Laparoscopic Sigmoid Colectomy for Complicated Diverticulitis

Steven D. Wexner, MD, FACS, FRCS, FRCSEd, FASCRS, FACG Chief Academic Officer Cleveland Clinic Florida

Weston, Florida

Faculty Disclosure

It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity.

Steven D. Wexner, MD, FACS, FRCS, FRCSEd, FASCRS, FACG, has served as a consultant for AHRM, Century Medical (Japan), ConvaTec, EZ Surgical, Food and Drug Administration, Incontinence Devices, Inc, Karl Storz Endoscopy America, Inc, LifeBond, Mederi Therapeutics, Medtronic, Inc, NeatStitch, NiTi, Pacira Pharmaceuticals, Signalomics GmbH, and Ventrus Biosciences. He has received honoraria from Adolor, GlaxoSmithKline, LifeCell, and Oceana Therapeutics. He is a stock shareholder for CRH Medical, EZ Surgical, Intuitive Surgical, LifeBond, and NeatStitch. He has received other financial support from Covidien, Karl Storz Endoscopy America, Inc, and Unique Surgical Innovations, LLC.

Learning Objective

• Evaluate the evidence for therapeutic options that may improve gastrointestinal recovery postsurgery and integrate these efforts toward supporting overall surgical quality measures

History of the Present Illness

• 44-year-old male

• 2 previous hospitalizations for acute diverticulitis

History of the Present Illness• First episode: 2.5 years ago

– Tmax 100.5F, WBC 12,000/uL

– CT: uncomplicated long segment sigmoid diverticulitis

• Second episode: 1 month ago – Tmax 101F, WBC 16,000/uL

– CT abdomen/pelvis: extensive inflammation of the sigmoid colon with an abscess 2.5 to 3.9 cm in size

– Managed with out-patient oral antibiotics

Past Medical History

• Irritable bowel syndrome• No previous abdominal surgery• Medications:

– Fenofibricacid 45 mg one tablet daily– Omega-3 fatty acids 500 mg one capsule daily– Flaxseed oil 1000 mg one tablet daily

• Allergies: – Penicillin

• Habits: – Tobacco: never– Alcohol use: occasional

Examination

• Physical exam: – BMI 30.3 kg/m2

– Soft, flat, nontender, nondistended abdomen

• Laboratory investigations: (all within normal limits)– Hb 12.9 mg/dL

– WBC 5.8 1000/uL

• Colonoscopy: 6 months ago, unremarkable

• Imaging: Long segment of uncomplicated sigmoid diverticulitis

Preoperative Measures

• 10 days prior to surgery the patient complained of left-sided abdominal pain; without fever or change in bowel habits

• Oral antibiotic treatment was started and continued until day of surgery

Preoperative Measures

• Preoperative counseling visit with colorectal surgical nurse to discuss– Surgical procedure

– Principles of enhanced recovery

– Preoperative fasting (midnight on day before surgery)

– Mechanical bowel preparation

– Medications to avoid

• Pulmonary clinic to obtain– Incentive spirometer and instructions regarding its use

and importance

Why Laparoscopy?

Guller U, et al. Arch Surg. 2003;138:1179-1186.

Open Sigmoid Resection, n = 17,735

Laparoscopic Sigmoid Resection, n = 709

LOS: Length of stayTo read more about this study, click on the following link: http://www.ncbi.nlm.nih.gov/pubmed/14609864

Advantages of Laparoscopic Colorectal Surgery Compared With Open Procedures

• Reduced surgical trauma• Reduced postoperative morbidity/complications• Reduced postoperative pain• Earlier passage of flatus; earlier bowel movement• Reduced hospital stay• Lower mortality• Similar oncologic outcomes• Less use of skilled nursing after discharge

Schwenk W, et al. Cochrane Database Syst Rev. 2005;CD003145. Delaney C, et al. Ann Surg. 2008;247:819-824.

For more information click on the following link: http://www.ncbi.nlm.nih.gov/pubmed/16034888

Enhanced Recovery Protocols (ERP) Optimize Outcomes

• Improved GI recovery• Decreased length of stay• Reduced complication rates• No change in readmission rates

Adamina M, et al. Surgery. 2011;149(6):830-840.Lassen K, et al. Arch surg. 2009;144:961-969.

Preadmission Education

and Counseling

Prophylaxis Against Thromboembolism

Minimization of Bowel Trauma

Avoidance of NG Tubes; Drains

Early Enteral Feeding

Goal-directed Fluid Therapy

Opioid-Sparing Analgesia

Enforced Early Ambulation

Breathing ExercisesPreset

Discharge Criteria

For more on health outcomes with enhanced recovery pathways, click on the following link: http://www.ncbi.nlm.nih.gov/pubmed/21236454

Laparoscopy + Fast Track Multimodal Management (LAFA-Study)

Treatment Group Median Length of Postoperative Hospital Stay (days)

Laparoscopy + Fast Track 5*

Laparoscopy + Standard Care 6

Open + Fast Track 6

Open + Standard Care 7

Vlug M, et al. Ann Surg. 2011;254:868-875.

Multicenter trial of 400 segmental colectomy patients randomized to 4 groups

*P < 0.001 compared with other 3 treatment groups

For more about the LAFA study, click here: http://www.ncbi.nlm.nih.gov/pubmed/21597360

Surgical Procedure: Preparation

• General anesthesia• Cystoscopy with prophylactic insertion of bilateral

ureteric stents and foley catheter• DVT prophylaxis:

– Sequential compression devices– Heparin 5000 u subcutaneous injection

• Antibiotic prophylaxis:– Cefoxitin 2 g IV 30 minutes prior to incision

Surgical Procedure: Technique

• 10 mm infraumbilical Hasson

• 2 x 10 mm right lower quadrant ports

• Instruments used: – 10 mm electrothermal bipolar

vessel sealer– 5 mm ultrasonic device– 5 mm endoscopic scissors– 10 mm babcocks

Surgical Procedure: Findings

• Findings: – Large (10 cm), rock-hard phlegmon in the left iliac fossa – Small bowel mesentery stuck to the colonic mesentery– Omentum draped over the colon with multiple

adhesions

Surgical Procedure: Technique

• Left colon mobilization to the mid-transverse colon• Inferior mesenteric artery and vein divided • Rectosigmoid junction cleared of fat and

transected • Descending and sigmoid colon was withdrawn

through infraumbilical incision (wound protector)• Descending colon to sigmoid junction was

circumferentially cleared of fat and transected

Surgical Procedure: Technique

• 33 mm anvil introduced in left colon and secured with pursestring clamp

• Abdomen was reinsufflated and a circular end to end anastomosis with a 33 mm stapler was performed

• Anastomosis was evaluated with flexible endoscopy

Surgical Procedure: Measures

• Operative time: 180 minutes• Estimated blood loss: 200 mL• Fluids given: 1000 mL of normal saline• Normothermia at all times (36.3C to 37.2C)• Prophylactic ureteral stents removed in operating

room at end of procedure• Drains and tubes:

– Bladder catheter– No nasogastric tube– No pelvic drain

Postoperative Course: Day 0

• No bowel movement or flatus, no nausea or vomiting

• Seated in chair

• Used incentive spirometer

• All vitals normal, adequate urine output

• Abdomen: soft, nontender, no distention

• Pain medication: – Hydromorphone IV PCA

– Ketorolac IV

– Acetaminophen PO

Postoperative Course: Day 1

• No bowel movement or flatus, no nausea or vomiting

• Ambulated along hallway and tolerated activity well

• Used incentive spirometer q1h

• All vitals normal, adequate urine output

• Abdomen: soft, nontender, no distention

• Pain medication:

– Hydromorphone IV PCA

– Ketorolac IV

– Acetaminophen PO

Postoperative Course: Day 1

• Clear liquid diet was tolerated• IV fluids decreased (30 mL/hr)• Bladder catheter removed

• No bowel movement or flatus, no nausea or vomiting

• Ambulated along hallway > 10 times• Used incentive spirometer q1h• All vitals normal, adequate urine output• Abdomen: soft, nontender, no distention• Incisions dry, clean, and intact

Postoperative Course: Day 2

Postoperative Course: Day 2

• Pain medication: – Hydromorphone PCA discontinued– Oxycodone offered (not used)– Ketorolac IV– Acetaminophen PO

• Diet was advanced to low residue• IV fluids stopped

Postoperative Course: Day 3

• Passes flatus, no bowel movement, no nausea or vomiting

• Abdomen: soft, nontender, no distention • Incisions dry, clean, and intact• Low residue diet was tolerated• Pain medication: acetaminophen PO• Patient was discharged in good condition

Postoperative Course: 6 Weeks

• Feels great• Did not require PO narcotics at home• Bowel movements 1-2 BM, formed/day• Back to daily activities 1 week postoperatively• Back at work 2 weeks postoperatively• All incisions well-healed, no hernias

Outcomes

• Time to start PO intake: 4 hours• Time to first flatus: 58 hours• Length of hospital stay: 80 hours• No complications• No ileus• No re-admission

Summary

• Preoperative patient education and counseling• Set appropriate patient expectations • Careful perioperative planning• Minimally invasive surgery• Follow enhanced recovery principles• Coordinated multidisciplinary effort