1. Sigmoid Diverticular Disease
Yair Edden, MD
Department of Surgery
Shaare-Zedek Medical Center
The Hebrew University School of Medicine
Jerusalem, Israel

2. Nomenclature
Diverticulum = sac-like protrusion of the colonic wall
Diverticulosis = describes the presence of diverticuli
Diverticulitis = inflammation of diverticuli

3. Nomenclature
True Diverticulum = all layers of the GI wall (mucosa to serosa) e.g. Appendix, Meckel, Congenital
False/Pseudo Diverticulum = Mucosa-submucosa herniates through the muscle layer (muscularis propria) and then is only covered by serosa e.g. Acquired pathology

4. Epidemiology- Sigmoid diverticulosis
Before the 20th century, diverticular disease was rare
Prevalence has increased over time
First reported resection of complicated
diverticulitis by Mayo % %

5. Epidemiology- Sigmoid divericulosis
Increases with age:
Age 40 <5%
Age %
Age %
Younger patients are diagnosed frequently

6. Endoscopic appearance

7. Double contrast Barium enema

8. CT Scan

9. CT Scan

10. From out side…

11. Anatomic location of diverticuli varies with the geographic location
“Westernized” nations have predominantly left sided diverticulosis
95% diverticuli are in sigmoid colon
35% can also have proximal diverticuli
4% have only right sided diverticuli

12. Anatomic location of diverticuli varies with the geographic location
Asia and Africa diverticulosis in general is rare and usually right sided
Prevalence < 0.2%
70% diverticuli in right colon in Japan

13. Pathophysiology
Diverticuli develop in ‘weak’ regions of the colon. Specifically, local hernias develop where the vasa recta penetrate the bowel wall

14. Pathophysiology Law of Laplace:
Pressure = K x Tension / Radius
Sigmoid colon has the smallest diameter resulting in highest pressure zone

15. Pathophysiology
Segmentation = motility process in which the segmental muscular contractions separate the lumen into chambers
Segmentation  increased intraluminal pressure  mucosal herniation  Diverticulosis
May explain why high fiber prevents diverticuli by creating a larger diameter colon and less vigorous segmentation

16. Pathophysiology

17. Lifestyle factors associated with diverticular disease
Low fiber  diverticular disease
Not absolutely proven in all studies but strongly suggested
Western diet is low in fiber with high prevalence of diverticulosis
In contrast, African diet is high in fiber with a low prevalence of diverticulosis

18. Lifestyle factors associated with diverticular disease
Obesity associated with diverticulosis – particularly in men under the age of 40
Lack of physical activity

19. Lifestyle factors associated with diverticular disease
Do patients need to avoid foods with seeds or nuts?

20. Lifestyle factors associated with diverticular disease
NO!

21. In most cases diverticular disease is a-symptomatic

22. A-symptomatic diverticulosis
Considered ‘a-symptomatic’
However, some patients will complain of cramping, bloating, irregular BMs, narrow caliber stools
Confused with IBS
Recent studies demonstrate motility abnormalities in patients with ‘a-symptomatic’ uncomplicated diverticulosis

23. Diverticulitis Diverticulitis = inflammation of diverticuli
Most common complication of diverticulosis
Occurs in 10-25% of patients with diverticulosis

24. Diverticulitis Subclinical inflammation to generalized peritonitis
Micro or macroscopic perforation of the diverticulum
Subclinical inflammation to generalized peritonitis
Previously thought to be due to fecaliths causing
increased diverticular pressure; this is really rare

25. Diverticulitis intraluminal pressure Inflammation
Erosion of diverticular wall from increased
intraluminal pressure
Inflammation
Focal necrosis
Perforation
Usually inflammation is mild and microperforation is
walled off by peri-colonic fat and mesentery

26. Diagnosis of Diverticulitis
Classic history: increasing, constant, LLQ abdominal
pain over several days prior to presentation with fever
Crescendo quality – each day is worse
Constant – not colicky
Fever occurs in % of cases

27. Diagnosis of Diverticulitis
Previous episodes of similar pain
Associated symptoms
Nausea/vomiting %
Constipation 50%
Diarrhea %
Urinary symptoms (dysuria, urgency, frequency) 10-15%

28. Diagnosis of Diverticulitis
Diagnosis can be made with typical history and
examination
Radiographic confirmation (CT) is often… (100%)
performed
Rules out other causes of an acute abdomen
Determines severity of the diverticulitis

29. CT Scan

30. CT Scan

31. Simple vs. Complicated Diverticulitis
Complicated diverticulitis = Presence of
macroperforation, obstruction, abscess or fistula
Simple diverticulitis = Absence of the above
complications

32. Simple vs. Complicated Diverticulitis
Complicated diverticulitis = Presence of
macroperforation, obstruction, abscess or fistula
Simple diverticulitis = Absence of the above
complications

33. Simple Diverticulitis
Hospitalization !?

34. Simple Diverticulitis
IV Antibiotics
Bowel rest, clear liquids for 2-3 days
Based on clinical findings advance diet (low residue)
and PO antibiotics

35. Simple Diverticulitis
After resolution of attack - high fiber diet
with supplemental fiber

36. Simple Diverticulitis
Follow-up: Colonoscopy in 4-6 weeks
Purpose
Exclude neoplasm
Evaluate extent of the diverticulosis

37. Simple Diverticulitis
Prognosis after resolution
30-40% of patients will remain asymptomatic
30-40% of patients will have episodic abdominal
cramps without frank diverticulitis
20-30% of pts will have a second attack

38. Simple vs. Complicated Diverticulitis
Complicated diverticulitis = Presence of
macroperforation, obstruction, abscess or fistula
Simple diverticulitis = Absence of the above
complications

39. Complicated Diverticulitis
Hinchey classification
Pericolic abscess
Distal abscess
Purulent peritonitis
Fecal peritonitis
Hinchey EJ et al. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978

40. Complicated Diverticulitis
Hinchey classification
Pericolic abscess
Distal abscess
CT guided drainage

41. Complicated Diverticulitis
Hinchey classification
3. Purulent peritonitis
4. Fecal peritonitis
Surgery

42. Complicated Diverticulitis
Hartman’s Procedure

43. Complicated Diverticulitis
Other clinical presentation
Bleeding
Stricture
Fistula

44. Complicated Diverticulitis
Other clinical presentation
Bleeding

45. Complicated Diverticulitis

46. Complicated Diverticulitis

47. Complicated Diverticulitis
Most only have symptoms of bloating and diarrhea but no significant abdominal pain
Painless hematochezia
Start – stop pattern; “water faucet”
Diverticulitis rarely causes bleeding
Right > Left

48. Complicated Diverticulitis
Other clinical presentation
Stricture

49. Complicated Diverticulitis
Chronic inflammation
Bloating
Constipation

50. Complicated Diverticulitis
Other clinical presentation
Stricture
Surgery

51. Complicated Diverticulitis
Other clinical presentation
Fistula

52. Complicated Diverticulitis
Chronic inflammation
Small Bowel
Bladder
Vagina (s/p Hysterectomy)
Retro – peritoneum

53. Complicated Diverticulitis
Other clinical presentation
Fistula
Surgery

54. Re-operative Surgery for Crohn’s Disease

55. What Will Be Your Approach?
Open vs. Lap.?

56. Re-operative Surgery For Crohn’s Disease

57. Re-operative Surgery For Crohn’s Disease

58. Re-operative Surgery For Crohn’s Disease
Sometimes it looks like this:

59. Re-operative Surgery For Crohn’s Disease

60. So, Why Bother? Less pain Shorter stay
Less morbidity compared with open ?!
Faster return to normal activity
Immunologic & metabolic benefits
Adhesion formation, reduced SBO
Lower recurrence in Crohn’s ?
Cosmesis

61. Anticipated Problems 1 Port of entry & pneumoperitoneum
Adhesions & limited exposure
Anatomical orientation due to previous resection / procedure

62. Anticipated Problems 2 Identification of pathology
Potential Intra-operative complications (bleeding, enterotomies, adjacent organs i.e. ureter)

63. How to Avoid the Pitfalls
Get complete information & understanding of the previous procedure
Plan surgical strategy: Port sites position, complete Lap, Lap assisted, hand assisted

64. How to Avoid the Pitfalls
Positioning: both arms tucked in, Lithotomy - team positioning flexibility
Room setup: 2 TV monitors!

65. How to Avoid the Pitfalls
(Technical Considerations)
Open technique for insufflation
First port placement away from scars
(a-traumatic Trocars / Visual ports)
Finger adhesiolysis (to create initial work space)
Angled scope – only!
A-traumatic intestinal graspers & dissectors

66. How to Avoid the Pitfalls
(Technical Considerations)
Adhesiolysis and additional port placement
Reestablish / confirm Anatomy
Identify pathology (tattoo in CRC, IOUS for solid organs)
Urethral stents (depending procedure)
HALS?
Sound judgment & low threshold for conversion

67. Re-operative Laparoscopic Colorectal Surgery
Our Experience
1443 Lap. Colorectal procedures Oct Oct. 2010
42 Reop (2.8%) :
31 IBD (27 Rec Crohn’s, 4 UC) Rec. CRC
4 Benign disease
26M, 16F, 21-79y old
1-13y - time from last procedure

68. Re-operative Laparoscopic Colorectal Surgery
Our Experience
37 prev. open procedure (5 pts. 2-4) 5 prev. lap. procedure
Procedures:
Ileocolic resection 22
Small bowel resection 11
Strictureplasty 5
Segmental colectomy 9
Comp. proctectomy IAP 4

69. Re-operative Laparoscopic Colorectal Surgery
Our Experience
Results:
Conversion rate 12% (n=6) exposure & adhesions bleeding - 1
Morbidity 19% (n=8): prolonged ileus - 6 post op intestinal bleeding - 2 (1 relaparotomy)
LOS mean 9 (6-21) days

70. The Role of Re-operative Laparoscopic Surgery
Literature Review

71. Re-operative Laparoscopic Surgery
Anti reflux
Colorectal (IBD mostly Crohn’s disease, CRC)
Morbid obesity
SBO (adhesion related)

72. Re-operative Laparoscopic Surgery For Crohn’s Disease
70 – ileocolic resection
28/70 – previous ileocolic resection
1 – conversion ( in redo group)
7- complications (leak, stricture, hemorrhage, PE, SBO, line sepsis, UTI) all in primary group
Canin J, Salky B, Edye M Surg Endosc

73. Re-operative Laparoscopic Surgery For
Crohn’s Disease
Conclusion: Experience required for successful laparoscopic management in complicated Crohn’s
Canin J, Salky B, Edye M Surg Endosc

74. Re-operative Laparoscopic Resection for
Crohn’s Disease
23 patients underwent laparoscopic reoperation for recurrent Crohn’s.
Conversion rate - 69% (n=16(
Complication, length of operation were the same
Uchikoshi et al, Surg Endosc October 2004

75. Laparoscopic Assisted Ileocolic Resection
for Crohn’s Disease
168 laparoscopic-assisted ileocolic resections. 78.4% (n=124) redo
Previous resection was not a predictor of conversion to laparotomy
Edden Y. et al. JSLS 2008

76. Laparotomy vs. Laparoscopy?
Major Complication post Laparoscopic Surgery Requiring Re-Exploration
Laparotomy vs. Laparoscopy?

77. Is a Laparoscopic Approach Useful for Treating Complication After Primary Laparoscopic Colorectal Surgery?
510 patients
5.2% reoperation (n=27)
65% anastomotic leak (n=15)
Lap. approach 17 pts. (13/17 anast leak)
Open approach 10 pts. (2/10 anast leak)
Rotholz NA, Laporte M, et al. Dis Colon Rect 2009

78. Is a Laparoscopic Approach Useful for Treating Complication After Primary Laparoscopic Colorectal Surgery?
Results: LOS d vs. 18d (P=NS) Complications 1/17 vs. 3/10 (P=NS)
Rotholz NA, Laporte M, et al. Dis Colon Rect 2009

79. Reoperation Following Minimally Invasive Surgery:
Are the ‘Rules’ Different?
Trocar sites are the most common cause of bowel obstruction in the early post operative period
McCormick JT.& Simmang CL. Clin Colon Rectal Surg 2006

80. Concluding Comments
Results comparable/similar to primary laparoscopic resection
Late in the learning curve, experienced team
Patients selection

81. Concluding Comments Expect higher conversion and longer OR time
Surgeon’s sound judgment to ensure patients safety

83. LAP HAND ASSISTED RIGHT COLECTOMY

85. SURGICAL INSTRUMENTS AND EQUIPMENT
Angled scope
Intestinal Graspers & Dissectors
Tissue and Vascular division:
Harmonic Scalpel (LCS)
Ligasure
Endo Staplers
Endoclips

86. Lap assisted ileocolic resection in Crohn’s dis.:
are phlegmons, abscess or recurrent disease a contraindication?
46 pts. lap
Group 1 : 14 inlam mass
Group 2 : 10 recurrence after prev resection
Group 3 : 22 none of above
Group 4 :70 pts. Open
Conclusion: inlam mass, prev resection – not contraindication
Gr 4
Gr 3
Gr 2
Gr 1
245 cc
195 cc
131 cc
151 cc
blood loss
21%
15%
10% 0%
morbidity 2 1
conversion
Wu J, Fleshman J, 1997 Surgery

87. LAPAROSCOPIC SURGERY FOR RECURRENT CROHN’S DIS.
61 laparoscopic procedures,26.2% (n=16)
redo
No differences in the rate of postoperative
complications
Hasegawa H. et al. Br J Surg 2003