**Background:** The Hartmann procedure—resection of the lower sigmoid and upper rectum with closure of the rectal stump and end colostomy—remains a critical emergency operation for advanced or complicated rectosigmoid neoplasms, peritoneal sepsis, intestinal occlusion, and fragile colonic walls. Despite advances in surgical techniques, the procedure carries significant morbidity and a 40% failure rate for stoma reversal (Hartmann II). Laparoscopic approaches may improve outcomes, but adoption remains limited.
**Methods:** This retrospective study reviewed medical records of all patients who underwent Hartmann procedure (open or laparoscopic) at the First Surgery Clinic between 1 January 2016 and 31 December 2020. The study compared 58 cases of classic (open) Hartmann with 30 cases involving laparoscopy (7 laparoscopic Hartmann and 23 diagnostic laparoscopies with conversion). Univariate and multivariate statistical analyses were performed using SPSS, with statistical significance set at p < 0.05. The surgical technique involved modified lithotomy positioning, 30-degree laparoscope, standard oncological principles (early proximal vascular ligation, appropriate lymphadenectomy with mesorectal excision), and either Veress needle or Hasson trocar for pneumoperitoneum.
**Key Results:** Of 985 operations for intestinal and colonic occlusion (7.15% of total clinic operations), 531 (54%) were non-tumor occlusions and 454 (46%) were occlusive tumors, yielding 88 Hartmann operations. Only 7.3% were laparoscopically performed. Mean age was 70 years for open Hartmann (range 37-91), 80 years for classic non-tumoral occlusion, and 69 ± 11.43 years for laparoscopic Hartmann. Most patients had comorbidities: cardiopathies 60% (57 patients, 65.51%), hepatopathies 40% (33, 38%), anemia 30%, pulmonary diseases 10%. ASA III risk was present in 56.30% (49 patients). Statistical analysis demonstrated that cardiac comorbidities increased general postoperative complication rates sevenfold (chi-square, p = 0.031 for local complications), and pulmonary comorbidities increased general complications 2.5-fold. Peritonitis was statistically significantly associated with local complications (over 80% of peritonitis patients developed local postoperative complications). No significant association was found between occlusion and local (p = 0.646) or general (p = 0.803) complications. Among Hartmann patients, 28% had local complications, 43% general complications, and 29% had no morbidities. Laparoscopically treated patients showed 80% complication-free evolution versus 50% for open surgery. Postoperative mortality was 10% for all intestinal occlusion patients and 21% for Hartmann patients. Tumor staging showed predominantly T3 (43%) and T4 (36%), with N0 (31%), N2 (33%), and M0 (93%). Lymph node excision averaged 19 nodes for open surgery and 22 for laparoscopic. Hospital stay was significantly shorter for laparoscopic approach (mean 5 days, maximum 8) versus open (mean 12 days, p = 0.015). Tumor differentiation was G1 in 14%, G2 in 36%, and G3 in 50%.
**Clinical Implications:** The Hartmann procedure remains a widely used, life-saving emergency operation, particularly for patients with advanced colorectal cancer, significant comorbidities, or peritoneal sepsis. Laparoscopic approaches demonstrate clear advantages including significantly shorter hospital stays and lower complication rates, though adoption remains low (7.3%) due to advanced disease presentation and poor patient condition. The study confirms that cardiac and pulmonary comorbidities are strong predictors of postoperative complications, and peritonitis specifically predicts local complications. The high mortality (21%) and morbidity (65%) rates reflect the critically ill patient population. The 40% failure rate for Hartmann reversal underscores the need for careful patient selection and counseling. The authors suggest that with appropriate surgical expertise, laparoscopy may become the standard approach for both the Hartmann procedure and its reversal, though conversion rates of 8-40% and the need for expensive equipment remain barriers.