Minimally invasive emergency colorectal surgery in nonspecialist surgical centers: a necessity, not a luxury

Hartmann’s surgery is a critical surgical intervention for patients with sigmoid colon perforation, particularly if accompanied by hemodynamically unstable generalized fecal peritonitis [1]. Historically performed primarily by general surgeons, the execution of Hartmann’s surgery has become more commonly performed by colorectal surgeons with the rise of colorectal surgery as a subspecialty. However, sigmoid colon perforations still occur in hospitals without colorectal specialists, requiring general surgeons to be proficient in performing these potentially life-saving surgeries.

Recently, evidence has shown that minimally invasive approaches can improve the outcomes of elective and emergency colorectal procedures. However, the laparoscopic Hartmann’s surgery remains technical challenging for many general surgeons, especially during emergency settings in which the patient’s condition is often unstable. This underscores the importance of equipping general surgeons with advanced laparoscopic skills to effectively manage acute colorectal conditions.

Cattanach et al. [2] conducted a retrospective cohort study entitled, “Emergency laparoscopic Hartmann procedure no longer a subspecialist operation: a retrospective cohort study at an Australian non-subspecialized center.” This study compared the outcomes of laparoscopic and open Hartmann’s procedures in a nonspecialist hospital setting. This study has limitations in that it is a single-center retrospective cohort study with a small number of patients, and it did not statistically demonstrate the absence of differences in patient characteristics between the two groups being compared. In particular, although the postoperative intensive care unit admission rate and the severity of peritonitis appeared to differ meaningfully between the groups, no statistical analysis was performed, leaving it unclear whether these differences may have been influenced by patient characteristics. Nevertheless, Patients who underwent laparoscopic surgery had a faster return to bowel function (adjusted incidence rate ratio [IRR], 1.34; 95% confidence interval [CI], 1.00–1.81) and shorter hospital stay (adjusted IRR, 1.64; 95% CI, 1.25–2.15) compared with those who had open surgery. Moreover, laparoscopic Hartmann’s surgery was associated with a significantly higher likelihood of laparoscopic reversal (91.7% vs. 33.3%) [2].

Using National Surgical Quality Improvement Program data, Amodu et al. [3] performed a propensity-matched analysis and found that laparoscopic Hartmann’s surgery for complicated diverticulitis resulted in lower rates of superficial surgical site infections, with comparable outcomes regarding morbidity and mortality and a similar length of stay.

Additionally, data on Hartmann’s reversal procedures further support the use of minimally invasive techniques. Chavrier et al.’s meta-analysis [4] confirmed that laparoscopic reversal of Hartmann’s surgery was associated with lower postoperative morbidity, wound infection, and postoperative ileus without increasing mortality. A more recent international study by Mostafa et al. [5] emphasized improved outcomes in multiport and single-incision laparoscopic reversals compared with open methods. Furthermore, a multicenter propensity score-matched study demonstrated a significantly lower incidence of postoperative ileus following laparoscopic Hartmann’s reversal than following an open approach [6].

In the enhanced recovery after surgery era, early recovery, reduced complication rates, and shorter hospitalizations are highly valued outcomes, even in emergency surgery. If laparoscopic techniques can be safely used in such settings, their use should be encouraged. Although data suggest that outcomes are often superior if colorectal subspecialists are involved [7], such expertise is not always readily available, especially in regional or community hospitals. Thus, general and acute care surgeons must be trained and supported in performing minimally invasive colorectal emergency surgeries.

This evidence make a strong case for the incorporation of laparoscopic colorectal techniques, including Hartmann’s surgery, into general surgical training and institutional protocols. Prospective multicenter studies comparing the outcomes between subspecialists and no subspecialists in emergency laparoscopic Hartmann’s surgery are warranted. Current evidence supported empowering general surgeons with the skills and confidence to perform these procedures safely and effectively, ensuring high-quality emergency care across all hospital settings.