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Hartmann’s procedure is the name given to the operation to remove the diseased part of the large bowel. This is done either as a planned operation or as an emergency and can be done in two ways.
• It can either be performed in the traditional method of opening up the tummy from above your navel (belly button) down in a straight line (approximately 20 centimetres in length). The wound will either be stitched, stapled or glued back together at the end of the operation and will heal in 7 – 10 days in an uncomplicated case.
• Or the operation can be performed laparoscopically. The other names for laparoscopic surgery are keyhole surgery, minimal access surgery or minimally invasive surgery.
The decision of which method is used to perform your operation will always be made with your best interests in mind. However occasionally it is necessary to abandon laparoscopic surgery and open up the abdomen if it becomes difficult to proceed safely with laparoscopic surgery.
The Large Bowel
The large bowel (intestine or colon) is approximately 1-1.5 metres long. This part of the digestive tract carries the digested food material from the small bowel and gets rid of it as waste through the opening in your bottom.
This operation can be done for a number of medical problems with the most common ones being diverticular disease or cancer. The aim of the surgery is to remove the section of bowel affected by the disease following which one end of the remaining bowel is brought out onto the surface of the skin as a colostomy (stoma). The colostomy allows waste from the body to pass out through the abdomen and into a stoma bag. The waste from this part of the bowel is very similar to the waste from your bottom.
Your consultant or stoma nurse will explain to you the reason why the two cut ends of your bowel cannot be joined up again at the time of the surgery. It is possible for some patients to have their bowel rejoined and the colostomy closed at a later date. Your consultant will inform you if this is possible for you. You will have the opportunity to see the stoma care nurse specialist before your surgery and she will give you advice and information about a colostomy. The stoma nurses’ telephone number is on the back of this leaflet.
Risks of any operation
As with any operation, the risks include:
• Chest Infection – This would require antibiotics and physiotherapy.
• Wound infection/failure to heal
• Blood Clots in the legs (deep vein thrombosis) or in the lung (pulmonary embolism) – We decrease this risk by using elastic stockings and blood thinning injections which will be given to you every day you are in hospital and even when you have gone home for up to 28days.
• Anaesthetic – this operation is carried out under a general anaesthetic (you will be asleep). If you would like an explanation sheet about general anaesthetics and the associated risks please ask
for one. If you are at increased risk because of other medical problems your consultant will refer you to an anaesthetist for a formal assessment before the operation.
• Patients who are very overweight, smoke or have other medical problems are at increased risk of all of these complications.
• Compartment Syndrome – Compartment syndrome is a rare but painful and potentially serious condition caused by bleeding or swelling to an enclosed space within the muscles. The pressure within the space can increase to such an extent that it affects the function of the muscle and nerves. The area most likely affected with the operation you are having is the legs, this is due to the position your legs have to be in during the operation, however it can affect your arms, tummy or the cheeks of your bottom. Pain is the most common symptom followed by numbness.
The treatment is an operation called a fasciotomy. The surgeon would need to open the skin and muscle of the area affected to relieve the pressure and prevent permanent damage. The wound is dressed but is not closed with stitches until approximately 48-72 hours later. You may not be allowed to get out of bed and weight bare until the wound has been closed The risks of this operation also include:
• Increased risk of infection – because the bowel is an organ full of bacteria. This may be in the form of a wound infection or an infection inside the abdomen in the form of an abscess. Antibiotics
are given to help control the infection and sometimes drainage of an abscess is necessary.
• Bowel stops working – This is temporary but can cause bloating of the tummy and sickness.
• Damage to other internal organs whilst removing the diseased bowel in particular the Spleen, bladder and small tubes to the bladder from the kidneys.
• Pelvic Nerve Damage – there may be a risk of damage to the nerves of the pelvis which supply control to the sexual organs. In a man this can lead to impotence, in a woman this can lead to painful intercourse. If you are at particular risk of this complication the consultant will discuss this with you before your operation.
This is a major operation that has serious risks from which a small number of people do not survive. Your consultant will discuss your individual risks with you and answer any questions you have. Measures are taken to reduce these risks; however it is not possible to eliminate risks completely.
Risks of not having the surgery
Just as there are risks of having surgery there are also risks of not having surgery. Depending on the reason for your surgery, these include
• Symptoms can become worse
• the bowel could fistulate (form a new tract to another organ in your body) or even burst which could lead to further complications and/or may need surgery.
Preparation for Surgery
The day before your operation you may eat and drink normally unless you have been told otherwise. On the day of your operation, your letter (or if you are already in hospital), nursing staff will inform you when you have to stop eating and drinking in preparation for your anaesthetic. You may be given an enema into your bottom approximately 2 hours before your operation. The stoma nurse will see you and mark with a pen on your tummy where the surgeon will need to place the stoma. It is important to mark this position to make sure the stoma would be placed in a suitable position for you to manage.
If you have been told you are to follow the enhanced recovery programme please read the enhanced recovery information sheet. Enhanced recovery is a way of preparing you for surgery so that your stay in hospital is as short as possible.
The recovery period after bowel surgery varies. It usually involves a stay in hospital from three to ten days (in uncomplicated cases) depending on whether you have had open or laparoscopic surgery. Immediately after your operation the following tubes may be in place to help us care for you:
• Pain control will be administered through either an epidural (tube into your back) or a drip (tube into the veins on your arm). This will help you move around more freely. As you recover these will be removed and pain killers will be given in the form of tablets. The pain gradually eases, particularly once you are up and moving around.
• Fluids in the form of a drip in your arm will keep you hydrated until you are able to drink freely.
• A catheter (tube to your bladder) will drain your urine into a collection bag so we can accurately measure the amount.
• A drain may be placed into your tummy – this is a tube to drain fluid away from the operation site. This will be removed when it finishes draining which is usually within two to five days. These tubes will be removed as soon as possible depending on your recovery. The nursing staff will help you get out of bed as soon as possible after the operation, being mobile will help to reduce the risk of complications from the operation.
You may be able to eat during the first few days of recovery but your appetite will probably be reduced. It is important to eat small frequent amounts of easily digested food. In the first few days you will be given specific advice on what you can eat. Meals can be supplemented with nourishing soups and snacks and high energy drinks. The body requires lots of calories during the healing process. After the first few days there is no special diet and we encourage you to build up to your normal diet as soon as you can tolerate it.
The bowel may take a little while to recover. Your colostomy will start passing wind and this is a sign that your bowel is working again. It is normal for the colostomy to be irregular just after your operation and sometimes it is necessary to give mild laxatives to encourage the bowel to move. Do not be worried if you occasionally pass some stool out of your bottom for up to a few weeks after your surgery, it is emptying what was left in your bowel from before your operation.
Your bottom will also continue to produce mucus and you will occasionally pass this out of your bottom. The bowel normally produces mucus as a lubricant and this is completely normal and harmless. You may also still get the sensation that you need to go to the toilet, again this is normal and the best way to manage this is by sitting on the toilet and gently bearing down as if trying to pass a stool.
You will be encouraged to get out of bed the following day and you will be seen by a physiotherapist who will help you do this. You will be wearing elastic stockings to reduce your risk of a blood clot but moving around will also help. The physiotherapist will also give you deep breathing exercises as this will help prevent chest infections. Lifting after abdominal surgery is not recommended
for approximately six weeks after your operation. The stoma nurse will give you detailed advice on lifting.
The stoma nurse specialist will see you regularly to give you help and advice on managing your stoma and you will be given all the equipment you need to do this. You have to be able to manage the stoma without help before you can be discharged home. The stoma nurse will also visit you at home within a few days after discharge to monitor your progress.
Check with your insurance company about any exclusion they may have. This includes being under the influence of some pain medication. You must be able to perform an emergency stop and you are not excluded from wearing a seat belt.
When you go home
When you go home you may find that on some days you feel better than on other days. It is quite normal to have ‘good’ and ‘not so good’ days. However it is important to contact the GP if any of the following occur:
• Discharge or leakage from the wound or drain site
• High temperature
• Uncontrolled shivering/feeling hot then cold
• Pain when passing urine/frequent need to pass urine or very offensive smelling urine
• Difficulty with breathing, chestiness or cough with green or yellow phlegm
• Pain in the calf, leg or chest
• Abdominal pain which is different from the usual post operative soreness
• Bleeding from the back passage
Results of your Operation
The piece of bowel that is removed is sent to the laboratory for detailed testing. The results will take ten to twenty days to be processed and a report will be sent to your consultant. Your consultant or nurse specialist will then arrange an appointment to discuss with you the results.
As part of your treatment some kind of photographic record may be made. For example, photographs or video. You will always be told if this is going to happen. The photograph or video will be kept with your notes and will be held in confidence as part of your medical record. This means that it will only be seen by those involved in providing care for you or by those needing to check the quality of care you have received.
The use of photographs and video is also extremely important for other NHS work, such as teaching or medical research. If we would like to use the information for these purposes we would only do so with your permission. We do not use any information in a way that identifies you.
Teresa Williams Colorectal and Stoma Nurse Practitioner 01908 996951.