Hartmann's closure versus elective colectomy: Similar anastomosis, different circumstances

An interesting perspective exists around the dichotomous nature of surgical emergencies resulting in a Hartmann's procedure and the elective decision to pursue subsequent reversal. The index operation is frequently emergent in the setting of a threat to life from sepsis due to colonic perforation, obstruction, or ischemia. The etiology of these conditions is broad, including benign or malignant disease, as well as trauma. In the end, the patient undergoes a critical operation resulting in the creation of a colostomy. The benefit of the index case nearly always outweighs the risk given the often life-threatening indication. The second procedure is quite the opposite. Generally, the patient has recovered and the reversal of their colostomy is purely elective. The risks with the creation of a new anastomosis, including anastomotic failure and intra-abdominal sepsis, essentially re-creates the indication for which the index surgery was performed. Aside from patients with severe body image issues related to the ostomy or those with poorly functioning stomas, there is no disease process to be addressed. The only purpose of the second operation is to allow the patient to defecate out of their anus as opposed to their abdominal wall. Therefore, the preoperative considerations should focus on the level of risk acceptable to achieve this goal.