Chapter 2


Laparoscopic approach of diverticular disease








Chapter 2.1



Elective laparoscopic - assisted sigmoid resection for diverticular disease




Q.A.J. Eijsbouts, M.A. Cuesta, L.M. de Brauw, C. Sietses



Surg Endosc 1997;11:750-3



Abstract

Background: Although the laparoscopic-assisted approach to colorectal cancer remains controversial, its use for benign diseases can have important advantages. The purpose of this study is to determine the feasibility of this approach for the treatment of elective diverticular disease and to identify preoperative and perioperative factors which can help to select the best procedure for each patient: either assisted laparoscopic resection (ALR) or dissection - facilitated laparoscopic resection (DLR).


Methods: From November 1991 to the present, we conducted a prospective study of 41 patients approached electively for diverticular disease.


Results: Twenty-nine patients underwent an ALR, seven were approached by DLR, and another five patients were converted to laparotomy (15%). Morbidity was 17.5% and there was no mortality in this series. The mean hospital stay after operation was 6.5 days.


Conclusions: Because of the complexity of this inflammatory process, choice of either an assisted or a more invasive laparoscopic facilitated approach is necessary. The decision is based on the technical difficulty as determined by data collected both preoperatively and during laparoscopy.


Introduction

Laparoscopic colonic resection performed by laparoscopy remains controversial in cases of colorectal cancer [14]. The appearance of cancer implants in trocar and wound sites warrants prospective studies [5, 13]. Nevertheless, its application in benign colorectal diseases is becoming an option due to the advantages of endoscopic procedures.

In most cases, however, benign surgery of the colon and rectum involves inflammatory processes and these can be technically difficult to work on. A prospective study was therefore begun in November 1991 to analyze the feasibility of the laparoscopic-assisted approach in elective surgery of diverticular diseases. Of 83 patients approached laparoscopically for benign colorectal diseases (Table 1), elective sigmoid resection due to diverticular disease was performed in 41 of them.

Surgical indications for elective diverticular disease are [12]: resection following recurrent attacks of diverticulitis (after two attacks or after a single attack in either young patients or patients requiring chronic immunosuppressive therapy); diverticulitis associated with fistulas to the bladder or vagina; and elective resection following previously percutaneously drained pericolic abscesses (Hinchey stage I and II) [3].


Materials and methods

Forty-one patients (mean age 65 years) were included in this prospective study (Table 2). There were 19 males and 22 females. Twenty-seven patients had a recurrent attack of diverticulitis; another four patients (younger than 50 years) had had a single attack of diverticulitis; one patient had a fistula to the vagina and another four had fistulas to the bladder. Diverticulitis in combination with adenomatous polyps in the sigmoid was present in four patients and an elective resection of the sigmoid was indicated after a transrectally drained pelvic abscess in the last patient (Hinchey stage II].


Preoperative workup

Diagnosis of diverticulitis was confirmed by sigmoidoscopy and barium enema performed approximately 6 weeks after the attack. Sigmoidoscopy will help to differentiate diverticulitis from a sigmoid cancer and the barium enema is a tool for assessment of location of the process and the length of the sigmoid loop. Starting in 1993 we added an enhanced computer-assisted tomography (CT scan) with oral and rectal contrast in all patients who are candidates for surgery in order to establish the diagnosis and anticipate technical difficulties. All these studies together are an important aid in planning the operative approach, as the length of the sigmoid loop and the presence of any fistulas or phlegmon need to be determined.


Operating technique

Pilot study. Based on the initial experience obtained from the first six patients operated, two laparoscopic techniques were developed for the sigmoid resection. Which of the two was used for subsequent patients depended on the data obtained during the preoperative study and operative laparoscopic findings.


These data were obtained during the preoperative assessment:

• Presence of residual inflammatory phlegmon

• Presence of fistulas

• Short sigmoid loop


We have classified the laparoscopic findings based on the degree of difficulty of dissecting the sigmoid completely free and identifying the left ureter:

Grade I:    The presence of a relatively short segment of inflammation with loose adhesions to the abdominal wall or pelvis

Grade Il:    An extensive segment of inflammation sticking to the abdominal wall or pelvis; difficult dissection of the ureter

Grade III:     The presence of “woody’’ diverticulitis with a very strong fibrosis around the inflammatory process: nearly impossible dissection of the ureter

Grade IV:    The presence of a fistula


The data obtained from these two pre- and peroperative assessments will from the start determine the grade of technical difficulty of the procedure and facilitate the choice of laparoscopic approach.


Technique No. 1 (assisted laparoscopic resection, ALR)

We used the four or five-cannula approach depending on whether mobilization of the splenic flexure was necessary (Fig. 1). After mobilization of the sigmoid, the left ureter was identified; the most distal part of the descending colon and proximal rectum were then mobilized. In those cases where extensive inflammatory processes or fistulas were found, mobilization of the splenic flexure was performed and the procedure was continued as a dissection-facilitated laparoscopic resection (see technique No. 2). Devascularization took place after this dissection, clipping and cutting the sigmoid vessels, and once the distal level of resection was determined, the arcade vessels were cut. In the majority of cases the proximal rectum was cut with the endostapler (Endo-GIA blue, USSC, Norwalk, CT, USA) at the promontorium level. Then a small incision of 5 cm was made at the level of the superior iliac spine in the left lower abdomen and through it the specimen was retrieved. Resection was performed followed by introduction of the anvil in the proximal end. After its reintroduction into the abdomen and closure of the wound and reinsufflation, a double-stapled anastomosis was performed [1]. The anastomosis was checked by injecting methylene blue into the rectum. Finally the abdomen was drained and the ports were closed.

TROCARPL


Technique No. 2 (dissection-facilitated laparoscopic resection, DLR)

In cases where mobilization of the most affected segment of the sigmoid was not possible by assisted laparoscopy (ALR) because of the existence of a large phlegmon or fibrotic fistula track or ‘woody diverticulitis" or lack of identification of the left ureter, we proceeded with a dissection-facilitated laparoscopic resection (Fig. 2).


Table 1. Laparoscopic approach for benign colorectal diseases in 83 patients

Ileo-caecal resection (Crohn’s disease)

4

Left hemicolectomy (Crohn’s disease)

1

Total colectomy (Crohn’s disease)

1

Total colectomy + ileo-anal anastomosis ( 1 polyposis coli, 4 ulcerative colitis)

5

Rectopexy

17

Sigmoid resection in diverticulitis

41

Sigmoid resection (polyps)

6

Stoma creation

7

Take down Hartmann

1




After mobilization by laparoscopy of the major part of the sigmoid, descending colon, and splenic flexure, the sigmoid was devascularized using clips. For mobilization of the splenic flexure the patient is placed in the reverse Trendelenburg position and slightly tilted to the right side. The optic is changed to port No. 4 in the left lower abdomen and the surgeon dissects the flexure free using the umbilical and right abdominal ports (No. l and 2) while the assistant helps to hold the optic and the instruments through the upper left abdominal trocar (No. 5). After this we proceeded to perform a Pfannenstiel incision of about 7 cm in length. Through this incision we could continue with the rest of the mobilization of the sigmoid and proximal rectum and eventually identification of the ureter. After resection of the sigmoid, the anastomosis was performed extracorporeally either manually or using a double-stapled anastomosis.


Choice of operative technique

After the first six patients the choice of the laparoscopic approach was as follows. We performed an assisted laparoscopic sigmoid resection in the following cases:


Without mobilization of the splenic flexure:

• Grade I laparoscopic findings


With mobilization of splenic flexure:

• A short sigmoid loop

• Grade II laparoscopic findings


Facilitated laparoscopic dissection was performed in the following cases (with mobilization of the splenic flexure if necessary):


• Grade III and IV laparoscopic findings

• Grade II if impossible to dissect free from the pelvic wall


Postoperative treatment

Patients were treated prophylactically with 3,075 IU subcutaneous heparin (Fraxiparine, Sanofi Winthrop Co.) the night before the operation; treatment continued once a day until discharge from hospital. Antibiotics (Flagyl. 3 x 500 mg iv, Rhone Poulenc Co.; and Zinacef, 2 x 750 mg, Glaxo) were given prophylactically for 24 hours, starting with the premedication. The nasogastric tube was removed following the operation. If peristalsis was present, liquids were given to the patients on the 2nd and 3rd postoperative days followed by another 2 days of bland diet and finally a normal diet.


Results

According to the laparoscopic findings we classified 18 patients as having grade I diverticulitis, 15 patients as having grade II, three patients with diverticulitis grade III, and finally five patients with a fistula and therefore as grade IV. In grade I, all patients were operated using ALR (conversion grade 0%). In grade II, 11 of the 15 patients underwent an ALR and one a DLR, another three patients being converted to laparotomy (conversion rate 20%). A temporary loop ileostomy was created in the patient operated on by means of a DLR to protect the anastomosis – necessary because a pelvic abscess (Hinchey stage II) was preoperatively drained transrectally. In grade III, two patients underwent a DLR and the third was converted. In grade IV, four patients were operated on using a DLR and another one was converted at the outset because of cancer which had fistulized into the bladder (T4N0M0]. The procedure was converted to a median laparotomy in a total of six patients of 41 (15%) due to: a stapler perforation of the rectum (2x); failure to identify the left ureter (2x) (bladder perforation also occurred in one of these patients); perforation of the transverse colon during mobilization of the splenic flexure (lx); and a fistulized sigmoid cancer into the bladder (lx). The mean operating time was 3 h 15 min. In the first 20 patients this time was 3 h 55 min and in the last 20 patients 3 h 5 min. Mean blood loss was 225 ml. The converted patients were transfused with 3 units of blood on average. Only one of the grade I patients was transfused (two units of blood) due to bleeding from the sigmoid vessels during the laparoscopic procedure. In three patients the procedure was associated with a laparoscopic cholecystectomy because of symptomatic cholelithiasis and in a fourth with an extensive adhesiolysis. The mean hospital stay was 6.5 days after the operation. Morbidity was found in seven patients (17.5%). Two patients had a wound abscess, one patient developed a venous thrombosis in the popliteal vein, one had a small bile leakage due to an associated laparoscopic cholecystectomy (limited to 2 days), and another patient had bleeding at the trocar site. Another two patients were reoperated during the postoperative course, one having developed peritonitis due to a small-bowel perforation after laparoscopic adhesiolysis and one having a leakage of the anastomosis 3 days after discharge, which was treated by a Hartmann procedure. No mortality was registered in this series.


Discussion

Uncomplicated diverticulitis means the presence of peridiverticulitis or phlegmon which implies a limited inflammatory process which must be treated conservatively. Under complicated diverticulitis we understand one of the following conditions: the presence of obstruction, a free perforation in the abdominal cavity, the presence of a pericolic abscess or the development of a fistula (either to the bladder – 60% of the cases – or to the vaginal stump following resection of the uterus or to the abdominal wall) [12].

It is obvious that the existence of a free perforation or an obstruction implies an acute surgical intervention. In the case of a pericolic abscess this can be drained percutaneously and the patient prepared conservatively for elective intervention [11]. Fistulas are treated surgically during an elective procedure.

Surgical indications for elective procedures in diverticular disease are (1) recurrent attacks of uncomplicated diverticulitis (two attacks of diverticulitis or a single attack in patients younger than 50 years); (2) diverticulitis associated with fistulas in which the existence of a carcinoma has to be excluded; (3) elective resection after a previously drained pericolic abscess; and (4) one attack in a patient requiring chronic immunosuppressive therapy [12, 10].

Basic guidelines for this surgical resection include the excision of the sigmoid loop and anastomosis in the proximal rectum as a high anterior resection in order to avoid an anastomosis with the distal sigmoid where intraluminal high pressure can induce the recurrence of diverticulitis. More debate centers on the proximal level of the resection. No compelling data are available to suggest that all diverticula must be removed; rather, the involved segment of colon, which is identified by serosa changes of prior inflammation, has to be resected along with all bowel distal to the rectum [10]. Only in exceptional cases will more colon be resected if there is obvious gross inflammatory involvement in the descending colon or the presence of giant diverticulum. The anastomosis has to be performed without any resulting tension, occasionally necessitating mobilization of the splenic flexure. In the case of an extensive inflammatory process or the presence of a short sigmoid loop, the mobilization will be done before the anastomosis and in the rest of the cases once the anastomosis is performed, if any tension is observed.

Laparoscopic colon resection was introduced in 1990 for cancer and inflammatory process [4]. In almost all published series, a combination of cases involving malignancies and diverticulitis has been reported. Also, a small number of papers have been published concerning diverticulitis and fistulas exclusively [2, 8]. Liberman et al. [6] recently published one retrospective study comparing laparoscopic-treated diverticulitis with the conventional procedure, concluding that the laparoscopic approach resulted in a more rapid return of bowel function and shortened hospital stay. In spite of higher operating room charges, total hospital charges and general costs were significantly reduced. The general advantages of laparoscopic surgery have been described for this procedure. In our series, significant safeguarding of patient comfort along with preservation of peristalsis, quick resumption of food intake, and respect of the integrity of the abdominal wall are considered the most important advantages to the patient.

Not all so-called laparoscopic colon resections are technically the same. We need to distinguish between the dissection-facilitated laparoscopic resection where the dissection and sometimes the devascularization have taken place laparoscopically and the assisted laparoscopic resection where even the resection takes place laparoscopically with retrieval of the specimen through a small incision, the anastomosis being performed intracorporeally [7].

Although laparoscopic colorectal resection for cancer remains controversial because of the possibility of cancer implants at the port sites and incision places [13], laparoscopic resection for inflammatory colon processes has been performed with more caution because it is technically more demanding due to the inflammatory reaction and absence of planes. Complication rates can be high and so, too, the rate of consequent conversions [9].

In our series we have seen that this technique is feasible, having a low conversion and complication rate, if the surgeon plans and approaches this laparoscopic resection selectively. A thorough preoperative study together with the laparoscopic findings is important in planning the laparoscopic approach. Whereas a short inflammatory segment of the sigmoid may be approached by an assisted laparoscopic sigmoid resection, the presence of extensive inflammatory residual phlegmon or a short sigmoid loop will require a mobilization of the splenic flexure. In the same way a difficult local dissection caused by a fibrotic “woody” diverticulitis or the presence of a fistula to the bladder or vagina will be facilitated by mobilization of the sigmoid and proximal rectum by a Pfannenstiel incision in order to solve the local problem. With respect to the mobilization of the splenic flexure, a clear policy is difficult to plan. Only in extensive inflammatory processes or when a barium enema shows a short sigmoid loop to be present will the splenic flexure be mobilized prior to the completion of the anastomosis.


Conclusion

The laparoscopic-assisted sigmoid resection is a technically feasible procedure. With a good pre- and peroperative study, adoption of a complete or dissection-facilitated laparoscopic approach will solve the unpredictable difficulties of this important inflammatory disease.


References

1.    Cuesta MA, Borgstein PJ, Paul MA, de Jong D (1992) Surgery of the distal colon assisted by laparoscopy. Video Rev Surg 9: 10-21.

2.    Hewett PJ, Stitz R (1995) The treatment of internal fistulae that complicate diverticular disease of the sigmoid colon by laparoscopically assisted colectomy. Surg Endosc 9: 411-413.

3.    Hinchey EJ, Schaal PG, Richards GK (1978) Treatment of perforated diverticular disease of the colon. Adv Surg 12: 85-109.

4.    Jacobs M, Verdeja JC, Goldstein HS (1991) Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1: 144- 150.

5.    Lacy AM, Garcia-Valdecasas JC, Pique JM, Delgado S, Campo E, Bordas JM, Taura P, Grande L, Fuster J, Pacheco JL (1995) Short-term outcome analysis of a randomized study comparing laparoscopic vs open colectomy for colon. Surg Endosc 9(10): 1101-1105.

6.    Liberman MA, Phillips EH. Carroll BJ, Fallas M, Rosenthal R (1996) Laparoscopic colectomy vs traditional colectomy for diverticulitis. Outcome and costs. Surg Endosc 10: 15-18.

7.    Phillips EH, Rosenthal RJ (1995) Nomenclature in laparoscopic colon surgery. In: Phillips EH, RJ Rosenthal (eds) Operative strategies in laparoscopic surgery. Springer Verlag, New York, pp 215-218.

8.    Puente I, Sosa IL, Utpal Desai BS, Sleeman D, Hartmann R (1994) Laparoscopic treatment of colovesical fistulas: technique and reports of two cases. Surg Laparosc Endosc 4: 157-160.

9.    Reissman P, Salky BA, Pfeifer J, Edye M, Jagelman DG, Wexner SD (1996) Am J Surg 171(1): 47-50.

10.    Schoetz DJ (1993) Uncomplicated diverticulitis. Indications for surgery and surgical management. Surg Clin North Am 73: 965-974.

11.    Stabile BE, Puccio E, vanSonnenberg E, Neff CC (1990) Preoperative percutaneous drainage of diverticular abscesses. Am J Surg 159: 99105.

12.    Standard Task Force American Society of Colon and Rectal Surgeons (1995) Practice parameters for sigmoid diverticulitis-supporting documentation. Dis Colon Rectum 38: 126-132.

13.    Wexner SD, Cohen SM (1995) Port site metastases after laparoscopic colorectal surgery for a cure of malignancy. Br J Surg 82: 295-298.

14.    Wexner SD, Yoansen OB (1992) Laparoscopic bowel resection advantages and limitations. Ann Med 24(2): 105-109.








Chapter 2.2



Laparoscopic elective treatment of diverticular disease: a comparison between laparoscopic assisted and resection facilitated techniques




Q.A.J. Eijsbouts, J. de Haan, F.J. Berends, C. Sietses, M.A. Cuesta



Surg Endosc (in press)






Abstract


Background: Because of the presence of significant inflammatory reaction, elective surgical laparoscopic assisted treatment of complicated diverticular disease can be difficult and account for 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, taking down the fistula, but also resection and manual anastomosis can take place. In this study, factors such as operating time, conversion rate, complications and costs of both assisted and resection facilitated techniques are compared.


Methods: Two consecutive series of 35 patients with diverticular disease who underwent a sigmoid resection either assisted or dissection-facilitated are compared. Both groups are comparable concerning age, gender and the kind of complicated diverticular disease.


Results: Operating time, conversion rate and costs were reduced in the laparoscopic facilitated group. The fact that in this last group no conversions took place is the most important advantage of this study. Along with the possibility of conversion from the assisted laparoscopic approach to laparotomy (5 patients of 35), it is also possible to convert from the assisted to the facilitated form (7 of 35 patients).


Conclusion: Laparoscopic facilitated sigmoid resection is a feasible intervention for all forms of complicated diverticular disease with marked reductions in operating time, conversion rate and operative and general costs.


Introduction

Elective laparoscopic ‘assisted’ approach for diverticular disease remains a challenge for the surgeon because of the presence of acute and chronic inflammation and their consequences such as thick mesentery, fibrosis and fistulas to other organs [9, 16].

Several papers refer to the ‘assisted’ laparoscopic approach of the inflammated sigmoid and the various ways to solve the different complications found during a surgical intervention [1-11, 13-17, 19-23, 25].

In the laparoscopic assisted interventions, the presence of these local complications can lead to time consuming operations, high costs, a high conversion rate and postoperative complications [4, 5, 15, 17, 20, 22, 25].

Nevertheless, diverticular disease is quite frequent in the western world and if an elective laparoscopic technique can be designed suitable for the majority of patients undergoing this type of resection, many will benefit [24].

Therefore, after the first experience with the laparoscopic assisted approach, the results of which have been previously reported [9], a simpler strategy has been developed. Resection facilitated laparoscopic sigmoid resection implies mobilization of the sigmoid as much as possible (and splenic flexure if necessary), and practically no dissection of the difficult inflammatory process [18]. Through a Pfannenstiel incision, the difficult steps of the operation can take place: dissection of the inflammatory process, taking down the fistula, resection and manual anastomosis. In this way an important reduction in operating time and conversion rate may be achieved along with reduction of costs, maintaining all advantages of the minimally invasive procedure.

In order to analyze these questions, two consecutive groups of patients with diverticular disease (assisted and resection facilitated) were studied in order to determine differences in operating time, conversion rate, postoperative complications, hospital stay and costs.


Material and methods

Two consecutive groups of 35 patients with diverticular disease were approached either laparoscopically assisted (group a) or resection facilitated (group b). The intention of the study was that all patients in group a were to undergo a laparoscopically ‘assisted’ operation. If this assisted operation seemed impossible at the time of surgery, the patient was converted either to the facilitated form or to laparotomy. The 35 patients included in group b underwent a laparoscopic ‘facilitated’ operation, independently of preoperative and laparoscopic findings.


Characteristics of the groups

Both groups are comparable concerning distribution in age, sex, indications for surgery, Hinchey I stage and laparoscopic findings. Characteristics of both groups are depicted in Table 1.



Preoperative work-up

The diagnosis of diverticulitis was confirmed by CT scan with oral and rectal contrast in all patients to establish diagnosis and anticipate technical difficulties such as the presence of fistulas or abscesses. Six weeks after an attack of diverticulitis, a sigmoidoscopy was performed and a barium enema administered to assess the exact location of the process and the length of the sigmoid loop.


Laparoscopic findings

The following four-tiered classification is based on the degree of difficulty of dissecting the sigmoid free and identification of the ureter:

Grade I:    The presence of a relatively short segment of inflammation with loose adhesions to the abdominal wall or pelvis

Grade Il:     An extensive segment of inflammation sticking to the abdominal wall or pelvis; difficult dissection of the ureter

Grade III:    The presence of “woody’’ diverticulitis with a very strong fibrosis around the inflammatory process: nearly impossible dissection of the ureter

Grade IV:    The presence of a fistula.


Operating technique

Both techniques, the laparoscopic assisted resection and the resection facilitated technique, have been described elsewhere [9].


Technique No. 1 (assisted laparoscopic resection, ALR)

A four or five-cannula approach is employed depending on whether mobilization of the splenic flexure was necessary. After mobilization of the sigmoid, the distal part of the descending colon and proximal rectum, the left ureter was identified. In those cases where extensive inflammatory processes or fistulas were found, mobilization of the splenic flexure was performed and the procedure was continued as a facilitated laparoscopic resection (see technique No. 2). Devascularization took place after this dissection, clipping and cutting the sigmoid vessels, and once the distal level of resection was determined, the arcade vessels were cut. In the majority of cases the proximal rectum was cut with the endostapler (Endo-GIA blue, USSC, Norwalk, CT, USA) at the promontorial level. A small incision of 5 cm was then made at the level of the superior iliac spine in the left lower abdomen and through it the specimen was retrieved. Resection was performed followed by introduction of the anvil in the proximal end. After its reintroduction into the abdomen and closure of the wound and reinsufflation, a double-stapled anastomosis was performed. The anastomosis was checked by injecting methylene blue into the rectum. Finally the abdomen was drained and the ports were closed.


Technique No. 2 (dissection-facilitated laparoscopic resection, DLR)

After mobilization by laparoscopy of the major part of the sigmoid, descending colon (and splenic flexure if necessary), the sigmoid was devascularized using clips. For mobilization of the splenic flexure the patient is placed in the reverse Trendelenburg position and slightly tilted to the right side. The optic is changed to port No. 4 in the left lower abdomen and the surgeon dissects the splenic flexure free using the umbilical and right abdominal ports (No. 1 and 2) while the assistant helps to hold the optic and instruments through the upper left abdominal trocar (No. 5). After this we proceed to perform a Pfannenstiel incision of about 7-10 cm in length. Through this incision we could continue with the rest of the mobilization of the sigmoid and proximal rectum and eventually identification of the ureter. After resection of the sigmoid, the anastomosis was performed extracorporeally either manually or using a double-stapled anastomosis.


Postoperative treatment

Patients were treated prophylactically with 3.075 IU subcutaneous heparin (Fraxiparine, Sanofi Winthrop Co) the night before the operation; treatment continued once a day until discharge from the hospital. Antibiotics (Flagyl, 3x500 mg iv, Rhone Poulenc Co; and Zinacef, 2x750 mg, Glaxo) were given prophylactically for 24 hours, starting with the premedication. The nasogastric tube was removed following the operation. If peristalsis was present, liquids were given to the patients on the second and third postoperative days, followed by another 2 days of bland diet and finally a normal diet.


Results

Operating time

The mean operating time for the facilitated group was two hours and 30 minutes (range two hours to three hours and 55 minutes) and for the assisted group three hours 15 minutes (range three hours to three hours 55 minutes).


Associated procedures

In group a, the procedure was associated with laparoscopic cholecystectomy in three patients because of symptomatic cholelithiasis and in a fourth with extensive adhesiolysis. A temporary loop ileostomy was created in a patient in whom a pelvic abscess was preoperatively drained. In group b, the procedure was associated with laparoscopic cholecystectomy in two patients because of symptomatic cholelithiasis and in two others a loop ileostomy was created because of the presence of an abscess in the pelvis with a fistula to the vaginal stump and in the other a low anterior anastomosis because of the presence of a low fistula to the bladder. In one female patient, a left adnexectomy was performed because of an ovarian abscess.


Conversion from laparoscopic assisted to resection facilitated

In 7 patients of group a the laparoscopic operation was continued as DLR because of significant inflammation fixed to the pelvic wall in one patient, the presence of ‘woody’ diverticulitis in two others, and in four other patients because of the presence of a fistula which was difficult to dissect.


Conversions to laparotomy

The procedure was converted to a median laparotomy in a total of five of the 35 patients of group a due to stapler perforation of the rectum (1x), failure to identify the left ureter (2x) (bladder perforation also occurred in one of these patients); perforation of the transverse colon during mobilization of the splenic flexure (1x); and a fistulized sigmoid cancer to the bladder. No conversions to median laparotomy were performed in group b.

Hospital stay

The average hospital stay in the assisted group was nine days (range 5 to 42) after operation (in patients without conversion or complications eight days) and in the facilitated group eight days (without complications seven days).


Complications

Morbidity was found in seven patients in group a. Two patients had a wound abscess, one patient developed a venous thrombosis in the popliteal vein, one had a small bile leakage due to an associated laparoscopic cholecystectomy and another patient had bleeding from a trocar site. Another two patients were reoperated during the postoperative course, one having developed peritonitis due to a small bowel perforation after laparoscopic adhesiolysis and one having a leakage of the anastomosis three days after discharge, which was treated by a Hartmann procedure. In group b morbidity was found in three patients. One patient had a wound abscess. Another two patients were reoperated, one immediately after closure of the wound because of postoperative bleeding (sigmoid vessels), the other having an anastomotic leakage which was treated with a Hartmann procedure.


Costs (in dollars)

Operative costs of disposables used: for the assisted group, 1620 dollars, and for the facilitated group, 845 dollars.

Total costs: assisted group, 1620 plus operating room charges (1625) and admission fee (4900); total US$ 8145. For the facilitated group, 845 plus operating room charges (1250) and admission fee (4000); total US$ 6095.


Discussion

Complicated diverticular disease is common in the western world. Acute complications may be life-threatening and therefore indications for elective surgery have to be followed closely in order to minimize morbidity and mortality [9, 24].

Elective sigmoid resection because of diverticulitis can be performed by the laparoscopic assisted approach with all the advantages of minimally invasive surgery [5, 7, 9, 10, 15, 16, 19, 22]. Nevertheless, the presence of inflammatory reactions such as phlegmon of the sigmoid, residual abscesses, fibrosis and fistulas to other hollow organs can make this laparoscopic operation troublesome [5, 9, 15, 19, 20, 22, 25]. Lengthy operating times and the possibility of high complication and conversion rates lead to a longer hospital stay and higher postoperative complications and costs.

Two alternatives exist for this assisted laparoscopic approach. The first is the ‘hand assisted operation’ by means of a sleeve introduced into the abdomen at the beginning of the operation through a limited incision. With the help of other cannulas, the sigmoid is resected and the rest of the intervention completed. Introduction of the hand through a Pfannenstiel incision has as consequence a reduction in space which obstructs the correct visualization and dissection of the process. Advantages will be the tactile perception that will help to dissect the inflammatory process in the proper plane and to mobilize the splenic flexure if necessary. The ideal incision for the mobilization of the sigmoid and the splenic flexure will be the transumbilical incision, whereas for the retrieval of the sigmoid and the anastomosis the Pfannenstiel incision is preferable.

Published experience with the hand assisted method (dexterity pneumo- sleeve) is scarce. In two papers with a small number of patients, four and nine, operating time varies between the 109 minutes of the first and the longer 3 hours and 42 minutes of the second. Advantages are that the use of the hand is extremely helpful in identifying the resection plane and taking down a colo-vaginal fistula. Both authors stressed that this procedure retains the benefits of the laparoscopic procedure [1, 17].

The other alternative is the facilitated laparoscopic sigmoid resection [18]. This approach implies laparoscopic mobilization of the sigmoid as much as possible and splenic flexure if necessary according to the preoperative and laparoscopic findings. The difficult steps of the operation take place through a Pfannenstiel incision: dissection of the inflammatory process, taking down the fistula, resection and manual anastomosis.

In this study the operating time in the facilitated group, 150 minutes, compares favorably with of the assisted group, 195 minutes. These operating times are in accordance with the literature. The published operating times for the assisted method ranged between 165 and 397 minutes, the operating time for a conventional sigmoid resection for diverticulitis being around 120 minutes, which is significantly shorter [4, 5, 15, 20, 25]. The conversion rate depends on the peroperative diverticulitis findings. The rate of inflammation will establish the operating time and consequently the conversion rate. This conversion rate is significant in the laparoscopic assisted group whereas in the resection facilited group in which all the components of the inflammatory process may be treated adequately through the Pfannenstiel approach, its conversion rate may be virtually zero. In the assisted group, seven of 35 patients had to be converted to the facilitated laparoscopic operation and five patients more had to be converted to a median laparotomy. Almost one-third of the patients in this group therefore underwent some type of conversion. This percentage is high in comparison with those published in the literature but in the series of Sher et al., and depending on the complexity of the diverticulitis, the conversion rate can reach almost 38% [22]. Lower conversion rates are published for other series [5, 15, 16, 20, 25]. In contrast, no conversions were recorded in the facilitated group in which patient characteristics were comparable.

Conversions may influence the postoperative complication rate. The rates of between 5 and 21% recorded in the literature are in line with the results presented here [5, 10, 15, 16, 20, 25]. The number of anastomosis leakages, one patient in each group (2.8%), is acceptably low. There was no mortality in the presented series.

Hospital stay is a relative concept depending on not only the postoperative course, but also local circumstances and adequate postoperative care at home. Minimal differences were seen between the assisted and facilitated group (nine and eight days respectively) in this study. These results are longer when compared with the laparoscopic stay published in the literature of between four and eight days [5, 10, 15, 16, 22, 25]. The operating and total costs are somewhat lower than those found in other studies [5, 15, 16]. In this series, the differences found are due to the use of staplers in the assisted group and the manual anastomosis mostly employed in the facilitated group. It is difficult to compare these costs with those of conventional operations. Bruce et al. [5], and Liberman et al. [16], found that even if the operating room cost of laparoscopic groups was higher than conventional operations, the total costs were clearly reduced, due to a shorter hospital stay.


Conclusion

In the presented study the laparoscopic facilitated sigmoid resection seems more feasible (lower operating time and no conversions to laparotomy) and more cost effective than the more classical laparoscopic assisted sigmoid resection for diverticular disease. Both methods retain all advantages of the laparoscopic assisted procedures.


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