Laparoscopy-first Hartmann strategy for generalized diverticular peritonitis: a national multicenter overlap-weighted cohort study
In a national multicenter cohort study of patients with generalized diverticular peritonitis, a laparoscopy-first Hartmann strategy failed to improve early postoperative outcomes and resulted in significantly lower stoma reversal rates at 12 months compared to protected resection-anastomosis, supporting the latter as the preferred approach when technically feasible.
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When a section of the large intestine becomes inflamed and bursts, spilling waste into the abdominal cavity, the situation is a surgical emergency known as generalized peritonitis. This condition, often caused by a severe flare-up of diverticulitis, requires immediate intervention to stop the infection and remove the damaged tissue. For decades, the standard approach to this crisis was a two-step process: surgeons would remove the diseased bowel, close off the end of the remaining intestine, and bring the other end out through the abdominal wall to create a temporary bag, called a stoma, to collect waste. This method, known as the Hartmann procedure, was favored because it avoided the risk of a fresh connection failing in a dirty, infected environment. However, this approach left many patients with a stoma that was difficult or impossible to reverse later in life. In recent years, medical guidelines have shifted toward a different strategy: removing the damaged bowel and immediately reconnecting the healthy ends, sometimes with a protective bag to divert waste temporarily. This "restorative" approach offers a better chance of returning to normal bowel function, but it is technically more complex and carries risks in an emergency setting. The question facing surgeons today is whether a hybrid approach—starting with minimally invasive keyhole surgery but sticking to the Hartmann method if things get difficult—can offer the best of both worlds: the early recovery benefits of keyhole surgery without the long-term burden of a permanent stoma.
A large team of researchers across France set out to answer this question by analyzing the records of 340 patients treated for this specific type of severe infection between 2010 and 2021. They compared two distinct strategies used in emergency rooms. The first group underwent a "laparoscopy-first Hartmann" strategy. In this approach, surgeons began the operation using small incisions and a camera, intending to remove the bowel and create a stoma without reconnecting the ends. If the surgery became too difficult or the view was unclear, they would convert to a large open incision, but the plan remained the same: no immediate reconnection. The second group received a "protected resection-anastomosis," where surgeons removed the damaged bowel and immediately sewed the healthy ends back together, often with a temporary protective stoma to guard against leaks. This group included operations started either through keyhole incisions or large open cuts, depending on what the surgical team decided was best for that specific patient. The researchers used advanced statistical methods to balance the two groups, ensuring that differences in patient age, health conditions, and the severity of the infection did not skew the results.
The study found that the two strategies performed very similarly in the short term. Within 90 days of surgery, the rates of complications, such as infections or the need for further operations, were nearly identical between the two groups. The risk of death within that same period was slightly higher in the Hartmann group, but the data was not precise enough to declare a definitive difference. The real divergence appeared when the researchers looked at the long-term goal: getting the stoma reversed and restoring normal bowel continuity. At the one-year mark, patients who had undergone the protected resection-anastomosis were far more likely to have their stoma reversed. Specifically, 91.5 percent of these patients had their bowel reconnected, compared to only 71.7 percent of those who had the Hartmann procedure. This represents a difference of nearly 20 percentage points, a gap that remained consistent even when the researchers looked only at hospitals that used both methods or only at surgeries that began as keyhole procedures.
The researchers also examined whether starting with keyhole surgery helped the Hartmann patients. They found that about half of the Hartmann procedures that began laparoscopically had to be converted to open surgery, a rate similar to the conversion rate seen in the other group. Even among those who managed to complete the Hartmann procedure entirely through keyhole surgery, the rate of stoma reversal did not improve significantly compared to those who had to switch to open surgery. This suggests that the initial surgical approach did not overcome the inherent difficulty of reversing a Hartmann procedure later on. The study concludes that while starting with keyhole surgery is a valid option, it does not bridge the gap in long-term outcomes. For patients who are stable enough to tolerate the complexity of an immediate reconnection, the evidence supports the protected resection-anastomosis as the preferred strategy, as it offers a much higher likelihood of returning to a life without a stoma. The Hartmann procedure remains a vital tool for the most unstable patients, but for those where reconstruction is feasible, the data indicates that delaying the reconnection is not worth the trade-off.
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