Beyond Technical Feasibility: Patient Selection and Risk Stratification for Hartmann’s Reversal

Background: Hartmann’s procedure remains a commonly performed emergency operation for obstructive or perforated left-sided colorectal disease, yet bowel continuity is restored in only 25–40% of patients, and Hartmann’s reversal carries considerable morbidity (30–60%) and mortality of up to 7%. Non-reversal is frequently driven not by technical failure but by patient-related factors that preclude safe reoperation, underscoring the need for accurate preoperative risk stratification. Objective: To synthesize the evidence on predictors of non-reversal and postoperative morbidity after Hartmann’s reversal, propose a framework for patient selection, and discuss prehabilitation strategies that may improve outcomes. Methods: A comprehensive search of PubMed, Scopus, and Web of Science was conducted for studies published between 2005 and June 2026. Given the heterogeneity of the evidence, a narrative synthesis approach was adopted. Results: Reversal feasibility and outcomes are governed by the interplay between physiological reserve (age, frailty, ASA class, comorbidity, nutritional and body-composition status), disease-related factors (underlying pathology, oncological burden, peritoneal contamination), and treatment-related factors (timing, anastomotic technique, rectal stump characteristics, operative approach). No single predictor reliably determines outcome, and several key factors—nutritional status, smoking, and timing—are potentially modifiable. Conclusions: Successful reversal depends on far more than technical operability. An individualized, multidimensional risk-stratification framework combined with targeted prehabilitation and realistic counseling may improve patient selection. Standardized risk-assessment models and prospective studies are needed.