It is important to keep in mind a number of factors when deciding to proceed with Hartmann’s reversal. These factors will impact the likelihood of a patient having a complication either during or after the procedure. By optimizing the condition of the patient, one may be able to decrease the morbidity associated with this procedure.

The timing of the reversal has been examined, but there is no clear consensus as to when is the appropriate time to proceed. Aydin et al. studied 121 patients who underwent successful Hartmann’s reversal. They found that patients undergoing reversal at 4 months after the primary procedure were 2.5 times more likely to have a surgical complication when compared with those undergoing reversal within 4 months of the primary procedure. Those having their reversal at 8 months after the primary procedure were 5.5 times more likely to have a surgical complication when compared with those who had reversal within the 4-month window. This would suggest that closure within 4 months is the safest time to proceed. Pearce et al. reviewed 145 patients after Hartmann’s reversal and found that 6 out of 12 patients (50%) who underwent reversal in under 3 months from the time of the primary surgery suffered an anastomotic leak. Twenty-eight patients underwent reversal between 3 and 6 months after their initial surgery. Seven of the 28 patients (25%) suffered an anastomotic leak. Forty patients had their reversal after 6 months from the original surgery, and all healed well without evidence of leak. This paper suggests that a waiting period of 6 months is the safest for the patient. When Keck et al. reviewed their data of 111 Hartmann’s reversals, they found no difference in morbidity, mortality, or complication rates between those that had their takedown early (before 15 weeks) or late (after 15 weeks). They did find that those that were done early did have longer hospitalizations, and that the operations were perceived by the surgeon as being more difficult. It is important to note that none of these papers specifically looked at the severity or complexity of the original operation.
This would clearly affect the recovery time of the patients and would clearly have an effect on the ease and success of the reversal procedure.

It is generally accepted that early reversal (less than 3 months) may lead to complications secondary to adhesions and residual inflammation still present from the inciting process and the original surgery. This can lead to more difficult cases, prolonged surgeries, increased blood loss, and prolonged hospitalization. On the other end of the spectrum, it is thought that waiting too long may lead to difficulty in mobilizing and anastomosing the rectal stump, which decreases in size over time due to lack of use. It is important when reviewing this literature to consider the effect of the original operation on the outcome. None of these papers specifically looked at the complexity or indication for the original operation. Perhaps the increase in complications that is sometimes seen with waiting may be a reflection of the difficulty of the original operation, the severity of the disease process, patient comorbidities, and a prolonged recovery time from a difficult original surgery, rather than a reflection of just the passage of time.

The decision as to the appropriate timing of the reversal needs to be made on an individual basis. First and foremost, the patient must be in overall good condition with recovery from the primary surgery and able to undergo a second operation. Consideration of the original disease process, the operative intervention itself, as well as how the recuperation progressed will be helpful information in planning when to proceed with the reversal. Ideally, the patients should be at or close to their premorbid state with regard to ambulation, nutrition, and overall strength. If they needed to be placed on steroids for treatment of their disease process, these should be weaned if possible before colostomy takedown. The initial inciting event should have resolved, and enough time given to have resolution of the inflammatory process. Finally, there should be no sign of ongoing infection that could lead to an increased risk of wound infection or intra-abdominal abscess formation. The author takes all these factors into consideration when deciding when to reverse a colostomy but tends to aim for 6 months after the primary procedure.