This is one of the more difficult operations in this manual, so refer the patient if you can. Hartmann's operation will have left the proximal end of his gut blind, and his anal canal open. You will have to mobilize his proximal colon, open his distal colon, and bring his proximal colon down to meet it. The key step is to place all the sutures on the posterior (''Lembert', 9.3) layer of his gut, before you close any of them.
CLOSING HARTMANN'S OPERATION TIMING. Do it 6 to 12 weeks after the first stage.
PREPARATION. Give him fluids only for the first two days preoperatively. On the day before the operation wash out the proximal loop, and give the rectosigmoid stump an enema.
ANAESTHESIA. Subarachnoid anaesthesia, or general anaesthesia, intubation, and relaxants. Insert an intravenous line.
METHOD. Lay the patient supine, and raise the foot of his bed to give you better access to his pelvis. If you are right- handed, stand on his left. Open the previous wound (midline or paramedian). Using scissors and gentle blunt dissection, carefully separate the adhesions between his gut and his abdominal wall. If you operate at the best time (6 to 12 weeks) these should be light.
Find the proximal end and free it for 15 cm, without damaging its mesentery. To do this, incise the peritoneum covering his posterior abdominal wall 1 cm lateral to his descending colon. Then mobilize his colon medially by blunt dissection (as shown by the arrows in Fig. 10-17a). Mobilize it well, so that it reaches the distal stump without tension.
Apply a crushing clamp 2 cm from the exit of the proximal end through his abdominal wall. Apply a non-crushing clamp well proximally to prevent contamination (his gut should be empty). Mobilize the proximal end, so that it can reach the distal end easily.
Dissect out the distal end (the suture you placed earlier will make this easier to find). Dissect across the top and about 2 cm down each side (Diagram B, line a-b). Cut it across 5 to 10 mm from its blind end (C, line c-d).
Insert about 10 atraumatic 2/0 multifilament sutures through the musculoserosal layer of the posterior aspect of both ends of his gut about 3 mm apart, leaving their ends long, and held in haemostats (D). Avoid the mucosa by turning this inwards. When these are complete draw them all together to approximate the bowel ends. Leave one suture at each end long (E). Insert a continuous ''all coats' layer of 2/0 chromic catgut or ''Vicryl' or ''Dexon', starting at one end and leaving the end long.
Continue the ''all coats' layer to close his gut anteriorly, and tie the ends of the suture together to complete it. Then insert Lembert sutures for the anterior musculo-serosal layer in the usual way. Use a long needle-holder and small (16[nd]25 mm needle) atraumatic sutures. Check the soundness of the anastomosis and the size of the lumen by pinching it between your thumb and finger (Q, 9-9).
Close any hole through which a loop of small gut might prolapse (see Section 10.10). Close his abdomen as a single layer (9.8), and manage him postoperatively as for any other gut anastomosis (9.9) and do Lord's procedure.
DIFFICULTIES [s7]CLOSING HARTMANN'S OPERATION If you CANNOT BRING THE ENDS OF HIS GUT TOGETHER easily, remove the non-crushing clamp, and mobilize more descending colon, by cutting his peritoneum further up his paracolic gutter, and raising more descending colon and mesentery. You can always bring the gut ends together if you mobilize enough mesentery.
If the ENDS OF HIS GUT ARE DIFFERENT SIZES (the proximal end is usually bigger), place the sutures for the wider end further apart.
If the LUMEN IS TOO NARROW, or there is a DOG EAR OF SPARE GUT, undo the anastomosis and start again. This may harm him, and should trouble your conscience.
If the ENDS OF THE GUT BLEED, press them firmly for up to 5 minutes. If there is a bleeding vessel beside the gut, clamp and tie it.
Fig. 10-17a CLOSING HARTMANN'S OPERATION. If you cannot refer a patient and have to close his colostomy, do it like this[md]his distal gut is usually deeper in his pelvis, even than shown here. A, mobilizing his colon. B, freeing his rectal stump. C, cutting off the top of his rectal stump. D, placing the seromuscular (Lembert) sutures that will draw the two ends of his gut together. You can use simple sutures like the three on the left, or the mattress sutures shown on right which are slightly more difficult. E, the sutures placed in D, have been pulled tight. Note that the two end ones have been left long.