Hartmann’s procedure for complicated diverticulitis: A critical reappraisal

Background: Complicated diverticulitis in advanced stages (Hinchey III, IV) is an important surgical emergency for which Hartmann’s Procedure (HP) has traditionally represented the gold standard treatment. HP, however, has high mortality and morbidity and a low percentage of reanastomosis rate. Increasing efforts have therefore been made in recent years to propose alternatives. Objective: To critically review studies on the outcome of HP vs. alternative procedures for complicated diverticulitis Resection-Anastomosis without [RA] or with [RAS] protective stomia, Laparoscopic Lavage [LL]. Methods: Literature search in PubMed for original and review papers in the past 20 years (up to July 2019) with keywords: Hartmann’s procedure, complicated diverticulitis. Results: Comparative studies on HP vs. RA/RAS overall reveal better outcomes of RA/RAS, i.e., reduced mortality, morbidity and healthcare costs. However, most studies have limitations due to lack of randomization, limited number of patients and significant impact of surgeons’ specialization and hospital setting/organization in the decision of the type of surgery to perform. These factors might induce preferential allocation of the most critical patients (advanced age, hemodynamic instability, numerous comorbidities) to HP rather than RA/RAS. LL shows promising results but has been tested in a too small number of trials vs. HP to draw definite conclusions. Conclusion: Though valid alternatives to HP are being increasingly employed, consensus on the best approach to complicated diverticulitis has not yet been reached. HP is still far from representing an obsolete intervention, rather it appears to be the preferred choice in the most critical patients.