Complications of Laparoscopic Surgery for

DiverticulitisBradley R. Davis, MD, FACS, FASCRS

Associate Professor of Surgery

University of Cincinnati

Disclosures

• Paid Consultant for Ethicon Endo Inc.

Diverticulosis

Prevalence USA• < 40 years old - 5%• >50 years old - 35%• >85 years old - 65%

Laparoscopic Resection for Diverticulitis

Diverticulitis

• benign disease

• relatively common

• technically challenging

• numerous studies

Diverticulitis

• Changing paradigms on when to offer elective resection– 4 episodes of uncomplicated disease– Fistula– Stricture– Persistent symptoms/phlegmon

• The days of a “chip shot” sigmoid colectomy are ending/over

Laparoscopy for Diverticulitis

• More than 100 studies published• Most single institution noncomparative• All comparative studies demonstrate:

– Longer operative times - 30-60 minutes– Quicker return of bowel function - 1-2 days– Shorter hospital stay - 2-7 days

Laparoscopy for Diverticulitis

• Large National US Database– 1998-2000 Nationwide Inpatient Samples– 709 (3.8%) laparoscopic sigmoid resections– 17735 (96%) open sigmoid resections

• Shorter mean LOS - 7.5 vs. 9.4 days• Fewer complications - 20% vs. 29%• More pts d/c to home - 91% vs. 71%

Guller, Arch Surg 2003;138:1179

Diverticulitis

Noel, JK et al. J Am Coll Surg. 2007 Feb;204(2):291-307

Colorectal Residents% Laparoscopic Resections

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 20050

5

10

15

20

25

30

35

40

45

50

Diverticulitis

Colon Cancer

LAR

IC Crohn's

IPAA

Schoetz, JACS, September 2006

Laparoscopy vs. Open

Gervaz et al. Ann Surg 2010

Laparoscopy vs. Open

Dwivedi at al. Dis Colon Rectum. 2002 Oct;45(10):1309-14

Laparoscopy vs. Open

Dwivedi at al. Dis Colon Rectum. 2002 Oct;45(10):1309-14

Factors Effecting Outcomes

• Complicated vs Uncomplicated– Fistula– Stenosis– Diverticulitis vs diverticulosis

• Experience – high volume vs low volume

Conversions

LeMoine et al. Br J Surg. 2003

Experience

Scheidbach et al. Dis Col Rect 2004

Experience

Jones et al. Ann Surg. 2008

Diverticulitis

• Increasing experience with the acute management of perforated diverticulitis– Laparoscopic washout and drainage– Laparoscopic Hartmann’s Procedure– Laparoscopic resection with anastomosis

Acute Diverticulitis

• 68 Patients– Hinchey I: 27– HincheyII: 29– Hinchey III: 7

• 16 Concurrent fistula• 8 Phlegmons

Titu at al. Colorectal Dis. 2009

Acute Diverticulitis

• Median OR time: 110mins (45-195)

• One Conversion

• Postoperative Mortality: 3.3%

• LOS: 5 days

Titu at al. Colorectal Dis. 2009

Laparoscopic Colectomy:Mastering the Complex Case• Set it up right• Start from known – work both sides of

the phlegmon• Put in right ports• Alternate

– Go open– Change extraction site– The approach – medial vs. lateral

Alternate Approach –Perf Tic

• Medial• Good technique

– Traction– Set it up– Help your partner– Set the clock

Alternate Approach –Perf Tic

• Lateral• Good technique

– Traction– Set it up– Stay in the plane– Watch the smoke– Stay oriented– Set the clock

Alternate Approach –Perf Tic

• Lateral• Good technique

– Traction– Set it up– Stay in the plane– Watch the smoke– Stay oriented– Set the clock

Laparoscopic Colectomy:Mastering the Complex Case

• Alternate– Go open– Change extraction site– The approach – medial vs. lateral– The technique – put in a hand

Alternate - Extraction Site

• Midline– Easier to convert– Easier to perform

– Limited open exposure

• Pfannenstiel– Difficult to convert– Good access for HAL– Good exposure to

pelvis

– Difficult to perform especially small incision

Optimize Chances

• Ureteral catheters +/-• Hand Assisted through pfannestiel

– dissection and anastomosis “open” – deal with air leak, phlegmon

• Mobilize flexure• Resect to normal feeling colon to rectum

Ureteral Catheters

Wexner et al. Tech Coloproctol. 2008 Mar;12(1):45-50

Complicated Diverticulitis:Alternatives to Conversion

• Pfannenstiel incision after:– mobilization of splenic flexure– division of vascular pedicle

• Hand-assisted laparoscopy– allows tactile sensation– blunt separation

Conclusion

• Complex case• Experience counts• Maximize chances

– Approach– Extraction– HAL– +/- Ureteral catheters

• Alternate approach early