth, diffution from vascular to lumen, CO2 from chemical reaction, metabolit and fermentation reaction
Rectum
Vasculary
DEFINITION
The Hartmann procedure is an operation in which the rectum and a portion of bowel are surgically removed. This procedure is sometimes performed as an emergency procedure in cases where the bowel is perforated or obstructed. Hartmanns procedure is the name used for a procedure where the distal part of the
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PRE OPERATIVE CONDITION
Prior to undergoing a Hartmann operation, a patient might be evaluated for his or her overall physical health. This general health check is carried out to determine whether he or she is fit enough to undergo this physically stressful procedure.
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The health check might include X-rays, an electrocardiogram and blood tests. This preparation can be carried out only for a planned procedure, though, because when the operation is carried out as an emergency measure, there might not be sufficient time for a full series of tests.
Clinical Evaluation
Clinical Assessment A complete history and physical examination is the starting point for evaluating any patient with suspected disease of the colon and rectum. Special attention should be paid to the patient's past medical and surgical history to detect underlying conditions that might
If patients have had prior intestinal surgery, it is essential that one understand the resultant gastrointestinal anatomy. In addition, family history of colorectal disease, especially inflammatory bowel disease, polyps, and colorectal cancer, is crucial. Medication use must be detailed as many drugs cause gastrointestinal symptoms.
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Before recommending operative intervention, the adequacy of medical treatment must be ascertained. In addition to examining the abdomen, visual inspection of the anus and perineum and careful digital rectal exam are essential.
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Anoscopy
The anoscope is a useful instrument for examination of the anal canal. Anoscopes are made in a variety of sizes and measure approximately 8 cm in length. A larger anoscope provides better exposure for anal procedures such as rubber band ligation or sclerotherapy of hemorrhoids. The anoscope, with obturator in place, should be adequately lubricated and gently inserted into the anal canal. The obturator is withdrawn, inspection of the visualized anal canal is done, and the anoscope should then be withdrawn. It is rotated 90 degrees and reinserted to allow visualization of all four quadrants of the canal. If the patient complains of severe perianal pain and cannot tolerate a digital rectal examination, anoscopy should not be attempted without anesthesia. 5/20/2010 rahardjoherry@yahoo.com 43
Proctoscopy
The rigid proctoscope is useful for examination of the rectum and distal sigmoid colon and is occasionally used therapeutically. The standard proctoscope is 25 cm in length and available in various diameters. Most often, a 15- or 19-mm diameter proctoscope is used for diagnostic examinations. The large (25-mm diameter) proctoscope is useful for procedures such as polypectomy, electrocoagulation, or detorsion of a sigmoid volvulus. A smaller "pediatric" proctoscope (11mm diameter) is better tolerated by patients with anal stricture. Suction is necessary for an adequate proctoscopic 5/20/2010 rahardjoherry@yahoo.com 44 examination.
Examination Technique
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Barium Enema Contrary to the opinion of some computed tomography (CT) and magnetic resonance imaging (MRI) enthusiasts, a double-contrast barium enema continues to be a viable option in a setting of suspected colitis, colorectal cancer screening and detection, and follow-up after therapy
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X-RAY EXAMINATION
Plain films of the abdomen depict the distribution of gas in the intestines, calcifications, tumor masses, and the size and position of the liver, spleen, and kidneys. In the presence of acute intraabdominal disease, erect, lateral, and oblique projections and lateral decubitus views are helpful.
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X-ray of normal colon. The colon has been rendered radiopaque by a barium enema (single-column technique)
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Indications for colonoscopy Diagnostic indications

Age 50 Personal or family history of colorectal cancer, polyps, or specific familial cancer syndromes Post abnormal or equivocal barium enema or episode of unexplained rectal bleeding Post abnormal sigmoidoscopy (eg, polyps) Inflammatory bowel disease Therapeutic indications Excision of polyps Control of bleeding Removal of a foreign body Detorsion of volvulus Decompression of pseudo-obstruction Dilation of strictures Destruction of neoplasms
GENERAL PROCEDURE
After general anesthesia of the patient, the first stage in the Hartmann procedure is an incision made in the abdomen. Next, the abdomen is opened up to expose the bowel and rectum. The diseased portions of tissue are then identified and removed.
Next, a stoma, or surgical hole, is created in the abdominal wall. The cut end of the bowel is connected to the stoma in order to allow fecal waste to exit the body.
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POST OPERATIVE CONDITION

In the final portion of the Hartmann procedure, the patient is fitted with a colostomy, a small external bag that collects the waste. For some people, the colostomy is reversible; for others, it might be permanent. Whether the colostomy is reversible depends on individual circumstances and cannot always be predicted in advance.
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POST OPERATIVE TREATMENT
From start to finish, the Hartmann procedure typically takes between two and four hours. After the operation, a patient will stay in the hospital for five to 12 days, depending on his or her overall physical health and the outcome of the procedure.
If the operation was carried out as a treatment for cancer, the patient might begin chemotherapy during this time. Full recovery takes several weeks. During this time, it is best to avoid heavy lifting and other strenuous activities.
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Long periods of inactivity also must be avoided, however, to prevent complications such as thrombosis. A regimen of short bursts of gentle exercise or light activity, alternated with rest periods, is recommended.
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DIET MANAGEMENT
For the first few days after the procedure, patients typically must follow a liquid diet to allow time for the bowel to heal. Most people can return to a modified version of their normal diet within a few days. Certain foods must be avoided to make care of the stoma and colostomy easier. Dietary modifications can be discussed with a nurse, dietitian or nutritionist before or after the surgery.
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INDICATION OF THE HARTMANS PROCEDURE

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It is most commonly used after resection of the sigmoid due to a volvolus with gangrene It was used to treat colon cancer or a distal malignancy of the colon when anastomosis is not advisable or not possible for technical reasons. This technique can used to treat diverticulitis. Localized or generalized peritonitis caused by perforation of the bowel secondary to the cancer Viable but injured proximal bowel that, in the opinion of the operating surgeon, precludes safe anastomosis. These days its use is limited to emergency surgery when immediate anastomosis is not possible, or more rarely it is used palliatively in colorectal tumours.[1] Use of the Hartmann's procedure has been associated with a low perioperative mortality of 9%, but at the cost of a colostomy that, in up to two5/20/2010 rahardjoherry@yahoo.com 56 thirds of patients, is never reversed.
End Sigmoid Colostomy With Hartmann's Pouch
End sigmoid colostomy with a Hartmann's pouch is the procedure of choice when permanent fecal diversion is required. In some clinics, the distal portion of the rectosigmoid colon is exteriorized as a mucous fistula in lieu of a Hartmann's pouch. The need for this in colonic problems related to gynecologic
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Physiologic Change
In this operation, the fecal stream is diverted from the rectum and anus. Compared with transverse colostomy, end sigmoid colostomy gives additional length to the colon for absorption of fecal fluid. Therefore, the stool is similar to that passed per anum. End sigmoid colostomy offers an opportunity for colostomy regulation that is generally not available in transverse colostomies. A single stoma improves the fit of the colostomy bag and reduces
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Points of Caution
An adequate incision is needed to identify, mobilize, and open the mesentery of the sigmoid colon. The incision should be selected to fit the needs of the individual patient, ensuring proper placement of the colostomy stoma. The stoma should not be placed in the patient's waistline, where clothing will interfere with it, and should never be placed on the underside of a large abdominal panniculus in obese patients. Several sutures placed from the serosal surface of the bowel to the peritoneum will reduce herniation and prolapse of the colon through the stoma.
Technique operation of the hartmanns procedure
1. The patient is placed in the supine position. The abdomen is opened through a left paramedian or midline incision. The sigmoid colon is identified, mobilized, and elevated. The site for transection of the bowel is made on consideration of the pathologic diagnosis. The mesentery is opened for approximately 8 cm. Often, the superior hemorrhoidal branch of the inferior mesenteric artery must be clamped and divided, but the inferior mesenteric artery itself is generally preserved. The gastrointestional anastomosis (GIA) autosuture stapler is placed across the colon and activated.
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2. With the GIA stapler, the proximal end of the distal segment of the colon (Hartmann's pouch) is adequately closed. No further surgery to this segment is needed.
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The appropriate site for the colostomy stoma has been marked on the patient's abdomen with indelible ink prior to surgery. An Allis clamp is placed on the skin at this site and elevated. While the skin is held on traction, a knife is used to remove a disc of skin and subcutaneous tissue of appropriate diameter
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5. The skin disc has been removed. 6. The subcutaneous fat is elevated with an Allis clamp.
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7. With the fat elevated, a knife is used to remove the remaining fatty tissue, exposing the rectus fascia. 8. The rectus fascia is exposed.
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9. The rectus fascia is elevated with an Allis clamp. A knife is used to remove a disc of rectus fascia 4 cm diameter. 10.A large Kelly clamp is inserted through the peritoneum, bluntly penetrating the fibers of the rectus muscle. This incision is expanded with the Kelly clamp and fingers until two fingers (4 cm) traverse the defect from the skin to peritoneum without difficulty.
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11.A Babcock clamp is inserted through the abdominal wall defect. The distal segment of the descending colon is grasped. 12.This distal segment of the descending colon is pulled through the defect for a distance of approximately 7 cm. Excess fatty tissue on the mesenteric side of the colon is clamped and tied up to but not exceeding 3 cm.
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13.The excess fatty tissue is removed. The blood supply of the colon is such that up to 5 cm of colon can be nourished from the point of ligation of vessels in the mesentery. Colon in excess of this amount may become ischemic and necrose. 14.The stapled end of the proximal colon is elevated with a forceps and resected with curved Mayo scissors.
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15.A "rosebud" stitch is utilized to evert the colon onto the skin, thereby elevating it off the skin edge by 1 1/2 cm. Elevating the stoma protects the skin from fecal spillage. The stitch is started on the surface of the skin 1 cm from the edge, goes through the epidermis and dermis, is passed through the serosa and muscularis of the bowel wall, and then transverses the edge of the bowel. 16.When tied, the stoma is inverted and raised off the level of the skin.
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17.The mesentery of the large bowel is sutured or stapled to the peritoneum to prevent internal hernia.
Copyright - all rights reserved / Clifford R. Wheeless, Jr., M.D. and Marcella L. Roenneburg, M.D. Atlas of pelvic surgery 5/20/2010 rahardjoherry@yahoo.com 69
Treatment strategy for endoscopically resected malignant polyps, according to thre japanese Guidelines for Colorectal cancer (5) with slight modifications
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Extent of resection for carcinoma of the colon, T=Tumor

Principles of Resection
The principle objective of resection for colon carcinoma is to remove the primary tumor along with its lymphovascular supply. Since the lymphatics of the colon accompany the main arterial supply, the length of the resected bowel depends on which vessels supply the segment involved in the cancer [3] .
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Before 2005, the Japanese General Rules for Clinical and Pathologic Studies on Cancer of the Colon and Rectum (JGR) recommended that a colectomy should be performed with at least 5- to 10-cmlong proximal and distal margins, and that the regional arterial blood supply should be taken at its origin, thus assuring an adequate mesenteric resection. In the new version of these rules (2006), the cut edge of the bowel is strictly standardized with careful attention being paid torahardjoherry@yahoo.com the main arterial 5/20/2010 73
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Clasification of the colorectal tumor

Dukes A : Tumor confined to bowel wall 2. Dukes B : Tumor invading through the bowel wall 3. Dukes C : Tumor cells found in the regional lymph nodes
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In 1932, Dr. Dukes described a staging system for rectal cancer. He originally described the following: Since his original article was published, this classification has been modified several times. One of the most commonly used rahardjoherry@yahoo.com 84 modifications is 5/20/2010 the inclusion of Dukes'
KEY POINTS: COLORECTAL CARCINOMA

Presenting symptoms may include intermittent rectal bleeding, vague abdominal pain, fatigue secondary to anemia, change in bowel habits, constipation, tenesmus, and perineal pain. 2. The current recommendations of the American Cancer Society for screening are a yearly digital rectal exam with testing for occult blood at age 40 years and for patients over 50 a flexible sigmoidoscopy every 3-5 years. 3. Patients with lymph node involvement 5/20/2010 rahardjoherry@yahoo.com 85 should receive chemotherapy
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References
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^ Balanzoni S, Perrucci A, Pasi L, Montanari M (1997). "[The Hartmann intervention. The current indications and the authors' own experience]". Minerva Chir 52 (4): 3836. PMID9265121. ^ Hartmann, H.: 30th Congress Francais de ChirurgieProcess, Verheaux, Memoires, et Discussions, 30:411, 1921 ^ Hotouras A. Henri Hartmann and his operation. Grand Rounds 8; L1 - 2, 2008. http://www.grandrounds-e-med.com/articles/gr089001.html DOI:10.1102/1470-5206,2008.9001 ^ Ronel D, Hardy M (2002). "Henri Albert Hartmann: Labor and discipline.". Curr Surg 59 (1): 5964. doi: 10.1016/S0149-7944(01)00572-4. PMID16093106. Diagnosis book Hamilton Bailey Schwarzts, principles of Surgery, 8th ed Zollinger's Atlas of Surgical Operations, 8th Edition Engtrom F Paul et all, Colon Cancer, NCCN Clinical practice guidelines in oncology,V.2.2006 Current Surgical Diagnosis & Treatment, 12th Edition, Editors: Doherty, Gerard5/20/2010 M.; Way, Lawrence W. Copyright 86 rahardjoherry@yahoo.com
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Hartmann Procedure

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Hartmanns Procedure

Herry Rahardjo, MD 20-5-2010

POKOK BAHASAN / SUB POKOK BAHASAN 1. 2.

from ileum until rectum. Colon including :

Artery of the colon

Vein of the colon

Distribution of the nodes

Nodes and Nerve of the rectum

Quadrant of the abdomen side

PRE OPERATIVE CONDITION

Indications for colonoscopy Diagnostic indications

POST OPERATIVE CONDITION

POST OPERATIVE TREATMENT

INDICATION OF THE HARTMANS PROCEDURE

End Sigmoid Colostomy With Hartmann's Pouch

Technique operation of the hartmanns procedure

Extent of resection for carcinoma of the colon, T=Tumor

Clasification of the colorectal tumor

KEY POINTS: COLORECTAL CARCINOMA

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