complications of laparoscopic surgery for diverticulitis bradley r. davis, md, facs, fascrs...
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Complications of Laparoscopic Surgery for
DiverticulitisBradley R. Davis, MD, FACS, FASCRS
Associate Professor of Surgery
University of Cincinnati
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
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
Factors Effecting Outcomes
• Complicated vs Uncomplicated– Fistula– Stenosis– Diverticulitis vs diverticulosis
• Experience – high volume vs low volume
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
Complicated Diverticulitis:Alternatives to Conversion
• Pfannenstiel incision after:– mobilization of splenic flexure– division of vascular pedicle
• Hand-assisted laparoscopy– allows tactile sensation– blunt separation