Meticulous surgical technique serves to preserve tissue integrity. Bleeding along wound edges may initially be taken as encouraging evidence of good blood flow, but hemostasis should be promptly achieved, as any significant hematoma formation at a wound edge can impede perfusion as well as provide a nidus for infection that would threaten the integrity of the closure. Similarly, adequate removal of any surrounding contamination is important for limiting impending infectious and inflammatory changes along the wound edge, which predispose to wound dehiscence [1]. Another very important consideration, especially when creating a long Hartmann stump, is selecting a stump margin well within the domain of segmental blood supply and avoiding watershed regions. This is less of an issue with rectal stumps due to the rectum’s redundant blood supply via the inferior mesenteric artery (superior rectal artery), internal iliac artery (middle rectal artery), and pudendal artery (inferior rectal artery).

The next issue the surgeon must address is how to close the stump. Numerous studies have compared anastomotic leak rates with stapled versus handsewn and single- versus double-layer closures. The bulk of these demonstrate no clinically significant difference, though stapled and single-layer closures afford shorter operative times [2–7], which in the arena of emergency surgery can be critical. This can all presumably be extrapolated to stump closures, and a few recent studies in high-risk patient cohorts have indeed shown no difference in stump leak rates by closure method [8, 9].

Alternatively, maturation of a mucus fistula may be considered. Given the additional wound management requirements necessary with mucus fistula, stump closure is generally preferred unless a fistula can be brought up alongside the ostomy in a pseudo-loop fashion to facilitate future local restoration of continuity. Additional indications for fistula include presence of a distal obstruction, anticipated chemotherapy that may be initiated more quickly in the absence of a healing staple or suture line, and patient comorbidities that elevate concern for stump leak and/or catastrophic delay in recognition of a leak.

The heightened concern for stump leak among those patients undergoing subtotal colectomy for refractory inflammatory bowel disease—a particularly high-risk group given that they are often malnourished with recent exposure to high-dose steroids and/or anti-TNF agents and inherently inflamed tissue edges—has prompted a handful of studies of stump management options in this high-risk cohort. Historically, mucus fistula maturation was standard for this patient population, but a series of investigations in the 1990s demonstrated that the incidence of pelvic sepsis with stump closure was not significantly different from that with mucus fistula. Thus, incurring the added morbidity of a mucus fistula has become less popular. Instead, multiple authors have proposed leaving the stump long enough to facilitate subcutaneous placement, either at the inferior aspect of the midline incision or at a separate site in the left lower quadrant. Proponents argue that although this leaves additional potentially diseased tissue in situ, the subcutaneous location allows for safer control in the instance of a leak, which would generate a wound infection amenable to superficial management rather than pelvic sepsis requiring more invasive measures. Also, at the time of completion of proctectomy and ostomy reversal, the stump may be more readily identified than if it were left intraperitoneal. Interestingly, one recent comparison of intraperitoneal versus subcutaneous stumps found no significant difference in stump-related morbidity, including stump leak, pelvic sepsis, or wound infection, although patients with intraperitoneal stumps did experience significantly shorter time to return of bowel function, along with shorter operative times and fewer conversions from laparoscopic to open [8].

The decision to leave a drain often incites a great deal of discussion. Proponents of intraperitoneal drain placement suggest that drains offer an opportunity to remove any lingering contamination and provide a means to control any infectious complication or leak that may arise. Opponents suggest that the drains themselves generate irritation and means for pathogen exposure that potentially increase the likelihood of wound breakdown [1]. In our opinion, if any concern exists about lingering contamination, inclusion of less-than-ideal bowel in the stump margin, or presence of significant patient factors that would contribute to wound dehiscence, then drain placement is a prudent measure. Significant patient risk factors can be categorized broadly into those that compromise blood supply (hemodynamic instability, vasopressor requirement, diabetes, significant underlying vascular disease or tobacco history, pelvic irradiation, chemotherapy with anti-angiogenesis agents such as bevacizumab), and those that compromise collagen deposition and cell turnover for wound healing (advanced age, diabetes, connective tissue disorders, significant tobacco history, malnutrition or significant alcohol history, jaundice, uremia, immunosuppression, or chemotherapy). Similarly, placement of a transanal drainage catheter to encourage decompression of remnant stool is a low-risk intervention that reduces the likelihood of distal stump obstruction and may reduce the incidence of pelvic sepsis [10].