Diseases of the Colon & Rectum

, Volume 35, Issue 10, pp 975–980 | Cite as

Low Hartmann's procedure for severe anorectal Crohn's disease

  • Marc E. Sher
  • Joel J. Bauer
  • Stephen Gorphine
  • Irwin Gelernt
Original Contributions


Perineal wounds often fail to heal following proctectomy for Crohn's disease. Twenty-five patients with severe anorectal Crohn's disease and perineal fistulas, necessitating excisional surgery, underwent a low Hartmann's procedure in lieu of a standard proctectomy. Fifteen of the 25 (60 percent) patients had a completely healed perineum and required no further surgical therapy. Although perineal disease persisted in the other 10 patients, their perinea were much improved compared with the initial presentation. Following a low Hartmann's procedure, the rectal stump becomes atrophic and anoperineal disease regresses, thereby permitting subsequent perineal proctectomy in less inflamed tissues. Since only a 3-cm to 5-cm cuff of rectum was retained from the initial surgery, a perineal intersphincteric approach could be employed and no abdominal dissection was necessary. Of the 10 patients who subsequently underwent perineal proctectomies, three patients still have an unhealed perineum. Twenty-two of the 25 (88 percent) patients have a completely healed perineum (mean follow-up period, 69.1 months). No attempt was made to establish intestinal continuity in any of the 25 patients. We conclude that the problem of the unhealed perineal wound can be averted with this approach, thereby reducing the long-term morbidity to the patient.

Key words

Crohn's disease Perineal wound healing Hartmann's procedure 


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  1. 1.
    Corman ML, Veidenheimer MC, Coller JA, Ross VH. Perineal wound healing after proctectomy for inflammatory bowel disease. Dis Colon Rectum 1978;21:155–9.Google Scholar
  2. 2.
    deDombal FT, Burton I, Goligher JC. The early and late results of surgical treatment for Crohn's disease. Br J Surg 1971;58:805–15.Google Scholar
  3. 3.
    Ritchie JK. Ileostomy and excisional surgery for chronic inflammatory disease of the colon: a survey of one hospital region. Gut 1971;12:528–40.Google Scholar
  4. 4.
    Irvin TT, Goligher JC. A controlled clinical trial of three different methods of perineal wound management following excision of the rectum. Br J Surg 1975;62:287–97.Google Scholar
  5. 5.
    Keighley MR, Allan RN. Current status and influence of operation on perianal Crohn's disease. Int J Colorectal Dis 1986;1:104–7.Google Scholar
  6. 6.
    Bauer JJ, Gelernt IM, Salky BA, Kreel I. Proctectomy for inflammatory bowel disease. Am J Surg 1986;151:157–62.Google Scholar
  7. 7.
    Tuxen PA, Castro AF. Rectovaginal fistula in Crohn's disease. Dis Colon Rectum 1979;22:58–62.Google Scholar
  8. 8.
    Sher ME, Bauer JJ, Gelernt I. Surgical repair of rectovaginal fistulas in patients with Crohn's disease: transvaginal approach. Dis Colon Rectum 1991;34:641–8.Google Scholar
  9. 9.
    Fry RD, Shemesh EI, Kodner IJ, Timmcke A. Techniques and results in the management of anal and perianal Crohn's disease. Surg Gynecol Obstet 1989;168:42–8.Google Scholar
  10. 10.
    Williams JG, Hughes LE. Abdominoperineal resection for severe perianal Crohn's disease. Dis Colon Rectum 1990;33:402–7.Google Scholar
  11. 11.
    Wolff BG, Culp CE, Beart RW Jr, Ilstrup DM, Ready RL. Anorectal Crohn's disease: a long term perspective. Dis Colon Rectum 1985;28:709–11.Google Scholar
  12. 12.
    Buchmann P, Keighley MR, Allan RN, Thompson H, Alexander-Williams J. Natural history of perianal Crohn's disease. Am J Surg 1980;140:642–4.Google Scholar
  13. 13.
    Saha SK, Robinson AF. A study of perineal wound healing after abdominoperineal resection. Br J Surg 1976;63:555–8.Google Scholar
  14. 14.
    Silen W, Glotzer DJ. The prevention and treatment of the persistent perineal sinus. Surgery 1974;75:535–42.Google Scholar
  15. 15.
    Oakley JR, Fazio VW, Jagelman DG, Lavery IC, Weakley FL, Easley K. Management of the perineal wound after rectal excision for ulcerative colitis. Dis Colon Rectum 1985;28:885–8.Google Scholar
  16. 16.
    Baudot P, Keighley MR, Alexander-Williams J. Perineal wound healing after proctectomy for carcinoma and inflammatory disease. Br J Surg 1980;67:275–6.Google Scholar
  17. 17.
    Manjoney DL, Koplewitz MJ, Abrams JS. Factors influencing perineal wound healing after proctectomy. Am J Surg 1983;145:183–9.Google Scholar
  18. 18.
    Lubbers E-J. Healing of the perineal wound after proctectomy for nonmalignant conditions. Dis Colon Rectum 1982;25:351–7.Google Scholar
  19. 19.
    Lee EC, Dowling BL. Perimuscular excision of the rectum for Crohn's disease and ulcerative colitis. Br J Surg 1972;58:229–32.Google Scholar
  20. 20.
    Lyttle JA, Parks AG. Intersphincteric excision of the rectum. Br J Surg 1977;64:413–6.Google Scholar
  21. 21.
    Scammell BE, Andrews H, Allan RN, Alexander-Williams J, Keighley MR. Results of proctocolectomy for Crohn's disease. Br J Surg 1987;74:671–4.Google Scholar
  22. 22.
    Linares L, Moreira LF, Andrews H, Alexander-Williams J, Keighley MR. Natural history and treatment of anorectal strictures complicating Crohn's disease. Br J Surg 1988;75:653–5.Google Scholar
  23. 23.
    Goligher JC. The long-term results of excisional surgery for primary and recurrent Crohn's disease of the large intestine. Dis Colon Rectum 1985;28:51–5.Google Scholar
  24. 24.
    Scammell BE, Keighley MR. Delayed perineal wound healing after proctectomy for Crohn's colitis. Br J Surg 1986;73:150–2.Google Scholar
  25. 25.
    Farnell MB, Van Heerden JA, Beart RW Jr, Weiland LH. Rectal preservation in nonspecific inflammatory disease of the colon. Ann Surg 1980;192:248–53.Google Scholar

Copyright information

© American Society of Colon and Rectal Surgeons 1992

Authors and Affiliations

  • Marc E. Sher
    • 1
  • Joel J. Bauer
    • 1
  • Stephen Gorphine
    • 1
  • Irwin Gelernt
    • 1
  1. 1.Department of Surgery, Mount Sinai Hospital, Mount Sinai School of MedicineThe City University of New YorkNew York

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