1. Complications of Laparoscopic Surgery for Diverticulitis
Bradley R. Davis, MD, FACS, FASCRS
Associate Professor of Surgery
University of Cincinnati

2. Disclosures
Paid Consultant for Ethicon Endo Inc.

3. Diverticulosis Prevalence USA < 40 years old - 5%
Diverticulitis affects 25% fo these patients

4. Laparoscopic Resection for Diverticulitis
benign disease
relatively common
technically challenging
numerous studies

5. 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

6. Laparoscopy for Diverticulitis
More than 100 studies published
Most single institution noncomparative
All comparative studies demonstrate:
Longer operative times minutes
Quicker return of bowel function days
Shorter hospital stay days

7. Laparoscopy for Diverticulitis
Large National US Database
Nationwide Inpatient Samples
709 (3.8%) laparoscopic sigmoid resections
17735 (96%) open sigmoid resections
Shorter mean LOS vs. 9.4 days
Fewer complications - 20% vs. 29%
More pts d/c to home - 91% vs. 71%
Guller, Arch Surg 2003;138:1179

8. Diverticulitis
Noel, JK et al. J Am Coll Surg Feb;204(2):

9. Colorectal Residents % Laparoscopic Resections
Schoetz, JACS, September 2006

10. Laparoscopy vs. Open
Gervaz et al. Ann Surg 2010

11. Laparoscopy vs. Open
Dwivedi at al. Dis Colon Rectum Oct;45(10):

12. Laparoscopy vs. Open
Dwivedi at al. Dis Colon Rectum Oct;45(10):

13. Factors Effecting Outcomes
Complicated vs Uncomplicated
Fistula
Stenosis
Diverticulitis vs diverticulosis
Experience – high volume vs low volume

14. Conversions
LeMoine et al. Br J Surg. 2003

16. Experience
Scheidbach et al. Dis Col Rect 2004

17. Experience
Jones et al. Ann Surg. 2008

18. Diverticulitis
Increasing experience with the acute management of perforated diverticulitis
Laparoscopic washout and drainage
Laparoscopic Hartmann’s Procedure
Laparoscopic resection with anastomosis

19. Acute Diverticulitis 68 Patients 16 Concurrent fistula 8 Phlegmons
Hinchey I: 27
HincheyII: 29
Hinchey III: 7
16 Concurrent fistula
8 Phlegmons
Titu at al. Colorectal Dis. 2009

20. Acute Diverticulitis Median OR time: 110mins (45-195) One Conversion
Postoperative Mortality: 3.3%
LOS: 5 days
Titu at al. Colorectal Dis. 2009

21. 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

22. Alternate Approach –Perf Tic
Medial
Good technique
Traction
Set it up
Help your partner
Set the clock

23. Alternate Approach –Perf Tic
Lateral
Good technique
Traction
Set it up
Stay in the plane
Watch the smoke
Stay oriented
Set the clock

24. Alternate Approach –Perf Tic
Lateral
Good technique
Traction
Set it up
Stay in the plane
Watch the smoke
Stay oriented
Set the clock

25. Laparoscopic Colectomy: Mastering the Complex Case
Alternate
Go open
Change extraction site
The approach – medial vs. lateral
The technique – put in a hand

26. 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

28. 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

29. Ureteral Catheters
No ureteral injuries in either group
Time to identify the ureter not stated
Wexner et al. Tech Coloproctol Mar;12(1):45-50

30. Complicated Diverticulitis: Alternatives to Conversion
Pfannenstiel incision after:
mobilization of splenic flexure
division of vascular pedicle
Hand-assisted laparoscopy
allows tactile sensation
blunt separation

31. Conclusion Complex case Experience counts Maximize chances
Approach
Extraction
HAL
+/- Ureteral catheters
Alternate approach early