With the patient in the anti-Trendelenburg position the gastrocolic ligament is opened using the ultrasound scalpel. The phrenocolic and splenocolic attachments ...
Surg Endosc (2004) 18: 1344–1348 DOI: 10.1007/s00464-003-9178-6 Ó Springer Science+Business Media, Inc. 2004
Laparoscopic treatment of sigmoid diverticulitis A retrospective review of 103 cases R. Pugliese, S. Di Lernia, F. Sansonna, I. Scandroglio, D. Maggioni, C. Ferrari, A. Costanzi, O. Chiara Department of General and Emergency Surgery, Hospital Niguarda Ca’Granda Milano Piazza Ospedale Maggiore, 3, 20162, Milano, Italy Received: 3 July 2003/Accepted: 17 February 2004/Online publication: 23 June 2004
Abstract Background: Laparoscopic treatment of sigmoid diverticulitis is commonly accepted in Hinchey cases I and II, whereas it is debated in the case of purulent peritonitis, and not indicated for fecal peritonitis. Methods: A single-center experience of 103 patients treated for Hinchey I–III sigmoid diverticulitis was reviewed. One-stage laparoscopic resection and primary anastomosis constituted the planned procedure. Abscesses in patients with Hinchey IIa were drained percutaneously before surgery. Patients with Hinchey III underwent surgery in emergency. A four-trocar approach with left iliac fossa minilaparotomy was used. Fistulas were treated laparoscopically with Harmonic Scalpel dissection. Results: Laparoscopic treatment was successfully completed for 100 patients. Intraoperative complications occurred in 2.9% of the cases. Postoperative procedurerelated morbidity was 8%, occurring mainly in Hinchey I patients. A longer hospital stay was recorded among Hinchey IIb patients treated for colovescical fistula. No mortality was observed. Conclusions: Laparoscopic surgery for sigmoid diverticulitis in experienced hands can be a safe and effective gold standard procedure also for patients with fistula or purulent peritonitis. Key words: Sigmoid diverticulitis — Hinchey classification — Laparoscopy — Colectomy — Internal fistula — Purulent peritonitis
Surgical treatment of complicated colonic diverticular disease still is debated, especially in relation to elderly patients with concurrent medical disease. The Hinchey classification, modified according to Wexner, provides criteria for evaluating the severity of sigmoid diverticuCorrespondence to: R. Pugliese
litis, suggesting indications for selective surgical management [12, 16]. Resection of the involved colonic tract after attacks of complicated sigmoid diverticulitis was advocated in 1995 by the Standard Task Force of the American Society of Colon and Rectal Surgeons [19]. The advent of laparoscopic techniques for colorectal surgery in 1991 seemed to increase indications for early resection. However, this technique still is hardly accepted by surgeons, particularly for diverticulitis complicated by complex abscess associated with fistula (Hinchey IIb) or generalized purulent peritonitis (Hinchey III). The existence of fecal peritonitis (Hinchey IV) is unanimously considered a contraindication for laparoscopy [4–6, 8, 9, 11, 13, 17, 20, 21]. Multicenter studies [5, 13] and comparative studies [16] with open surgery have confirmed that laparoscopic resection for diverticulitis can be performed without additional morbidity in cases of Hinchey I, and with a reduced length of hospitalization in cases of Hinchey I or II. The purpose of this study was to review laparoscopic resections for sigmoid diverticulitis performed in a single center by senior surgeons, and to discuss patient selection criteria in view of advances in expertise and technology. Patients and methods Population of the study From January 1996 to May 2003, 601 patients underwent laparoscopic colorectal surgery in our department. Laparoscopic procedures for perforated or complicated forms of sigmoid diverticulitis were performed for 103 patients (17%) (56 men and 47 women) with a mean age 64 years (range, 49–81 years). The American Society of Anesthesiology (ASA) Score was I for 55 patients, II for 41 patients, and III for 7 patients. The indications for surgery varied from one single attack of diverticulitis in patients younger than 50 years to at least two recurrent attacks in patients older than 50 years. The indications for surgery also included diverticulitis complicated with stenosis or bleeding. During the same period, 95 patients underwent open surgical procedures in 25 cases for fecal peritonitis (conversion after laparoscopic inspection was not counted as a laparoscopic procedure) and in 15 cases for hemorrhagic complications with unstable hemodynamics.
1345 In 43 cases of generalized purulent peritonitis (Hinchey III), patients underwent open procedures because of anaesthesiologic contraindications to pneumoperitoneum (ASA score of 3 or above) or unavailability of a trained laparoscopic surgeon. In 10 cases of elective surgery for complicated diverticulitis (Hinchey II), laparotomic surgery was the procedure of choice because of anesthesiologic contraindications to pneumoperitoneum or previous colorectal surgery. In two of the most recent cases in the series (Hinchey IIA), laparoscopic exploration, washout, and drainage comprised the procedure of choice. Delayed laparoscopic left colectomy could be performed in the first case, whereas in the second case the patient died of septic shock.
Table 1. Surgery indications for 103 patients according to Hinchey classification (modified according to Wexner) Stage
Pathology
Patients (n)
%
I II a II b
Diverticulitis or pericolic abscess Diverticulitis with pelvic abscess Diverticulitis with internal fistulas 8 Coloileal 6 Colovaginal 17 Colovescical Perforated diverticulitis with diffuse purulent peritonitis
49 11 31
47.5 10.7 30
12
11.6
III
Preoperative evaluation and preparation Patients with Hinchey I were investigated with barium or water-soluble contrast enema, computed tomography (CT) scan, or both. In cases of Hinchey IIa, preoperative workup included ultrasonography and CT scan followed by percutaneous drainage of distant abscess. In cases of Hinchey IIb, barium enema was used to demonstrate colovesical and coloileal fistulas, whereas direct fistulogram was the most useful examination for individuating colovaginal fistulas. Flexible endoscopy and biopsy was indicated only for patients with chronic obstructive condition or bleeding. Whenever possible, bowel preparation was obtained using 4 l of paraminoglicolic acid given orally 2 days before surgery, followed by 2 l of paraminoglicolic acid in addition to 30 tablets of vegetal carbon given the day before surgery. Perioperative (24 h) antibiotic prophylaxis consisted of cephazolin 6 g and metronidazole 1,500 mg given intravenously. Prophylaxis against thromboembolism was achieved by subcutaneous low-dose heparin started preoperatively.
Study design All patients with the diagnosis of sigmoid diverticulitis during the period of the study were included. The parameters considered in this clinical series were operating time, day of nasogastric tube removal (after a minimum of 24 h, when its output showed less than 200 ml), time of first bowel evacuation and start of oral intake (following resolution of post-operative ileus or first evacuation), intraoperative and postoperative morbidity, mortality, and length of hospital stay (LOS). All data were retrospectively derived from the analysis of clinical reports and analyzed with the SPSS 11.0 statistical package.
Surgical technique For the laparoscopic procedure, patients are positioned in the Lloyd– Davis position (the right thigh lower than the left thigh in right lateral decubitus with a pillow under the left flank). Four trocars are used, with the first operator and optic assistant on the right side of the patient, the third assistant on the left side, and the scrub nurse between the limbs. Routinely, the first trocar is introduced via an incision 4 to 5 cm above the umbilicus by the open Hasson technique, and pneumoperitoneum is insufflated to 12 mmHg. Second and third trocars are placed under direct vision respectively at the right of the umbilicus and in the right iliac fossa, and a fourth trocar is placed in the left iliac fossa. A 30° laparoscope is introduced through the second port, and after visual inspection of the peritoneal cavity, the complicated diverticular lesion is approached first to bring the anatomy of the surgical field as close to normality as possible. Only after anatomic normality is restored is a laparoscopic colonic resection performed according to well-codified steps, allowing avoidance of injuries attributable to the thickening of the structures, especially in the identification and dissection of vessels and urethers. With the patient in the anti-Trendelenburg position the gastrocolic ligament is opened using the ultrasound scalpel. The phrenocolic and splenocolic attachments are divided to mobilize the splenic flexure of the colon so a tension-free anastomosis can be created. The lower margin of the pancreas is approached with exposure of the Fredet fascia and recognition of the anterior layer of the Toldt fascia overlying the left kidney. Partial mobilization of the descending colon along Monk’s line completes the first step.
Table 2. Age and gender of 103 patients according to Hinchey classification (modified according to Wexner) Stage
Mean age (range)
Gender (M/F)
I II a II b III
59 58 65 59
11/14 7/4 21/10 6/6
(43–81) (50–67) (54–69) (35–71)
Table 3. Laparoscopic procedures associated with sigmoid resection Procedure
n
Cholecystectomy Anterior rectal resection for adenoma Goldberg operation for rectal prolapse Splenectomy for ITP
9 2 2 2
ITP, idiopathic thrombocytopenic purpura
The patient then is turned in the Trendelenburg position, and the peritoneum overlying the medial aspect of the mesentery is dissected to expose the iliac vessels, the left urether, the gonadic vessels, and the hypogastric nerves. Two spaces between the mesentery and the Toldt fascia are created, above and below the inferior mesenteric artery. The artery is divided using clips or a vascular linear stapler after the origin of left colic artery and laterally to the hypogastric nerves. The inferior mesenteric vein is divided between clips only when further mobilization is needed. Dissection is completed with mobilization of the descending colon, the sigmoid tract, and the upper third of the rectum, which is divided by a linear stapler cutter. In patients with Hinchey IIb, colovesical and colovaginal fistulas are divided with the ultrasound scalpel and, unless an obvious defect is noted, no attempt is made to close the bladder or the vagina. A 6- to 8-cm minilaparotomy is performed in the left iliac fossa by enlarging the previous port incision. A wound protector (Steri-Drape; St. Paul, MN, USA) is placed, and the left colon is extracted to perform a left hemicolectomy. In the case of coloileal fistula, small bowel may be resected and anastomized through the minilaparotomy. A 29- to 31-mm head of a circular stapler is inserted in the colonic stump and tied with a 2.0 polypropilene purse-string suture. This is returned in the peritoneal cavity, and the incision is sutured in layers. The pneumoperitoneum is recreated, and a circular stapler is advanced via the anus. The pin of the stapler is pushed through the center of the stapler line at the upper third of the rectum, and a doublestapled anastomosis is obtained. Extensive saline lavage of the peritoneal cavity is performed using variation of the patient’s position to clean all spaces. Paranastomotic drainage is left in place; the trocars are removed; and the deep fascia of ports are sutured.
Results Laparoscopic primary sigmoid resection with intracorporeal anastomosis was offered to all patients with
1346 Table 4. Intraoperative and postoperative morbidity in 103 cases of sigmoid diverticulitis initially managed through the laparoscopic approach according to Hinchey (H1, H2, H3) classification (modified according to Wexner) Complication (n)
Intraoperative morbidity Uretheric injury Anastomotic failure Anatomic difficulties Postoperative morbidity Wound infection Anastomotic leakage Intestinal obstruction Anastomotic bleeding Intraperitoneal bleeding Pneumonia Total
H1
H2a
H2b
H3
Total
Management
— 1 —
— 1 —
— — —
1 — 2
— — —
1 Repair 1 Repair, 1 conversion 2 Conversions
2 1 1 1 1 — 6
— 1 — — — — 1
1 — — — — 2 3
3 2 1 1 1 2 10
Local treatment Conservative treatment Conservative treatment (aspiration) Endoscopy Laparotomy Antibiotics, oxygen
Table 5. Operating time, days of nasogastric tube, postoperative (PO) bowel function, start of oral feeding, and length of hospital stay, for each Hinchey groupa Hinchey group Operating time (min) Nasogastric tube (days) Postoperative ileus (days) Oral intake (PO day) Length of hospital stay (days) I II III a
187 (155–215) 193 (160–240) 200 (175–210)
2.5 (1–3) 3.5 (2–5) 3.3 (2–4)
3.5 (2–5) 4.5 (3–6) 4 (2–5)
4.5 (3–5) 5.5 (4–7) 5 (3–6)
9.2 (5–28) 10.5 (7–18) 10 (7–14)
Mean values and range
Hinchey I–III diverticulitis. The operations were performed only by surgeons experienced in laparoscopic techniques. Patients with Hinchey I and IIb underwent surgery in elective settings after adequate bowel preparation. Emergency surgery was performed within 24 h after admission for patients with a clinical diagnosis of diffuse peritonitis. For patients with Hinchey IIa, CTguided drainage of the pelvic abscess was obtained initially and elective surgery was postponed 2 to 3 weeks Tables 1 and 2 summarize the characteristics of the patient population. For patients with Hinchey IIb, all coloileal fistulas required an additional extracorporeal ileal resection with laterolateral anastomosis using a linear stapler. Colovescical fistulas were treated in 16 cases with simple dissection using the ultrasound scalpel followed by urinary catheterization for 7 days. For only one patient, the defect of the bladder wall required a direct suture. Colovaginal fistulas all were successfully cured using only the ultrasound scalpel. Three intraoperative complications occurred. A left urether injury in a patient with Hinchey III resulted from difficulties in anatomic dissection consequent to the inflammation and thickness of the fat tissue of the mesentery’s medial aspect. The urether was repaired through a left iliac fossa minilaparotomy with direct suture and stenting. The other intraoperative complications were two anastomotic failures attributable to stapler malfunction: one in a patient with Hinchey I and the other in a patient with Hinchey IIa. The first was repaired laparoscopically with stitches, and the other required laparotomy. Conversion was necessary for three patients (2.9%). Two patients required open surgery for anatomic difficulties attributable to excessive
adhesions, purulence, and inability to mobilize a inflammatory diverticular pseudotumor adequately. Both were obese patients with Hinchey III. As previously reported, stapler misfiring was the cause of the third conversion. There were 15 associated procedures, all performed electively for patients with Hinchey I (Table 3). In two patients, rectal endoscopy could not remove large rectal adenomas, and colon resection was extended to a low anterior rectal resection. Another two patients were affected concomitantly by rectal prolapse and resection according to Goldberg procedure performed. In two additional patients, the coexistence of idiopathic thrombocytopenic purpura required an associated splenectomy. Neither hemathologic nor anesthesiologic contraindications resulted from preoperative investigations. Temporary ileostomy was performed for three patients: one for a patient with Hinchey I in whom anastomotic leakage was repaired laparoscopically, and two for associated low anterior resections. There were 10 postoperative complications (8 procedure-related and 2 respiratory) among patients who successfully completed laparoscopic resection, yielding an overall morbidity of 10% and no mortality (Table 4). Surprisingly, procedure-related complications tended to be found in patients with less severe diverticulitis. In contrast, postoperative pneumonia occurred only in two patients with Hinchey III. A patient with Hinchey I and concomitant thrombocytopenia experienced postoperative bleeding requiring an exploratory laparotomy for hemostasis. The overall mean operating time was 190 min (range, 155–240 min). In the Hinchey I group, mean operating time was 175 min when sigmoidectomy was
1347
the only surgical procedure and 200 min when associated operations were necessary. Operating time increased slightly but not significantly for the more severe forms of perforated diverticulitis (Table 5). For all the patients who completed laparoscopic surgery, the nasogastric tube generally was removed on postoperative day 3. Postoperative ileus lasted 4 days, and oral feeding was allowed on postoperative day 5. The mean hospital length of stay (LOS) was 9.6 days. A comparison of the mean values for the four classes of patients considered (Hinchey I to III) showed no significant difference (p > 0.05) among any of the results (Table 5) according to analysis of variance (ANOVA) and chi-square tests using the SPSS 11.0 package.
Discussion Diverticular disease of the large bowel is unusual in patients younger than 45 years. Its frequency then increases to reach 50% to 70% in the eighth decade. Nevertheless, this disease remains asymptomatic in 80% of patients, and in the case of an acute attack, the chance for recurrent disease is only 30%. However, the positive response to medical therapy decreases from 70% at the first attack to 6% at the third attack. Parks [14] reported that operative mortality in surgery increases from 3% at the first attack to 7.7% in recurrences. Hence, the common tendency currently is toward early treatment of complicated diverticular disease. Primary resection and anastomosis, with or without protective colostomy or ileostomy, generally are considered the safest option for all stages of complicated diverticulitis [1, 2]. The Hartmann operation is a two-stage procedure often performed in emergencies because of inadequate bowel preparation, but restoration of continuity is technically difficult and associated with a high rate of morbidity [3]. The delayed three-stage operation for peritonitis has been abandoned because of the high mortality rate [3, 7, 10, 15, 18, 22, 23]. Two multicenter studies showed that laparoscopic sigmoidectomy with primary anastomosis for diverticular disease is feasible and safe as elective procedures, whereas for diverticulitis and cases with fistula, it is more likely to be associated with complications [5, 13]. In the current series, patients with Hinchey I–III diverticulitis underwent surgery only by surgeons highly experienced in laparoscopy. Our mean operating time of 190 min compared favorably with the mean values reported by other series, which ranged from 141 to 300 min [4–6, 9, 13, 17, 19–21]. Although it is intuitive that the acute inflammatory process renders laparoscopy technically demanding, our conversion rate was only 2.9%, lower than that of other reports describing necessary laparotomy in 4% to 14% of cases [4–6, 9, 13, 17, 19–21]. The use of advanced technology and the refined surgical technique, together with a large experience in laparoscopic colonic surgery, may explain this result. In recent studies no operative mortality was observed with laparoscopic resection for diverticular disease, and morbidity reportedly was 6.5% to 16%. We
reported no mortality and a postoperative comparable morbidity of 10%, mainly represented by minor complications. Postoperative abdominal abscess formation also was not observed in cases of diffuse peritonitis, and patients with Hinchey III had a normal recovery, with progressive resolution of local and systemic inflammatory signs. Anastomotic leakage was observed in only two patients, and both resolved conservatively. These were patients with Hinchey I and II, and no anastomotic complication was recorded in the Hinchey III group. These data suggest that the presence of diffuse purulent peritonitis did not affect anastomotic healing in the present series. Our LOS was higher than in other studies [5, 6, 19–21, 24], which is acceptable considering the high incidence of Hinchey IIb and III cases. Thus, the longest stay was observed for Hinchey patients with IIb (mean LOS, 10.6 days) because of the need for prolonged postoperative urinary catheterization when a colovescical fistula was treated. Similarly, patients with Hinchey IIb required the longest time for recovery of bowel function, and this may be related to the chronic inflammatory context and to prolonged and extensive dissection during surgery. In contrast, the presence of diffuse peritonitis in the Hinchey III group did not prolong the postoperative ileus and LOS. In conclusion, this study demonstrates that in experienced hands, laparoscopic colonic resection may be considered the gold standard treatment for sigmoid diverticulitis not only in patients with Hinchey I and IIa, but also in patients with Hinchey IIb and III when the ASA score is 1 to 3 and no contraindications to the laparoscopic approach are raised. The operating time and conversion rate (2.9%) are acceptable. Mortality is 0, and morbidity rates are low (10%). In fact, no significant differences in terms of results were observed among the four groups of patients.
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