Acute and Elective Laparoscopic Resection for Complicated Sigmoid Diverticulitis: Clinical and Histological Outcome

Background

Surgical treatment of acute complicated sigmoid diverticulitis is still under debate while elective treatment of recurrent diverticulitis has proven benefits. The aim of this study was to evaluate the clinical and histological outcome of acute and elective laparoscopic sigmoid colectomy in patients with diverticulitis.

Methods

A retrospective review was conducted where 197 patients were analyzed undergoing laparoscopic sigmoid resection for acute complicated diverticulitis and recurrent diverticulitis. Single-stage laparoscopic resection and primary anastomosis were routinely performed using a 3-trocar technique. Recorded data included age, sex, American Society of Anesthesiologists (ASA)-score, operative time, duration of hospital stay, complications, and histological results.

Results

Ninety-one patients received laparoscopy for acute diverticular disease (group I) and 93 patients underwent elective laparoscopic sigmoid resection for diverticulitis (group II). M/F ratio was 49:42 for group I and 37:56 for group II. Mean operative time and hospital stay was similar in both groups. Majority of patients were ASA II in both groups. Rate of minor complications was 14.3 % in group I and 7.5 % in group II. Major complications were 2.2 % for acute treatment and 4.3 % for elective resections. No anastomotic leakage and no mortality occurred. In 32.3 % of the patients of elective group II, destruction of the colonic wall with pericolic abscess, fistulization, or fibrinoid purulent peritonitis were identified.

Conclusions

Laparoscopic surgery for acute diverticular disease is safe and effective. Continuing bowl inflammations in histological specimens justify sigmoid resection in elective patients, but more effective pre-operative parameters need to be found to identify patients that would benefit from surgery during the initial episode.     

Emergency laparoscopic management of perforated sigmoid diverticulitis: a promising alternative to more radical procedures

BACKGROUND: Classic emergency surgical management of complicated perforated sigmoid diverticulitis is based on the principle of a two-stage operation, with colon resection and temporary stoma (Hartmann's procedure). But the later second-stage operation can be technically difficult and can be associated with a significant morbidity rate. We argue that laparoscopy may be beneficial in such patients with peritonitis in terms of operative results and could facilitate later surgical management. STUDY DESIGN: We studied all consecutive patients with perforated sigmoid diverticulitis requiring emergency surgery between January 2000 and December 2004. RESULTS: Twenty-four patients underwent emergency laparoscopic management for perforated sigmoid diverticulitis. Nineteen patients (80%) were found to have a purulent or fecal diffuse peritonitis. No conversion and colostomy were necessary. The overall morbidity rate was 8%; 2 patients with pelvic abscesses required radiologic drainage. The median hospital stay was 12 days (range 7 to 35 days). Prophylactic sigmoid resection was performed by laparoscopy in all patients, with a conversion rate of 16%. CONCLUSIONS: Laparoscopic treatment of generalized peritonitis secondary to diverticulitis is feasible and safe and may be a promising alternative to more radical surgery in selected patients, avoiding fecal diversion and allowing a delayed elective laparoscopic sigmoid resection.     

Elective laparoscopic-assisted colectomy for sigmoid diverticulitis.

OBJECTIVES: The aim of this study was to evaluate the safety and effectiveness of laparoscopic-assisted sigmoid colectomy for diverticulitis and to assess its postoperative advantages. METHODS: From 1999 to 2001, 5 patients were selectively operated on with a laparoscopic-assisted procedure for uncomplicated sigmoid diverticulitis. In the preceding period (September 1997 through December 1998), 4 patients underwent open procedures for the same pathology. The surgical indication with the same criteria was restrictive: at least 2 acute episodes had occurred that were treated with hospital admission and that were separated by an adequate period (2 months) of medical therapy. RESULTS: No conversions of laparoscopy to an open procedure were necessary. Age, sex, weight, morbidity, and mortality were similar between the 2 groups. Operative time was 180 minutes for laparoscopy and 120 minutes for laparotomy. Postoperative resumption of peristalsis was 24 hours versus 4 days, resumption of alimentation was on the second postoperative day versus the fifth postoperative day, and hospital stay was 7 days versus 12 days for laparoscopy and laparotomy, respectively. CONCLUSION: This study shows the feasibility and the advantages of elective laparoscopic-assisted colonic resection for uncomplicated sigmoid diverticulitis. The advantages of the laparoscopic approach are the lower need for analgesics and the more precocious ambulation, canalization, resumption of alimentation, and the shorter hospital stay.     

Ergebnisse der Sigmaresektion bei akuter und komplizierter Divertikulitis

BACKGROUND: The aim of this study was to check the results of laparoscopic sigmoid resection for sigmoid diverticular disease with respect to stage of inflammation and time of surgical intervention. PATIENTS AND METHODS: All patients were divided into four groups: uncomplicated (Group 1) vs complicated diverticular disease (Group 2), and depending on surgical intervention in early elective (4-8 days, Group A) vs late elective sigmoid resection (4-6 weeks, Group B). RESULTS: At total of 244 patients underwent laparoscopically-assisted resection during the examination period. Differences in favor of Group 1 were found in duration of surgery (153 min vs 167 min), postoperative wound infections (3.55% vs 15.5%), and postoperative hospitalization period (12.2 days vs 14.6 days). Group A had more conversions (7.8% vs 0.9%), more minor complications (25.9% vs 12.9%), and more wound infections (16.4% vs 4.6%) than Group B. CONCLUSIONS: Laparoscopic sigmoid resection can be performed in cases of complicated diverticulitis without significantly increasing their overall morbidity. Because of the lower complication rate, we recommend that patients with acute sigmoid diverticulitis receive initial antibiotic treatment and then undergo late elective laparoscopic sigmoid resection.     

Laparoscopic surgery in the treatment of colonic polyps

BACKGROUND: Benign colonic polyps that are impossible to remove with the aid of the flexible colonoscope because of their size or location must be removed surgically. METHODS: Twenty patients with colonic adenomatous polyps that could not be resected by colonoscopy because of size or difficult location (n = 18) or polyps in combination with diverticulitis (n = 2) underwent polyp removal through a small 'assisted' incision in the abdominal wall using a standard 'dissection-facilitated' laparoscopic approach to the affected colonic segment. RESULTS: In six patients the polyp was removed through a colotomy, in three through a limited resection (two ileocaecal and one limited sigmoid resection) and in 11 through a standard colectomy (four right hemicolectomy, one left hemicolectomy, four sigmoid and two anterior resections) because of suspicion of cancer. In only one patient could the polyp not be found during laparoscopy, resulting in a second conventional surgical intervention. In four patients carcinoma was diagnosed in the specimen. CONCLUSION: Precise preoperative localization of the polyp and the use of dissection-facilitated laparoscopic colonic surgery make laparoscopic removal of benign colonic polyps an alternative to an open procedure.     

The Sigma-trial protocol: a prospective double-blind multi-centre comparison of laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis

Backround  

Diverticulosis is a common disease in the western society with an incidence of 33–66%. 10–25% of these patients will develop diverticulitis. In order to prevent a high-risk acute operation it is advised to perform elective sigmoid resection after two episodes of diverticulitis in the elderly patient or after one episode in the younger (< 50 years) patient. Open sigmoid resection is still the gold standard, but laparoscopic colon resections seem to have certain advantages over open procedures. On the other hand, a double blind investigation has never been performed. The Sigma-trial is designed to evaluate the presumed advantages of laparoscopic over open sigmoid resections in patients with symptomatic diverticulitis.     

Laparoscopy for diverticulitis

Although the literature on laparoscopic surgery for diverticulitis includes data on more than 1800 patients, the quality of the studies is insufficient to draw definitive evidence-based conclusions. Nonrandomized evidence suggests that laparoscopic resection for uncomplicated diverticulitis of the sigmoid may fare better than its conventional counterpart not only in short-term outcome (preservation of the abdominal wall, shorter disability), but also in the long term (decreased rates of late symptomatic small bowel obstruction). Five-year recurrence rates show that a laparoscopic or conventional access is unlikely to have an impact, provided that the oral bowel end is anastomosed to the proximal rectum rather than to the distal sigmoid. The superiority of laparoscopy should be proven by measuring health-related and patient-centered outcome rather than surrogate endpoints. Areas of concern include replacing a conventional resection with laparoscopic suture, drainage, and colostomy in patients with free perforation and peritonitis. The role of laparoscopic surgery should be limited to resection for uncomplicated diverticulitis of the sigmoid performed by adequately trained surgeons. Benefits can be expected with this procedure, provided that indications for surgery are not influenced by the mode of access and that postoperative complication rates remain within the range of that for traditional colorectal surgery.     

Surgical therapy in right-sided diverticulitis

INTRODUCTION: Left-sided diverticulitis is a common disease in Western countries, whereas right-sided diverticultitis is rare and symptoms are often similar to the clinical signs of an acute appendicitis. It was the aim of this study to analyse surgical experience in right-sided diverticulitis. METHODS: All patients who underwent resectional surgery for both right-sided and sigmoid diverticular disease were entered prospectively in a registry database (8-year observation period, 1996-2003). For the current study, a retrospective analysis of all patients who underwent ileocolic resection or right colectomy for right-sided colonic diverticulitis was performed, specifically focussing on incidence, clinical symptoms, indication for surgery, type of procedure, and histopathological parameters including immunohistochemistry, and outcome in right-sided diverticulitis. RESULTS: Within eight years, 481 patients were treated surgically for chronically recurrent or acute complicated diverticular disease: 468 patients with sigmoid diverticulitis, 12 patients with right-sided diverticulitis, and 1 patient with combined right-sided and sigmoid diverticular disease. This corresponds to an incidence of right-sided diverticulitis of 2.5 % related to the total number of resections for diverticulitis, and an incidence of 1.3 % in relation to the appendectomies in our patients. In 4 patients, acute appendicitis was presumed preoperatively. Most common diagnostic tool was ultrasonography. Right colectomy was performed in 9 patients with complicated cecal diverticulitis, whereas ileocolic resection was performed in 2 patients and simultaneous ileocolic and sigmoid resection was carried out in one patient. Postoperatively, no morbidity occurred. Histopathological assessment showed local perforation in 75 % (9/12). Hypoganglionosis or aganglionosis was detected in 5 of 12 resected specimen. DISCUSSION: As right-sided diverticulitis is a rare colonic disease in Western countries, the differentiation from acute appendicitis can be difficult. In general, there is no difference in the treatment of right-sided diverticulitis compared to left-sided diverticulitis, and surgery is only indicated in complicated right-sided diverticulitis. Resection of the inflamed colon with primary anastomosis is safe and can be performed by laparoscopy in experienced centers. At present, it can only be speculated whether hypoganglionosis or aganglionosis are causative factors in the etiology of right-sided diverticulitis.     

Laparoscopic surgery for diverticular disease complicated by fistulae.

OBJECTIVES: Elective laparoscopic surgery for recurrent, uncomplicated diverticular disease is considered safe and effective; however, little data exist on complicated cases. We investigated laparoscopic sigmoid resection for diverticulitis complicated by fistulae. METHODS: We conducted a retrospective review of patients who underwent laparoscopic treatment of enteric fistulae complicating diverticular disease performed by 4 surgeons at the Mount Sinai Medical Center. RESULTS: From 1994 to 2004, 14 patients underwent elective laparoscopic sigmoid resections for diverticular disease complicated by enteric fistulae. Patients' mean age was 62 and 4 were female. Multiple fistulae were present in 21%. Types of fistulae included 8 colovesical, 5 enterocolic, 2 colovaginal, 1 colosalpingal, and 1 colocutaneous. All patients successfully underwent sigmoidectomy, and 14% required additional bowel resections. No cases were proximally diverted. Conversion to open was necessary in 36% of cases, all due to dense adhesions and severe inflammation. The mean operative time was 209 minutes, and the mean blood loss was 326 mL. Two (14%) postoperative complications occurred, including one anastomotic bleed and one prolonged ileus. No anastomotic leaks or mortalities occurred. The mean postoperative stay was 6 days. CONCLUSION: Laparoscopic management of diverticular disease complicated by fistulae can be performed effectively and safely. The conversion rate is higher than traditionally accepted rates of uncomplicated cases of diverticulitis and is associated with severe adhesions and inflammation.     

Laparoscopic-assisted ileocolic resection for Crohn's disease.

BACKGROUND: This study reviews our experience with laparoscopic-assisted ileocolic resection in patients with Crohn's disease. The adequacy and safety of this procedure as measured by intraoperative and postoperative complications were evaluated. Special attention was paid to the group in which laparoscopy was not feasible and conversion to laparotomy was necessary. METHODS: Between 1992 and 2005, 168 laparoscopic-assisted ileocolic resections were performed on 167 patients with Crohn's ileal or ileocolic disease. Follow-up data were complete in 158 patients. RESULTS: In 38 patients (24%), conversion to laparotomy was necessary. Previous resection was not a predictor of conversion to laparotomy. Average ileal and colonic length of resected specimens was 20.9 cm and 6.5 cm, respectively, in the laparoscopic group, versus 24.9 cm and 10.6 cm in the converted group. Twenty of 120 specimens (16.6%) in the laparoscopic group were found to have margins microscopically positive for active Crohn's disease. None of the 38 specimens in the converted group had positive ileal margins. CONCLUSIONS: Laparoscopic-assisted ileocolic resection can be safely performed in patients with Crohn's disease ileitis. The finding of positive surgical margins following laparoscopic resections compared with none among conventional resections has to be thoroughly evaluated.     

Laparoscopic elective treatment of diverticular disease

BACKGROUND: Because of the presence of significant inflammatory reaction, elective surgical laparoscopic-assisted treatment of complicated diverticular disease can be difficult, leading to a high conversion and complication rate. Laparoscopic alternatives to this assisted approach consist of the hand-assisted method and the more conventional facilitated laparoscopic sigmoid resection. Facilitated laparoscopic sigmoid resection implies laparoscopic mobilization of the sigmoid as much as possible and splenic flexure when called for. Through a Pfannenstiel incision, the difficult steps of the operation-such as the dissection of the inflammatory process and taking down the fistula, but also resection and manual anastomosis-can be performed. In this study, we compare the operating time, conversion rate, complications, and costs of both assisted and resection-facilitated techniques. METHODS: We compared two consecutive series of 35 patients with diverticular disease who underwent a sigmoid resection by laparoscopy. Both groups were comparable in terms of age, gender, and kind of complicated diverticular disease. RESULTS: The operating time, conversion rate, and costs were all less in the laparoscopic-facilitated group. The fact that there were no conversions in this group is the most important finding of this study. Not only was it possible to convert from the assisted laparoscopic approach to laparotomy (five patients of 35), it was also possible to convert from the assisted to the facilitated form (seven of 35 patients). CONCLUSIONS: Laparoscopic-facilitated sigmoid resection is a feasible intervention for all forms of complicated diverticular disease and yields marked reductions in operating time, conversion rate, and operative and general costs.     

Elective laparoscopic colectomy for sigmoid diverticulitis. Prospective study of 56 cases

OBJECTIVE: The aim of this prospective study was to assess the feasibility and postoperative advantages of the laparoscopic-assisted elective colectomy for diverticular disease. PATIENTS AND METHODS: From january 1989 to december 1997, among the 114 patients electively operated on for diverticulitis, 56 patients were treated by laparoscopic approach. Evaluated parameters included: gender, age, weight, size, ASA score, operating time, duration of hospital stay, of analgesic treatment, and of postoperative ileus, morbidity and mortality rate. RESULTS: The study group consisted of 35 women and 21 men. Mean age was 59 years (34-81 years); 29 patients were ASA 1 and 27 ASA 2. Overall postoperative mortality rate was 0% and morbidity rate 16% (n = 9). There were no complications directly related to laparoscopic technique. The conversion rate was 14% (n = 8). Mean operating time was 300 min (200-600 min). Mean duration of postoperative ileus was 2.4 days. Mean duration of hospital stay was 9.4 days. CONCLUSION: This study demonstrates the feasibility of elective laparoscopic-assisted colonic resection for diverticular disease in more than 80% of cases with a postoperative morbidity and mortality rate comparable to those of conventional surgery.     

Predictive risk factors for intra- and postoperative complications in 526 laparoscopic sigmoid resections due to recurrent diverticulitis: a multivariate analysis

Background  

Laparoscopic sigmoid resection is a feasible and frequent operation for patients who suffer from recurrent diverticulitis. There is still an ongoing debate about the optimal timing for surgery in patients who suffer from recurrent diverticulitis episodes. In elective situations the complication rate for this procedure is moderate, but there are patients at high risk for perioperative complications. The few identified risk factors so far refer to open surgery. Data for the elective laparoscopic approach is rare. The objective of this study was to identify potential predictive risk factors for intra- and postoperative complications in patients who underwent laparoscopic sigmoid resection due to diverticular disease.     

Laparoscopic treatment of complicated colonic diverticular disease:A review

Up to 10% of acute colonic diverticulitis may necessitate a surgical intervention. Although associated with high morbidity and mortality rates,Hartmann's procedure(HP) has been considered for many years to be the gold standard for the treatment of generalized peritonitis. To reduce the burden of surgery in these situations and as driven by the accumulated experience in colorectal and minimally-invasive surgery,laparoscopy has been increasingly adopted in the management of abdominal emergencies. Multiple case series and retrospective comparative studies confirmed that with experienced hands,the laparoscopic approach provided better outcomes than the open surgery. This technique applies to all interventions related to complicated diverticular disease,such as HP,sigmoid resection with primary anastomosis(RPA) and reversal of HP. The laparoscopic approach also provided new therapeutic possibilities with the emergence of the laparoscopic lavage drainage(LLD),particularly interesting in the context of purulent peritonitis of diverticular origin. At this stage,however,most of our knowledge in these fields relies on studies of low-level evidence. More than ever,well-built large randomized controlled trials are necessary to answer present interrogations such as the exact place of LLD or the most appropriate sigmoid resection procedure(laparoscopic HP or RPA),as well as to confirm the advantages of laparoscopy in chronic complications of diverticulitis or HP reversal.     

Impact of surgeon and hospital caseload on the likelihood of performing laparoscopic vs open sigmoid resection for diverticular disease: a study based on 55,949 patients

HYPOTHESIS: High-volume surgeons and hospitals are more likely to perform laparoscopic procedures than open procedures for diverticular disease as compared with low-volume surgeons and hospitals. DESIGN: Real-world analysis. SETTING: United States community hospitals. PATIENTS: Patients with primary International Classification of Diseases, Ninth Revision diagnosis codes for diverticulosis or diverticulitis and International Classification of Diseases, Ninth Revision procedure codes for laparoscopic or open sigmoidectomy were selected from the 1992 to 2001 Nationwide Inpatient Samples commercially available US databases. MAIN OUTCOME MEASURES: The outcome variable was the likelihood of performing laparoscopic vs open sigmoid resection. The primary predictor variable was the annual caseload of sigmoid resections per surgeon and hospital. RESULTS: The study population included 55,949 patients who were predominantly white (70.5%) with a mean (SD) age of 60.7 (14.7) years. Unadjusted and risk-adjusted odds ratios of performing laparoscopic sigmoidectomy were significantly higher for high-volume surgeons and high-volume hospitals. In fact, high-volume surgeons were 8.80 times more likely to perform a laparoscopic sigmoid resection compared with low-volume surgeons. Similarly, in high-volume hospitals, patients were 3.02 times more likely to undergo a laparoscopic sigmoid resection compared with patients who underwent surgery in low-volume hospitals. These clinically relevant differences remained statistically significant in subset analyses stratified by age (<65 vs > or =65 years) and time of surgery (elective vs nonelective). CONCLUSIONS: The findings of the present investigation based on data from large US nationwide databases provide compelling evidence that high-volume surgeons and hospitals are significantly more likely to perform laparoscopic surgery for diverticular disease compared with low-volume surgeons and hospitals. Based on recent studies showing clear advantages of the laparoscopic technique over the open counterpart, our results should be considered by both patients and physicians.     

Capnocytophaga pleural empyema following laparoscopic Nissen fundoplication

In recent years, laparoscopy has had a significant impact on colorectal surgery. However, to date, totally laparoscopic procedures have required the use of stapling devices to fashion the anastomosis. Herein we report a case of totally laparoscopic sigmoid colectomy with intracorporeal hand-sewn anastomosis for diverticulitis. We describe the surgical technique, focusing on the advantages of and indications for the laparoscopic hand-sewn anastomosis.     

Surgery for right-sided colonic diverticulitis: results of a 10-year-observation period

INTRODUCTION: In contrast to sigmoid diverticular disease, right colonic diverticulitis is a rare disease in Western countries. The clinical presentation is often similar to acute appendicitis. OBJECTIVE: The aim of this study was to analyze surgical challenge in right-sided diverticulitis. MATERIALS AND METHODS: All patients who underwent resection for both right-sided and sigmoid diverticular disease were registered prospectively in a database (observation period, 1996-2005). A retrospective analysis of all patients who underwent resection for right-sided colonic diverticulitis (ileocolic resection, right colectomy) was performed. Special focus was set on incidence, clinical symptoms, indication, procedure, clinical outcome, and histopathologic findings including immunohistochemistry. RESULTS: From a total of 593 patients treated surgically for recurring or acute complicated diverticular disease, the majority (97.8%) suffered from sigmoid diverticulitis (n = 580), whereas 2.2% (n = 16) underwent surgery for right-sided diverticulitis (including three patients with combined sigmoid and cecal diverticulitis). Related to the total number of appendectomies (n = 1167), this represented an incidence of 1.4%. In five of 16 patients, acute appendicitis was presumed preoperatively. Most common diagnostic was ultrasonography. In the group of patients with right-sided diverticulitis, the most common procedure was right hemicolectomy (n = 10), followed by ileocolic resection (n = 3) and combined right colonic resection with sigmoid resection (n = 3). Histopathological investigation confirmed complicated diverticulitis of the cecum with local perforation or abscess in 75% of the patients (12/16). Hypoganglionosis or aganglionosis was diagnosed in seven of the 16 resected specimens. DISCUSSION: As right-sided diverticulitis is a rare colonic disease in Western countries, the differentiation from acute appendicitis may be difficult. In general, there is no difference in the treatment of right-sided diverticulitis compared to left-sided diverticulitis. As most cases will remain clinically unimminent, surgery is only indicated in complicated right-sided cases. Resection of the inflamed colonic segment with primary anastomosis is safe and can be performed laparoscopically. It can only be speculated whether hypoganglionosis or aganglionosis is a causative factor in the etiology of right-sided diverticulitis.     

Laparoscopic sigmoid resection for acute and chronic diverticulitis

BACKGROUND: Sigmoid diverticulitis is a common benign condition; however, cases of acute and chronic diverticulitis may be difficult for the surgeon to treat. We designed a study to compare the outcomes of patients who undergo laparoscopic resections for sigmoid diverticulitis with those who have similar resections for other indications. METHODS: From a prospectively accumulated database of 397 consecutive laparoscopic colorectal procedures performed by three surgeons, we reviewed the outcomes of 178 patients who underwent laparoscopic sigmoid resections with primary anastomosis. RESULTS: Laparoscopic sigmoid colectomies or anterior resections were performed in 22 patients with acute diverticulitis (AD), 70 patients with chronic diverticulitis (CD), and 86 patients with nondiverticular disease (ND). Patients with ND were significantly older than those with AD or CD (67 +/- 14 year versus 55 +/- 13 year, 55 +/- 12 year, p < 0.05). Conversion to open surgery was required in three AD patients (14%), three CD patients (4%), and 17 ND patients (20%) (chi2 = 8.23, p = 0.016). In cases completed laparoscopically, there was no significant difference in median operative time (AD, 165 min; CD, 150 min; ND, 165 min), proportion of patients with intraoperative complications (AD, one; CD, six; ND, one), or postoperative complications (AD, four; CD, 13; ND, 11). The occurrence of a postoperative complication significantly prolonged median time to full diet (4 days vs 3 days, p < 0.001) and discharge (9 days vs 5 days, p < 0.001) but not return to normal activity (16 days vs 15 days). CONCLUSIONS: In this study, patients who underwent laparoscopic sigmoid colectomies and anterior resections had similar outcomes regardless of diagnosis. This finding substantiates our view that laparoscopic resections for diverticulitis can be performed safely and with the same benefits as resections for other indications.     

Diverticular disease complicated by peritonitis: role of conservative surgical therapy

Peritonitis complicating diverticular disease may be treated by sigmoid resection (with or without primary anastomosis) or by a conservative surgical approach, either laparoscopically or by open surgery. The choice depends on the severity of the peritonitis (Hinchey), the patient's conditions (ASA) and the surgeon's experience. Sigmoid resection with primary anastomosis has a lower morbidity and mortality vs Hartmann's procedure. After the introduction of laparoscopy in colorectal surgery, exploratory laparoscopy combined with drainage has been proposed to treat acute episodes, followed by laparoscopic resection. Since 1982, over 1000 patients have been operated on for colorectal disease: 119 for complicated diverticulitis, 55 of which complicated by peritonitis. In the latter, we performed conservative surgery (25 patients) and resection (30 patients) laparoscopically or by open surgery. Our results show a higher morbidity and mortality for the Hartmann procedure vs sigmoid resection with primary anastomosis and a lower specific morbidity in patients undergoing laparoscopic exploration and drainage. Moreover, there was a low percentage (52%) of re-canalisations with the Hartmann procedure, with a morbidity of 32% associated with this procedure. In conclusion, we believe that a conservative laparoscopic surgical approach may be advocated in selected cases (Hinchey II and III without clear perforation), followed by laparoscopic sigmoidectomy, resection with primary anastomosis in Hinchey I or in cases of evident perforation with purulent or faecal peritonitis (possibly combined with a stoma), reserving the Hartmann procedure for compromised patients.     

Is laparoscopic surgery applicable to complicated colonic diverticular disease?

Background: Expanding upon our experience with laparoscopic surgery for colonic benign and malignant processes and for bowel obstruction, we have reviewed our experience with minimal access laparoscopic surgery for complicated diverticular disease. We propose an approach of surgical care incorporating diagnostic laparoscopy in those not responding to medical therapy alone. Methods: Our study includes data from two different surgical teams working in separate hospital-and-patient environments. Our theory that laparoscopy could be widely applicable to this complex disease process is borne out by experience in both locations. One hundred forty-eight patients were managed by laparoscopic or laparoscopically assisted methods with 18 patients requiring drainage only without resection. Results: Our management of 148 of 164 patients (90%) by laparoscopic approach was successful, with a very acceptable morbidity of 5% in the elective cases and decreased ileus (20% of open vs 7% laparoscopic) in acute complicated cases. Elective resections required hospitalization of 4–5 days, demonstrating the benefits of incorporating laparoscopy in the care of these cases, particularly when compared to standard open procedures requiring 8 days' hospitalization. Conclusions: We believe complications of diverticular disease including abscess, perforation, fistula, and bleeding can potentially be managed in this way by minimal access procedures, decreasing postoperative wound problems, decreasing length of hospitalization and overall morbidity, and improving patient care.