Primary Anastomosis Versus Hartmann’s Procedure in Acute Care Surgery: Evidence, Indications, and Barriers to Adoption

Purpose of ReviewThis review examines the contemporary role of Hartmann's procedure (HP) in acute care surgery, focusing on the two principal disease processes in which it remains commonly utilized: complicated diverticulitis and traumatic colon injury. We review the evolving evidence comparing HP with primary anastomosis (PA), with or without diverting loop ileostomy (DLI), while emphasizing differences in patient populations, operative decision-making, and factors influencing adoption in clinical practice.Recent FindingsIncreasing evidence supports the safety and feasibility of PA in appropriately selected patients with both perforated diverticulitis and traumatic colon injury. In complicated diverticulitis, randomized trials demonstrate comparable morbidity and mortality between HP and PA, while PA is associated with higher stoma reversal rates and reduced long-term stoma burden. In trauma populations, primary repair or resection with PA has similarly demonstrated favorable outcomes across a broad range of injury patterns. However, HP continues to play an important role in physiologically high-risk patients, particularly in the setting of profound instability, severe contamination, impaired healing potential, or circumstances in which an anastomotic complication would likely be catastrophic.SummaryContemporary evidence supports a more selective role for HP in modern surgical practice. While PA with or without DLI is increasingly favored in appropriately selected patients, operative management must remain individualized based on patient physiology, intraoperative findings, comorbidities, and surgeon judgment.