Emergency laparoscopic surgery for complicated diverticular disease
Emergency laparoscopic surgery for complicated diverticular disease
N Zafar, LV Titu, GL Greenslade*, AR Dixon
Affiliation: Departments of Colorectal Surgery and *Anaesthesia, North Bristol Hospitals NHS Trust, Frenchay Hospital, Bristol, United Kingdom
Correspondence: Mr Anthony Dixon, Consultant Colorectal Surgeon, North Bristol Hospitals NHS Trust, Frenchay Hospital, Bristol BS16 1LE, United Kingdom.
E Mail: Anthony.Dixon@nbt.nhs.uk
Key words: Laparoscopic colorectal surgery; complicated diverticular disease; emergency surgery.
Objective. The aim of this study was to analyse the outcome of emergency laparoscopic surgical management of complicated diverticular disease.
Methods. A prospectively collected electronic database of all colorectal laparoscopic procedures between April 2001 and September 2007 has been used to identify outcomes in patients presenting with complicated diverticular disease.
Results. 66 patients (28 male), median age 69yrs (23-95), ASA grade II (12), III (38), IV (16) have undergone emergency surgery for complicated diverticulitis – Hinchey grades I (27), II (29), III (7) and diverticular bleeding (3) over a 6 ½ year period: 43 high anterior resections, 17 Hartmann’s resections and 7 low anterior resections. Diverticular fistulas were seen in 16 patients: colovaginal (7), colovesical (2), colo-fallopian (4), entero-colic (3). The median operation time was 110 minutes (45 – 195 mins). There was one conversion to open surgery. Postoperative analgesia was provided by intravenous Paracetamol in 33 patients (50%), patient-controlled analgesia (PCA) 24, oral Paracetamol and Oramorph (8) and epidural opioid infusion (1). The median time to normal diet was 24 hrs (4hrs – 6 days) and median hospital stay 5 days (2-30). There were 2 deaths (3.3%); anastomotic leak, ventricular fibrillation (VF) cardiac arrest. Other complications included: wound infection 8 (12%), anastomotic leak 4 (8%), port-site hernia 1 and one case of Clostridium difficile colitis requiring colectomy. There were 5 (7.5%) returns to theatre and 2 readmissions (3%).
Conclusion. Laparoscopic resectional surgery in complicated diverticular disease is a feasible, safe and a largely predictive operation that allows for early hospital discharge and in our opinion improved patient care. We are encouraged to continue to offer our patients the option of an emergency laparoscopic resection.
Using traditional perioperative care, laparoscopic colorectal resection has many advantages1over more traditional operative modalities. Blood loss, postoperative pain, recovery time, length of stay, return to domestic activities are all reduced in laparoscopic surgery with no increase in surgical morbidity2,3,4. The most obvious benefit to the patient is the preservation of the integrity of their abdominal wall. In addition to patient benefits, laparoscopy also offers advantages to the surgeon e.g., magnified view and to the hospital through decreased hospital stay and its associated costs4.
Bowel rest with intravenous antibiotics and regular clinical assessment remains the cornerstone of treatment for uncomplicated diverticulitis5. However, patients with an acute diverticular mass or associated abscess, which do not settle on conservative management or cannot be drained percutaneously will progress to urgent surgery. The complexity and risks of a surgical intervention are perhaps at there greatest in these cases. Not only are these patients frequently elderly and have associated co-morbidities but the chronic inflammatory process and acute peritonitis makes them prone to develop major complications; mortality rates following primary resectional surgery are significantly lower (12%) than none resectional surgery (28%)6. During the past decade, primary resection and primary anastomosis have been advocated in selected patients7.
A number of reports have recommended laparoscopic none resectional surgery8,9,10 with the expressed aim of “converting a generalised purulent peritonitis to a localised diverticulitis which can then be safely treated by antibiotics”. These authors argue that once the inflammation has settled, a definitive laparoscopic resection can then be performed. Not surprisingly, this strategy has been called into question11. Our experience with laparoscopic surgery for colonic carcinoma, fulminate ulcerative colitis12 and acute bowel obstruction13 has led us to apply laparoscopy to our management of complicated diverticular disease not responding to standard medical therapy. In each case we have performed the same operation that we would choose to do at open surgery i.e. resection of the diseased segment with either a Hartmann’s type procedure or, under suitable conditions, a primary anastomosis with or without a covering stoma. In other words, the method of access has not determined our choice of operation11. Whilst laparoscopic resectional surgery is very appealing to an experienced laparoscopic colorectal surgeon, its use in this setting is poorly defined and controversial. We report our up to date experience.
Patients and methods
A prospectively collected electronic database of all colorectal laparoscopic procedures performed between April 2001 and September 2007 has been used to identify surgical outcomes in consecutive patients who have undergone emergency laparoscopic management of complicated colonic diverticular disease. Faecal peritonitis was considered a contraindication to laparoscopic management. CT scans and contrast enemas were performed where indicated and where appropriate, percutaneous drainage or endoluminal stenting was considered. All patients were made aware that the laparoscopic approach was new and controversial; each gave informed consent. All procedures were performed or supervised by the senior author.
All patients with potential for a restorative resection received a Fleet enema (De WittÒ) to facilitate a stapled colorectal anastomosis. Patients were placed in the dorso-lithotomy position using Allen stirrups, with arms extended by their side and minimal hip flexion. Urinary catheters, antibiotic prophylaxis (Gentamicin and Metronidazole) and thrombo-prophylaxis were used routinely. The surgeon and surgeon’s assistant stand on the patient’s right, with the assistant cephalad to the surgeon; a single monitor is placed to the patient’s left side, at the level of the pelvis. A 12-mm camera port is placed in umbilical tube using an open approach or 3cm above and lateral to the umbilicus in “short” abdomens or when a phlegmon was palpable. A 10mm 300-angle laparoscope is used throughout. Additional disposable ports are placed under direct vision in the right iliac fossa (12mm) and lower right flank (5mm), approximately one-hand’s breadth above the previous one. The exact site of port placement is ultimately dependent on the patient’s body habitus, with additional 5mm ports occasionally required in the left iliac fossa or left upper quadrant.
With the patient in reverse Trendelenburg and rotated to the right, enabling the small bowel to be displaced into the upper abdomen, dissection begins in the left lower quadrant after aspiration of any purulent fluid. The colon is retracted using a Johan’s forceps (Karl Storz EndoscopyÒ, Slough, UK) and the bowel mobilised using the Harmonic Scalpel (Ethicon EndosurgeryÒ, Bracknell, UK). As in open surgery, the key to surgical success is accurate bowel mobilisation. Dissections are approached individually in a pragmatic manner using both medial and lateral approaches as dictated by fibrosis, abscess, site of fistulization and degree of obstruction/peritonitis. In many instances, i.e. in the presence of dilated small bowel loops, we adopt an inferior to superior approach, mobilising and dividing the mesorectum in the mesorectal plane from right to left and then transecting the rectum using the ATG45 endoscopic stapler – (Ethicon EndosurgeryÒ, Bracknell, UK). This allows cranial and right lateral retraction of the rectum, aided by gravity, to facilitate left lateral dissection and identification of the gonadal vessels and ureter. The superior rectal vessels are then grasped and retracted ventrally towards the abdominal wall and the dissection continued cranially to allow division of the inferior mesenteric artery using a vascular staple firing (Ethicon EndosurgeryÒ, Bracknell, UK). Fistulas are approached in the same pragmatic fashion and divided at the most appropriate time to facilitate dissection. All bladder defects are closed with a continuous absorbable suture whilst vaginal defects are left open. The splenic flexure is not routinely mobilised in Hartmann’s resection cases, to facilitate a definitive laparoscopic resection/restoration of bowel continuity at a later date13. Ureteric stents are not used.
The divided colon is grasped and carefully delivered either through the newly prepared colostomy site (suitably dilated) or through a vertical trans-umbilical incision (transverse supra-umbilical when the port was placed superior and lateral to the umbilicus) where intestinal continuity was to be restored. The peritoneal cavity is finally irrigated with saline and an 18F drain placed into the pelvis via a grasper passed from “in to out” through the 5mm port. Primary anastomoses are only considered if the proximal colon is healthy and the anastomosis could be performed beyond any involved rectum and in a region free of gross sepsis. All low anterior rectal resections are covered with a loop ileostomy raised through the dilated 12mm port site. The remaining port sites are then closed and the wounds infiltrated with local anaesthetic.
Oral fluids are allowed immediately postoperatively as tolerated. Patients are mobilised the same evening and offered a light diet. In the absence of a colo-vesical fistula, symptomatic bladder outflow obstruction or the need to monitor fluid output, catheters are removed in the recovery room. Analgesia is provided by intra-operative Fentanyl, Diclofenac and, more recently, i.v. Paracetamol. The latter two drugs are continued postoperatively and either supplemented by patient-controlled Morphine infusion or our preferred practice of oral Morphine (Oramorph). Post-operative antibiotics are continued as appropriate. Hospital discharge is determined by the patients’ general condition, social circumstances and the stoma nurses’ assessment of competency at stoma management.
There were 66 patients (28 male) with a median age of 69 years (23-95) and ASA grade II (12), III (38), IV (16) who underwent emergency/urgent surgery for complicated acute diverticulits - Hinchey15 grades I (27), II (29), III (7), and diverticular bleeding (3) over a 6 ½ year period. Surgical interventions comprised 43 high anterior resections, 17 Hartmann type resections and 7 low anterior resections. There were 16 concurrent fistulae; colovaginal (7), fallopian tube (4), enterocolic (3), colovesical (2). Eight patients presented with large bowel obstruction secondary to a phlegmon; two had been stented pre-operatively. The median operation time was 110 minutes (45 – 195 mins). There was only one conversion for a large sigmoid inflammatory mass that could not be mobilised laparoscopically.
33 patients received only parenteral or oral Paracetamol (50%), Morphine PCA (24) or Paracetamol supplemented with Oramorph (8). Only one patient was managed with an epidural opioid infusion. The median time to normal diet was 24 hrs (4hrs – 6 days) and median hospital stay 5 days (2-30).
There were 2 deaths (3.3%) from sepsis following an anastomotic leak and a VF cardiac arrest. Other complications included; eight wound infections (12%), four anastomotic leaks (8%), one right iliac fossa 12mm port-site hernia, a stoma retraction and a single case of Clostridium difficile colitis requiring an emergency colectomy. Three patients required short-term nasogastric decompression for gastric ileus. Only one patient presenting with severe diverticular bleed required a postoperative blood transfusion. There were 5 (7.5%) returns to theatre following an anastomotic leak (2), re-site a stoma, correct a port-site hernia and the colectomy above. There were 2 readmissions (3%) with wound infections.
Continuous technological innovation encourages surgeons to attempt more complex laparoscopic colorectal interventions. The objectives are reduced postoperative pain, early mobilisation, reduced rates of wound sepsis, rapid return of gastrointestinal function, early discharge from hospital, return to normal life, avoidance of incisional hernias and long-term improvements in cosmesis. Laparoscopic colorectal interventions in sigmoid diverticular disease, for the most part are performed electively in cases of peridiverticulitis, stenosis or recurrent attacks of inflammation. Conversion, complication and mortality rates with these interventions are acceptable, and the latter two are comparable to those following open intervention16,17.
Reports of laparoscopic surgery to treat complicated diverticulitis are surprisingly few, with analysis of only small patient populations and/or subgroups8,16,17. The Laparoscopic Colorectal Surgery Study Group16 reported a conversion rate of 18.2%, mortality rate of 2.2% and a global complication rate of 29% in 45 patients with perforated diverticulitis (Hinchey Stages I to IV). For patients with acute phlegmonous peridiverticulitis, recurrent attacks or stenosis the conversion rate (4.8%), mortality (0.9%) and complication rate (14.8%) were significantly lower. Franklin et al., reported8 successful laparoscopic management in 43 of 58 patients with zero mortality and decreased ileus (20% of open vs 7% laparoscopic7) and overall length of hospital stay.
Although laparoscopic intestinal surgery has been employed in a variety of settings, many surgeons have remained sceptical about its application to complicated diverticulitis. These patients are not only at risk for developing septic complications but for problems arising out of their inflammatory process. Specifically, the mesentery can be very friable and vascular with obliteration of the normal retroperitoneal planes and fistulization is perhaps more common than one would expect18. Whilst open surgery can be demanding in itself, with increasing surgical skills, refinement of techniques as presented in this paper and improvements in instrumentation, we believe that a laparoscopic approach to the management of complicated diverticular disease has now become a logical and viable extension, provided that it is carried out only by highly experienced laparoscopic colorectal surgeons. Whilst lavage and drainage of purulent peritonitis may be effective, we are strongly of the opinion that the surgical management should follow the same principles as that which we would perform at open surgery. Ureteric stents were not employed; stents are not a warranty to prevent ureteric injury19.
A final consideration is potential cost benefit. Simple ways to save money are through a quicker postoperative recovery, fewer complications, earlier discharge, return to work and containment of equipment costs. Although we have not undertaken a comparison with open colectomy, we believe that we are well on the way to achieving these goals and that alongside improved cosmesis, zero incisional hernias to repair to date and relatively ease of laparoscopic restoration of bowel continuity14 the costs of the disposable equipment are justified. Costs are counterbalanced in our practice by a shorter anaesthetic and operative time, absence of an epidural, no routine high dependency requirement and fewer pulmonary and wound complications. The Cleveland Clinic group have reported on a formal comparison of total direct costs comparing elective open and laparoscopic resection for sigmoid diverticulitis in favour of the latter group20.
We have show that laparoscopic resectional management of complicated diverticulitis is technically feasible and can be performed with out an unduly lengthy operation. More importantly, it is also safe and largely predictable. We are encouraged to continue to offer our patients what perhaps some UK surgeons might consider controversial surgery. We do not however support triumph for technology over sound common sense and consider faecal peritonitis an absolute contraindication.
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