OT notes · General Surgery

Hartmann's procedure (emergency sigmoid resection with end colostomy)

Usual anaesthesia
General with rapid sequence induction
Position
Supine (lithotomy-Trendelenburg if low pelvic access or rectal washout is expected)
Setting
emergency

Operative note template for emergency sigmoid resection with end colostomy and closure of the rectal stump, with a filled example for gangrenous sigmoid volvulus.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • colostomy, which may be permanent if reversal is not possible
  • leak from the rectal stump and pelvic abscess
  • injury to the left ureter, bladder or spleen
  • stoma problems: necrosis, retraction, prolapse, parastomal hernia
  • wound infection and burst abdomen
  • prolonged ileus and small bowel obstruction
  • septic shock, ICU care and risk of death
  • a second major operation to reverse the colostomy

Pre-operative details for this operation

  1. IndicationPerforated diverticulitisPerforated or obstructing sigmoid carcinomaGangrenous sigmoid volvulusColonoscopic perforationRectal / sigmoid injury
  2. Imaging / endoscopyX-ray or CT findings; flexible sigmoidoscopy attempt if volvulus
  3. Resuscitation and sepsis statusfluids, blood, urine output, BP, lactate; NG tube and urinary catheter placed
  4. Stoma site markedsite, by whom, patient sitting and lying
  5. Consent for colostomyTaken, possibility of permanent stoma explained
  6. DVT prophylaxisstockings / LMWH / compression device

Anaesthesia and position

  1. AnaesthesiaGeneral, rapid sequence induction
  2. PositionSupineLithotomy-Trendelenburg
  3. Preparation areanipples to pubis

Operative findings

  1. Peritoneal contaminationNoneLocalised pusGeneralised purulent peritonitisFaecal peritonitisvolume; culture sent
  2. Pathologyfor volvulus: direction and degree of twist, gangrene extent; for perforation: site and size; for tumour: size, fixity, nodes, liver
  3. Proximal colonhealthy / dilated / ischaemic; level used for colostomy
  4. Rectosigmoid / rectal stumphealthy, thickness, level of division
  5. Left ureterIdentified and safeNot identified (reason)

Procedure (steps)

  1. Skin preparation and draping
  2. IncisionLower midlineFull midline
  3. Fluid sampled for culture, peritoneal toilet, small bowel packed away
  4. Sigmoid and left colon mobilised along the white linestarted above the area of inflammation
  5. Left ureter identifiedwhere; traced into pelvis
  6. Gangrenous volvulus: loop not untwistedGangrene present: base of mesentery clamped and loop resected without detorsionLoop viable: twist undone, then resectedwrite that detorsion was avoided if gangrene was seen, and whether the pedicle was controlled before handling the loop
  7. Resection levels chosenproximal and distal points on healthy bowel
  8. Mesentery dividedClose to bowel (benign disease)Oncological level with nodes (suspected cancer)ligature material
  9. Distal division and stump closureLinear staplerHand-sewn in two layersstapler size and cartridge, or suture material
  10. Stump tagged and / or fixedLong non-absorbable tag suturesTacked to sacral promontory / pelvic fasciaNeither
  11. Proximal divisionLinear staplerClamp
  12. Specimen removed
  13. Peritoneal lavagewarm saline, volume; haemostasis checked
  14. Colostomy trephineskin disc about 2 cm at marked site; cruciate sheath incision; rectus split not cut; admits two fingers
  15. Colon brought out without tensionWithout extra mobilisationAfter splenic flexure / descending colon mobilisation

Closure, drains and dressing

  1. DrainNonePelvic drain (abscess present)type and size
  2. Fasciasuture material, size and technique
  3. SkinLoosely closedLeft open and packedDelayed primary closure plannedStaples
  4. Colostomy matured after wound is closed and coveredstaple line or clamp removed; mucocutaneous sutures, material and size; stoma colour; appliance fitted

Specimens and implants

  1. Sigmoid colon sent for HPElength in cm; mark proximal end
  2. Peritoneal fluid / pus for culture
  3. Stapler cartridgestype, size and number; stickers pasted

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. ICU / HDU or wardwhere, and why
  2. Vitals, urine outputfrequency; urine output target
  3. Stoma checkstoma colour on each ward round and nursing check; report dusky or black stoma
  4. Nasogastric tube and dietfree drainage; advance diet with bowel sounds, flatus or stoma output
  5. IV fluids and electrolytestype and rate; daily Na, K, creatinine
  6. Antibioticsdrug, dose, frequency, planned duration; review with culture report
  7. Drainchart output and character
  8. Urinary catheterplanned removal day
  9. DVT prophylaxis until walkingdrug and dose / stockings
  10. Stoma nurse and teachingappliance change, diet advice
  11. Plan for reversaltiming and investigations before reversal

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. B.J., 64 years, 2 days of gross abdominal distension and absolute constipation, X-ray showing a bent inner-tube sigmoid loop, tender loop with rising pulse; flexible sigmoidoscopy showed dark mucosa; taken for emergency laparotomy.

Case details

Date: 10/09/2026. Emergency. Emergency OT.

Decision 08:30. In OT 09:40. Induction 09:50. Skin incision 10:05. Closure completed 12:05.

Surgeon: Dr A. (3rd-year resident, General Surgery). Assistant: Dr B. (2nd-year resident). Consultant: Dr C., scrubbed for stump closure.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: sigmoid volvulus with suspected gangrene (dark mucosa on sigmoidoscopy, tender loop, pulse 118/min).

Resuscitation: 3 L RL over 4 hours, urine output 30 ml/h. Hb 12.6 g/dl, creatinine 1.4 mg/dl, K 3.3 mmol/l, corrected with IV potassium before surgery. Ryle's tube and Foley catheter in place.

Stoma site marked in left iliac fossa over the rectus by Dr A. with patient sitting and lying.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from patient and son. Colostomy, its possible permanence, and later reversal explained.

WHO checklist sign in and time out done. Inj ceftriaxone 2 g IV and inj metronidazole 500 mg IV at 09:52, before incision. Stockings on.

Anaesthesia and position

GA with rapid sequence induction. Supine. Parts painted with povidone-iodine from nipples to pubis and draped.

Procedure

Midline incision from above the umbilicus to the pubis.

Findings: 300 ml blood-stained foul fluid, sent for culture. Hugely dilated sigmoid loop twisted 360 degrees anticlockwise on a narrow mesentery. About 40 cm of the twisted sigmoid black and gangrenous, no perforation. Descending colon and upper rectum pink and healthy. Small bowel normal. Liver normal.

Small bowel packed into the upper abdomen with moist packs. Self-retaining retractor placed.

Descending colon and sigmoid mobilised along the white line starting above the gangrenous part. Left ureter identified at the pelvic brim over the iliac vessels and kept in view.

Because the loop was gangrenous, it was not untwisted. The base of the sigmoid mesentery below the twist was clamped first to control the pedicle.

Mesentery divided close to the bowel between clamps and ligated with silk 2-0 (benign disease). Gangrenous loop kept twisted and handled as little as possible.

Distal division at the rectosigmoid on healthy bowel with a 60 mm linear stapler, 4.8 mm staples. Slight ooze from staple line seen. Stump tagged with two long polypropylene (Prolene) 2-0 sutures.

Proximal division at the distal descending colon on healthy, bleeding bowel with a 60 mm linear stapler. Specimen removed.

Peritoneal lavage with 5 L warm saline. Haemostasis checked.

2 cm skin disc excised at the marked left iliac fossa site. Anterior sheath opened in a cross, rectus split, peritoneum opened to admit two fingers. Descending colon brought out without tension.

Closure

No drain (no abscess cavity).

Linea alba closed with continuous polyamide (nylon) No. 2. Skin closed loosely with interrupted polyamide (Ethilon) 2-0, wound covered before maturing the stoma.

Staple line on the colostomy excised. End colostomy sutured to the dermis with interrupted polyglactin 910 (Vicryl) 3-0 full-thickness bites. Stoma pink, 1 cm spout. Appliance fitted.

Specimens and implants

Sigmoid colon, 45 cm, sent for HPE in formalin, proximal end marked with a stitch.

Peritoneal fluid for culture and sensitivity.

Two linear stapler cartridges (60 mm, 4.8 mm) used; stickers pasted in the case sheet.

End of procedure

Estimated blood loss 300 ml. No transfusion. IV fluids in OT: 2.5 L RL.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications. Ureter not injured.

Shifted to surgical ICU intubated for overnight ventilation because of sepsis. Pulse 108/min, BP 102/64 mmHg on no inotropes.

Post-op orders

Pulse, BP, SpO2 hourly. Urine output hourly, target more than 0.5 ml/kg/h.

Check stoma colour on every nursing round. Inform surgeon at once if dusky or black.

Nil by mouth. Ryle's tube on free drainage.

IV RL and DNS as per chart. Na, K, creatinine and CBC on POD 1.

Inj ceftriaxone 2 g IV once daily and inj metronidazole 500 mg IV 8-hourly. Review duration with culture report.

Inj paracetamol 1 g IV 6-hourly.

Stockings and LMWH as per VTE risk score until walking.

Foley catheter to stay till at least POD 3.

Stoma nurse review on POD 2. Plan reversal after recovery, typically 6 to 12 weeks.

Signature

Dr A., JR-3, General Surgery. Reg. no. ________. 10/09/2026, 12:20.

Must document for this operation

  • Level of the rectal stump and how it was closed, tagged or fixed. The surgeon doing the reversal needs to find and join the stump, and a low or untagged stump makes that much harder.
  • That the left ureter was identified, and where. Ureteric injury is the classic complication of sigmoid resection, and the note is the evidence it was looked for.
  • For volvulus, whether the loop was gangrenous and whether it was untwisted before resection. Untwisting a dead loop can release toxins into the circulation, so the note must show the choice made and the reason.
  • Findings that justified a stoma rather than an anastomosis. The note must show why a primary anastomosis was unsafe, for audit and for the patient.
  • Stoma site, how it was made, and its colour at the end. Early stoma necrosis needs early action, and the ward needs a baseline to compare with.
  • Colostomy consent, including possible permanence. Many Hartmann's colostomies are never reversed, and the patient must have agreed to this risk.
  • Stapler cartridge details. Device traceability is needed for audit and if a device is recalled.

Common mistakes in these notes

  • Not writing how the rectal stump was closed or where it lies.
  • Leaving out whether the left ureter was seen.
  • Writing 'colostomy done' without site, type and colour.
  • Not recording the degree of contamination.
  • No reversal plan in the post-op orders.
  • For gangrenous volvulus, writing 'twist undone' without recording that the loop was dead, which suggests an unsafe detorsion.

Indian practice and paperwork

  • If a colostomy or extra resection was not in the written consent, the note must say why it could not wait. The Supreme Court allows an unconsented extra procedure only when needed to save life or preserve health. (Samira Kohli v. Dr Prabha Manchanda, (2008) 2 SCC 1)
  • NABH standard MOM.10(d) (5th edition) asks for the batch and serial number of implanted medical devices in the medical record, the master logbook and the discharge summary. Stapler cartridges leave staples in the patient, so paste their stickers. (NABH Hospital Accreditation Standards 5th ed. (April 2020), MOM.10 OE d)
  • NQAS expects that braided biological sutures are not used in dirty wounds and catgut is not used to close abdominal fascia. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, OT checklist ME E15.3)
  • Bio-Medical Waste Management Rules 2016 put excised human tissue in Yellow category (a) human anatomical waste, and discarded formalin is chemical waste. Record where the specimen went. (DGHS/CPCB Guidelines for Management of Healthcare Waste as per BMW Rules 2016)

Sources

  • Bell RH Jr, Kaufman DB, eds. Northwestern Handbook of Surgical Procedures. Landes Bioscience; 2005, Ch 36, Colostomy: End Sigmoid with Hartmann's Pouch (Winchester DJ), pp. 98-100.
  • Scott-Conner CEH, ed. Chassin's Operative Strategy in General Surgery: An Expositive Atlas. 4th ed. Springer; 2014, Ch 65, Surgery for Colonic Diverticulitis and Other Benign Conditions of the Left Colon (Hartmann's Procedure), pp. 621-624.
  • Gvalani AK. Manual of Instruments and Operative Surgery. 2nd ed. CBS Publishers & Distributors, Ch 46 Small Intestine: volvulus of pelvic colon (emergency options incl. Hartmann's procedure; general advice only, not for gangrenous loop), pp. 266-267.
  • Scott-Conner CEH, ed. Chassin's Operative Strategy in General Surgery: An Expositive Atlas. 4th ed. Springer; 2014, Ch 48, Concepts in Surgery of the Large Intestine (Volvulus), pp. 429-430.
  • Moran B, Mittal R, Lord A, eds. Farquharson's Textbook of Operative General Surgery. 11th ed. CRC Press, Ch 13, Emergency small and large bowel surgery (Volvulus), pp. 257.
  • Bratzler DW, et al. ASHP/IDSA/SIS/SHEA Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 2013;70:195-283. Table 2: colorectal, ceftriaxone + metronidazole an option; Table 1 doses; within 60 min before incision. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf
  • Ceftriaxone 2 g powder for solution, SmPC section 4.2 (electronic medicines compendium): complicated intra-abdominal infection 1-2 g once daily. www.medicines.org.uk/emc/product/1362/smpc
  • Metronidazole 500 mg/100 ml IV infusion, SmPC section 4.2: anaerobic infection 500 mg every 8 hours. www.medicines.org.uk/emc/product/1842/smpc
  • NHS. How and when to take paracetamol for adults (1 g per dose, at least 4 hours apart, not more than 4 g in 24 hours). www.nhs.uk/medicines/paracetamol-for-adults/how-and-when-to-take-paracetamol-for-adults/

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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