Perioperative management - Rectal resection according to Hartmann

• Perforated sigmoid diverticulitis with fecal peritonitis (Classification of Diverticular Disease (CDD) Type 2c2) or in cases of immunosuppression
• Perforated rectal carcinoma with fecal peritonitis
• (Sigmoid) rectal carcinoma with pre-existing fecal incontinence
• Postoperative anastomotic insufficiency after colon/rectal resections with fecal peritonitis

In the example, it is a low-lying rectal carcinoma with covered perforation and abscess. Due to pre-existing fecal incontinence, the indication for discontinuity resection with a low Hartmann's stump is established.

• Severe comorbidity

Limited operability, e.g., due to severe lung disease, heart failure, liver cirrhosis, etc.; whether this comorbidity constitutes a contraindication to surgery must be assessed individually.

• Sphincter infiltration or insufficient safety margin between the lower tumor edge and the distal resection margin

In this case, an abdominoperineal rectal extirpation is to be performed.

Laboratory: CBC, CRP, coagulation, creatinine, electrolytes, blood type, antibody screening test, if applicable, CEA

In case of perforated sigmoid diverticulitis: CT abdomen/pelvis with i.v. and rectal contrast administration

In case of perforated carcinoma: CT abdomen/pelvis with i.v. and rectal contrast administration

In case of postoperative anastomotic insufficiency: CT abdomen/pelvis with i.v. and rectal contrast administration

In case of suspected carcinoma and anamnestically impaired sphincter function:

• Clinical examination including digital rectal examination. This allows for an assessment of the height of the tumor and its mobility relative to the surroundings in the case of a rectal tumor.
• Rigid rectoscopy to determine the distance from the lower edge of the tumor to the anocutaneous line;
• Colonoscopy with biopsy for histological confirmation (mandatory) Note: If a colonoscopy is not possible preoperatively due to an impassable stenosis, it should be performed 3-6 months postoperatively.
• CT abdomen/thorax, MRI pelvis for staging, if applicable, endosonography, MRI liver or contrast-enhanced ultrasound of the liver
• Sphincter function measurement (clinically and/or manometrically) to objectify sphincter function

In emergency situations (perforation), the preoperative phase should be kept as short as possible, as the duration until surgical repair significantly determines the mortality of the procedure.

Early initiation of antibiotic therapy (in case of perforation immediately after diagnosis); individual selection of antibiotics depending on endogenous (e.g., immunosuppression) and dispositional (e.g., postoperative fecal peritonitis; "second hit") factors

In elective surgery:

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  • Written patient information
  • Clarification of operability, if necessary, involving other departments for a consultative assessment of operability.
  • Anesthesiological consultation
  • Discussion regarding stoma care and marking of a stoma passage site
  • Shaving of the surgical area
  • Provision of blood units

• Wound infection/intra-abdominal abscess/infection
• Postoperative bleeding
• Thrombosis/embolism
• Injury to intra-abdominal structures, particularly ureter, spleen
• Disturbance of bladder and sexual function
• Restriction of fecal continence in planned reconnection
• Possibly discussion and documentation of a potential extension of the operation depending on findings (e.g., towards abdominoperineal rectal extirpation in very low-lying carcinoma)