**Background:** Hartmann's operation is performed when primary anastomosis of the colon is difficult due to severe peritonitis or unstable vital signs. Hartmann reversal is often performed subsequently, but surgeons may hesitate to use laparoscopic surgery due to peritoneal adhesions from prior surgery. Although advantages of laparoscopic Hartmann reversal (LHR) have been reported, multicenter studies with robust matching are rare. This study aimed to confirm the advantages of LHR over open Hartmann reversal (OHR) using propensity score matching on data from multiple institutions.
**Methods:** This was a multicenter retrospective cohort study conducted at six institutions under the Catholic Medical Center of the Catholic University of Korea. Patients who underwent Hartmann reversal between January 1, 2005 and December 31, 2021 were included. Exclusion criteria were conversion to open surgery and missing data for propensity score matching covariates. Among 337 patients, 15 who underwent conversion were excluded, leaving 322 patients (89 LHR, 233 OHR). Propensity score matching (1:1 ratio using logistic regression with nearest-neighbor method) was applied, yielding 63 patients per group. Covariates included age, sex, body mass index, smoking, diabetes, hypertension, heart disease, pulmonary disease, liver disease, cerebrovascular disease, stump length, cause of perforation (cancer or benign), combined resection, anastomosis method, and stapler size. The primary outcome was postoperative ileus (POI) frequency, defined as any situation requiring return to nil per os or nasogastric tube insertion. Secondary outcomes were time to solid diet (days), length of hospital stay (days), and postoperative complications. Statistical significance was set at p<0.05.
**Key Results:** After propensity score matching, baseline characteristics were well balanced between the LHR and OHR groups (63 patients each). There was no difference in adhesiolysis frequency (77.8% vs. 82.5%, p=0.503) or operation time (210 min [IQR 159–290] vs. 233 min [IQR 160–280], p=0.718). For the primary outcome, the LHR group showed significantly lower POI frequency than the OHR group (4.8% [3/63] vs. 22.2% [14/63], p=0.0041). For secondary outcomes, the LHR group had a significantly shorter median time to solid diet (4 days [IQR 3–5] vs. 6 days [IQR 5–8], p<0.0001) and significantly shorter median length of hospital stay (9 days [IQR 8–11] vs. 12 days [IQR 10–16], p<0.0001). There were no differences in overall postoperative complications (Clavien-Dindo ≥IIIa: 4.76% vs. 7.94%, p=0.7175), wound infection (7.94% vs. 14.29%, p=0.2568), anastomotic stricture (0% vs. 7.69%, p=0.2189), anastomotic leakage (0% in both groups), or intraabdominal abscess (0% in both groups). Subgroup analysis of patients who had undergone open or conversion Hartmann's operation showed similar trends: POI frequency was 4.4% for LHR vs. 21.5% for OHR (p=0.055), time to solid diet was 5 vs. 6 days (p<0.001), and length of stay was 9 vs. 12 days (p<0.001).
**Clinical Implications:** This multicenter propensity score-matched study provides strong evidence that LHR is associated with significantly lower rates of postoperative ileus, faster return to solid diet, and shorter hospital stays compared to OHR, without increasing other complications. The conversion rate of 14.4% in this study is consistent with prior literature (average ~16.1%), and conversion did not worsen postoperative prognosis compared to OHR. These findings support current guidelines from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons recommending minimally invasive surgical approaches for colorectal surgery. However, the authors acknowledge limitations including the retrospective design, potential selection bias, and lack of detailed records on reasons for Hartmann's operation and degree of adhesions. A multicenter randomized study with long-term follow-up is needed to verify these results.