Emergency colorectal surgery · UK
Hartmann’s procedure — a major operation for a life-threatening bowel emergency.
A plain-English UK guide to Hartmann’s procedure — the operation, the ITU stay, the end colostomy, life afterwards, and the honest question of whether reversal is right for you.
Why this pathway matters
- 01
A consultant colorectal surgeon, in a proper theatre
This is an emergency major operation. Not a training-list case — a named colorectal surgeon leads, with ITU on standby.
- 02
Stoma nurse from day one
A specialist stoma nurse sees you before and after — bag fitting, skin care, community follow-up. It is the difference between coping and struggling.
- 03
Honest about reversal
Only about half of survivors ever have their Hartmann’s reversed. We tell you why, and what the second operation actually involves.
The pathway and its cost
A Hartmann’s procedure is NHS-funded because it is an emergency.
There is no private waiting list for a perforated bowel. What we can help with privately is a second opinion, elective reversal planning and stoma-life support after discharge.
In short
The operation itself: NHS-funded, emergency. The private conversation: second opinion, reversal planning, stoma life.
| Step of the pathway | Cost | Typical duration | Turnaround |
|---|---|---|---|
| Hartmann’s procedure (emergency) | NHS-funded | 2–4 hrs | Emergency admission |
| HDU / ITU stay (typical) | NHS-funded | 2–7 days | Included |
| Surgical ward stay (typical) | NHS-funded | 7–21 days | Included |
| Stoma nurse teaching and community follow-up | NHS-funded | Ongoing | Included |
| Hartmann’s reversal (elective, 6–12 months on) | NHS-funded | 3–5 hrs | Elective waiting list |
| Private colorectal opinion (second opinion) | £250–£450 | 45–60 min | Within 1–2 weeks |
Length of stay depends on how sick you were at admission, whether the abdomen could be closed at the first operation, and how well the stoma settles. Complications extend the stay. The reversal, if you have one, is a separate elective admission six to twelve months later.
Where Hartmann’s fits today
A hundred-year-old operation that still saves lives.
Described by Henri Hartmann in Paris in 1921, this operation was the gold standard for perforated diverticulitis for decades. Trials like DIVA and SCANDIV have shifted fit patients towards primary anastomosis with a defunctioning ileostomy — but for the unstable, septic and frail, Hartmann’s two-stage safety still beats any single-stage cleverness.
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The unstable patient
Septic shock, faeculent peritonitis, unstable physiology. A join would leak. A colostomy is the safe move.
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The frail patient
Older, comorbid, malnourished. A stoma is far safer than a fragile anastomosis in a hostile abdomen.
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The contaminated abdomen
Perforation, ischaemia, penetrating trauma. Anastomosis inside a contaminated field is not a reasonable gamble.
The pathway
From A&E to community stoma nurse — in order.
The NCEPOD emergency-laparotomy pathway is designed around this exact patient. It works when everyone plays their part.
Phase 1 · Before theatre
A&E, imaging, resuscitation
Phase 2 · Operation and ITU
Hours in theatre, days in critical care
Phase 3 · Ward and after
Weeks to months of recovery
- 01
Before theatre
Emergency presentation
You arrive acutely unwell — perforated diverticular disease, an obstructing tumour, an iatrogenic bowel perforation or ischaemic bowel. CT confirms it.
- 02
Before theatre
Resuscitation and decision
IV fluids, antibiotics, urinary catheter, arterial line where needed. The NCEPOD emergency laparotomy pathway kicks in. A named consultant surgeon and anaesthetist decide the operation.
- 03
Before theatre
Stoma nurse marks the site
Even in an emergency, the stoma nurse marks the left iliac fossa before you go to theatre — a well-sited stoma is easier to live with for life.
- 04
Operation & ITU
In theatre
General anaesthetic, laparotomy (occasionally laparoscopic if you are stable and the team is skilled), the diseased sigmoid is resected, the rectal stump is stapled closed, an end colostomy is brought out in the left iliac fossa. Washout. Abdomen closed, or left open as a laparostomy if you are unstable.
- 05
Operation & ITU
Straight to HDU or ITU
Physiological support, sepsis management, ongoing antibiotics, careful fluid balance. Most people spend two to seven days on a critical-care unit.
- 06
Ward & after
Ward, mobilisation, stoma training
Seven to twenty-one days on a surgical ward. Dietician, stoma nurse teaching, physiotherapy, VTE prophylaxis. ERAS elements applied where the physiology allows.
- 07
Ward & after
Community follow-up and reversal question
Stoma nurse in the community. Six to twelve months later, if you are fit and motivated, we discuss Hartmann’s reversal — a major operation in its own right.
Typical inpatient stay: 9–28 days. Full physical recovery: 3–6 months. Reversal decision: 6–12 months later.
When it is needed
The situations that lead to a Hartmann’s.
Almost always an emergency, almost always a sick patient. And one red flag that means 999, not a clinic.
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Perforated diverticulitis (Hinchey III/IV)
Purulent or faeculent peritonitis from a burst diverticular abscess — the classic indication for a Hartmann’s.
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Obstructing left-sided colorectal cancer
A tumour blocking the sigmoid or rectosigmoid in a patient unfit for on-table lavage and primary anastomosis.
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Perforated colorectal cancer
A tumour that has perforated into the peritoneum — sepsis, contamination and often unstable physiology.
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Iatrogenic perforation
A perforation caused during colonoscopy or previous rectal surgery, where primary repair is not safe.
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Colorectal ischaemia
A segment of dead bowel from vascular compromise — resect the dead bowel, defer the join.
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Penetrating abdominal trauma
Stab or gunshot injury to the sigmoid or rectum, with contamination that makes anastomosis unsafe.
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Salvage after anastomotic leak
An earlier bowel join has leaked — take down the anastomosis, form an end colostomy, close the rectal stump.
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Red flag: peritonitis, sepsis, obstruction
Severe abdominal pain with fever, a rigid abdomen or absolute constipation and vomiting are emergencies — 999, not a clinic booking.
Technique options
The variants a colorectal surgeon actually chooses between.
The decision is made in theatre, on the physiology in front of the team. These are the choices on the table.
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Open Hartmann’s (laparotomy)
A midline incision. The standard in the unstable, septic or obese patient — fastest access, best control of contamination.
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Laparoscopic Hartmann’s
Keyhole approach in a stable patient with a skilled team. Less pain and quicker recovery, but not for every emergency.
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Damage-control laparotomy
In extremis: resect the diseased segment, staple ends, temporary closure, back to ITU. Definitive stoma and closure at a second look 24–48 hours later.
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Laparostomy (open abdomen)
The abdomen is left open with a temporary dressing when swelling or contamination make closure unsafe — closed in stages over subsequent operations.
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Rectal stump — stapled closed
The most common option. The rectal stump is closed with a linear stapler and left in the pelvis.
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Rectal stump — mucous fistula
Occasionally the rectal stump is brought out to the skin as a mucous fistula — used when the stump is too short or too contaminated to close safely.
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Primary anastomosis + defunctioning ileostomy
The modern alternative in fit patients: resect, join the bowel, and protect the join with a loop ileostomy. DIVA/SCANDIV trial territory — not Hartmann’s, but often discussed alongside.
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Hartmann’s reversal (later)
The second operation, six to twelve months on. The colostomy is taken down and joined to the rectal stump. A major operation with 15–30% morbidity.
Standards we hold the team to
The non-negotiables of a well-run emergency laparotomy.
NCEPOD, ACPGBI and the RCS have made emergency laparotomy one of the most audited operations in the country. These four points are the ones patients and families should ask about.
Emergency-laparotomy standards
How a well-run Hartmann’s pathway is put together.
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Consultant colorectal surgeons on the emergency rota, not general trainees leading the case
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Anaesthetist and ITU bed confirmed before knife-to-skin
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Stoma nurse marks the stoma site before theatre wherever the clock allows
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NCEPOD/ACPGBI/RCS emergency-laparotomy pathway followed with audit-quality documentation
Safety, recovery and risks
The honest numbers — and what daily life looks like.
This is a major, life-changing operation done in a life-threatening situation. Being told the real risks and the real recovery — early — is part of good care.
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A major operation for a life-threatening problem
Thirty-day mortality is 5–25% depending on how sick you are at the door — elective Hartmann’s under 5%, emergency for faeculent peritonitis 20–40%. Honest numbers matter.
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Wound infection is common
Twenty to thirty per cent of laparotomy wounds get infected after emergency contamination. It is expected, treated, and rarely dangerous — but often delays discharge.
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Rectal stump breakdown
The stapled rectal stump can leak into the pelvis. It is uncommon but serious — signalled by pelvic pain, fever, or discharge per rectum, and needs urgent imaging.
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Incisional hernia later
A midline emergency wound has a real long-term risk of herniation. Weight, smoking and wound infection all raise the risk.
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Stoma complications
Parastomal hernia (20–30%), prolapse, retraction, skin dermatitis and bag-fitting problems are all common. The stoma nurse is the single most important person in the first year.
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Sepsis, MI, VTE, AKI
Big physiological hits. HDU/ITU exists to catch and manage them. Prophylactic dalteparin, mechanical DVT prevention and early mobilisation cut the risk.
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Psychological adjustment to a stoma
A colostomy changes body image, intimacy and clothing choices overnight. Peer support, counselling and the stoma-nurse community team make the difference between coping and struggling.
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Reversal is a second major operation
Only around half of survivors ever have their Hartmann’s reversed — the rest are too frail, have too much comorbidity, or choose not to. Reversal carries 15–30% morbidity, 1–5% mortality, 10–20% anastomotic leak.
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Red flags after discharge
Fever, spreading abdominal pain, a stoma that is dusky/black or not working, heavy bleeding, or a wound that opens up — 999 or your surgical team the same day.
Reading your operation note
Your operation note in four parts. Read the last one first.
Whichever variant was performed, the note the colorectal surgeon dictates keeps to the same shape.
A quiet reminder
Surgical language is precise and can read coldly — we translate it for you.
If you would like us to talk you through the operation note before your follow-up, just ask.
- 01 Header
Indication and physiology at operation
Why the operation was done — perforated diverticulitis, obstructing cancer, ischaemia — and how sick you were when you went to theatre (P-POSSUM, NELA score).
- 02 Technique
Approach, resection and stoma
Open or laparoscopic, what was resected, whether the rectal stump was stapled closed or brought out as a mucous fistula, and where the end colostomy was sited.
- 03 Findings
Contamination, histology, unexpected finds
Purulent versus faeculent peritonitis, tumour location and initial staging notes, ischaemic segments, incidental disease. Formal histology follows in two weeks.
- 04 Impression
Recovery plan, stoma care, reversal question
Read this first: HDU/ITU plan, expected ward stay, stoma-nurse follow-up, VTE prophylaxis on discharge, and the timing question for possible Hartmann’s reversal.
Recognised by major UK insurers
Emergency Hartmann’s procedures are NHS-funded. Private cover typically becomes relevant for elective Hartmann’s reversal, second opinions, and out-patient stoma and dietetic support.
Frequently asked
Everything patients and families ask about Hartmann’s.
Straight answers on risk, recovery, life with a colostomy and whether reversal is realistic.
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What is a Hartmann’s procedure?
It is an emergency bowel operation described by the French surgeon Henri Hartmann in Paris in 1921. The diseased sigmoid or rectosigmoid colon is removed, the rectal stump is closed off, and the healthy proximal colon is brought out as an end colostomy on the left side of the abdomen. It avoids a bowel join at a time when joining would be dangerous.
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Why not just join the bowel back together in one go?
In an unstable, septic or heavily contaminated abdomen, an immediate join has a high risk of leaking — with catastrophic consequences. Hartmann’s trades single-stage function for two-stage safety. In fitter patients the modern alternative is a primary anastomosis protected by a defunctioning loop ileostomy, as studied in the DIVA and SCANDIV trials.
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Is a Hartmann’s permanent?
It depends. The colostomy is potentially reversible six to twelve months later — but only around half of survivors ever have the reversal. The rest are too frail, have too much comorbidity, have ongoing disease, or simply decide the second operation is not worth the risk.
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How long is the recovery?
Two to seven days on HDU or ITU, then seven to twenty-one days on a surgical ward. Three to six months to full physical recovery. Emotional and lifestyle adjustment to living with a stoma often takes longer — the stoma nurse team is central to both.
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How dangerous is the operation?
Thirty-day mortality ranges from under 5% for elective Hartmann’s in a fit patient, to 20–40% for emergency Hartmann’s in an elderly patient with faeculent peritonitis. Your surgeon can give you a personalised risk using the NELA or P-POSSUM scores.
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What is Hartmann’s reversal and when does it happen?
Reversal is a second, elective operation six to twelve months later. The colostomy is taken down, the rectal stump is found and joined to the descending colon. It is a major operation with 15–30% morbidity, 1–5% mortality and a 10–20% risk of the new join leaking — so it is only offered to fit, motivated patients with adequate rectal stump length and no ongoing disease.
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What is life with a colostomy actually like?
A well-sited colostomy, taught by a specialist stoma nurse, is compatible with work, exercise, travel and intimacy. Bag technology is discreet. The first three months are the steep learning curve. Community stoma-nurse follow-up, peer support and skin care make the biggest difference.
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When should I call 999 rather than my GP?
Severe abdominal pain with fever and a rigid abdomen, absolute constipation with vomiting, a dusky or black stoma, no stoma output for 24 hours with pain and vomiting, heavy rectal or wound bleeding, or a wound that opens up — all are reasons for 999 or the same-day surgical team, not a routine appointment.
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