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Laparoscopic Surgery for Diverticulitis

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17/03/2006


 

 

DEFINITIONS

Diverticulosis: Sac-like protrusions of the inner most part of the colonic wall through the colonic muscular layers.

Diverticulitis: Inflammation of one or more diverticula

Diverticular bleeding: Colon bleeding due to divertucula

 



WHO IS AT RISK?

Diverticulosis if very common in western society. It is less common in African and Asian populations. 
The chance of getting diverticulosis increases as you get older.  In general roughly 50% of the population has diverticulosis by the time they turn 70 years of age.   The majority of patients will be asymptomatic.

 

HOW DO DIVERTICULA FORM?

Diverticula form when the pressure inside the colon is high enough to push the inner lining of the colon through the muscular layer of the colon to form the sac like protrusions/hernias.  The strength or weakness of the wall of the colon is an important factor in who develops diverticula.  It is also thought that as people age a gradual weakening of the colon leads to the higher rates of diverticulosis in older people.

The main reason people will have excess pressures in the colon leading to diverticula is an inadequate amount of fecal bulk.  With decreasing amount of bulk there is a decrease in bowel diameter which increases the pressure in the bowel.  Decrease bulk results from inadequate ingestion of dietary fiber. A diet rich in dietary fiber or supplemented with commercially available fiber preparations, is thought to prevent the formation of diverticula.

DIVERTICULITIS


Diverticulitis develops in approximately twenty five percent of people with diverticulosis. It occurs in the sigimoid colon over 90% of the time.  This accounts for the fact that most patients have left lower quadrant abdominal pain. It is also true, however, that as many as ten percent of patients have no abdominal pain at all.  However, each of the pockets can behave like an appendix and get infected, erode into the adjacent blood vessel and bleed, or even rupture.  Repeated inflammation can lead to the bowel narrowing and a blockage developing. 

Diverticulitis usually occurs when a diverticula is filled with inspisated stool that eventually erodes through the colon leading to micro (or macro) perforation.


If an abscess forms it can discharge into the bladder or vagina and form a fistula. 
 

TREATMENT


The main initial treatment for diverticulitis is bowl rest, intravenous hydration, and antibiotics. This will work in the majority of patients.   If this does not work surgery is required.  The risk of surgery during an acute attack of diverticulitis is higher than elective surgery.  It is also true that having surgery during an acute attack increases the likelihood a temporary colostomy would be required. For this reason the usual approach to diverticulitis is to try to resolve the attack without surgery and then try to predict who is most at risk for having additional attacks. These patients can then have surgery to prevent future attacks.  Elective sigmoid resection can be done at a much lower risk, without a colostomy, and often using a laparoscopic approach.

Emergency laparoscopic Hartmann resection (removal of the inflamed bowel) with end colostomy (see photo) may be necessary in patients who fail to respond to medical therapy.  Laparoscopic resection offers great advantages in these ill patients.  In particular the patients, frequently elderly, make a more rapid and complete recovery.  Bowel continuity can be restored laparoscopically 3-4 months later .





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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051
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