A 64-year-old man with perforated sigmoid colon undergoes emergent surgery. Which operation is most appropriate in an unprepared patient?

A 64-year-old man with perforated sigmoid colon undergoes emergent surgery. Which operation is most appropriate in an unprepared patient?

• A. Left colectomy with primary anastomosis
• B. Hartmann procedure
• C. Proctocolectomy
• D. Abdominoperineal resection

Answer: (A)

When a perforated sigmoid colon is discovered in an unprepared patient, the priority is rapid source control and minimizing the risk of an anastomotic leak in a hostile abdomen. The safest and most forgiving approach is a damage-control resection that avoids connecting the bowel immediately. This is done by removing the diseased segment and bringing out a stoma (end colostomy) with closure of the rectal stump—classic Hartmann procedure. It effectively controls the contamination, reduces operative time, and allows the patient to stabilize before any attempt to restore bowel continuity. In contrast, attempting to join the ends of the colon with a primary anastomosis in a contaminated, inflamed abdomen of an unprepared patient carries a high risk of anastomotic failure and persistent sepsis. It demands a healthier, better-prepared field and often more stable physiologic status. The other options are either overly extensive for a perforated sigmoid in this setting or not the standard initial management: proctocolectomy or abdominoperineal resection would be unnecessarily large operations for an acute perforation, and left colectomy with primary anastomosis would not be favored due to the high leak risk in an unprepared, septic abdomen. Hartmann procedure thus offers safe source control, minimizes immediate operative risk, and preserves the option for later restoration of continuity once the patient has recovered.

When a perforated sigmoid colon is discovered in an unprepared patient, the priority is rapid source control and minimizing the risk of an anastomotic leak in a hostile abdomen. The safest and most forgiving approach is a damage-control resection that avoids connecting the bowel immediately. This is done by removing the diseased segment and bringing out a stoma (end colostomy) with closure of the rectal stump—classic Hartmann procedure. It effectively controls the contamination, reduces operative time, and allows the patient to stabilize before any attempt to restore bowel continuity.

In contrast, attempting to join the ends of the colon with a primary anastomosis in a contaminated, inflamed abdomen of an unprepared patient carries a high risk of anastomotic failure and persistent sepsis. It demands a healthier, better-prepared field and often more stable physiologic status. The other options are either overly extensive for a perforated sigmoid in this setting or not the standard initial management: proctocolectomy or abdominoperineal resection would be unnecessarily large operations for an acute perforation, and left colectomy with primary anastomosis would not be favored due to the high leak risk in an unprepared, septic abdomen.

Hartmann procedure thus offers safe source control, minimizes immediate operative risk, and preserves the option for later restoration of continuity once the patient has recovered.