Hartmann's procedure is performed for perforated sigmoid diverticulitis with feculent peritonitis. Six months later, the patient desires reversal. What is the main technical challenge of Hartmann's reversal that results in a 30–50% non-reversal rate?
- A Recurrent diverticulitis in the retained sigmoid colon
- B Dense adhesions and difficult identification of the rectal stump combined with high anastomotic leak risk ✓
- C Anastomotic stricture from radiation
- D Inadequate blood supply to the descending colon for re-anastomosis
Correct answer: B. Dense adhesions and difficult identification of the rectal stump combined with high anastomotic leak risk
Explanation
Hartmann's reversal is a technically demanding operation with significant morbidity (10–35%) and a high non-reversal rate (30–50%) primarily because: (1) dense adhesions in the pelvis make identification and mobilization of the rectal stump difficult; (2) the rectal stump may be short or difficult to locate; and (3) the anastomosis in a previously inflamed, irradiated, or post-peritonitic field carries a higher leak rate (~8–12%). These factors, combined with patient comorbidity, lead many surgeons and patients to opt against reversal.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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