Geen diatitel

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Laparoscopic sigmoidectomy
WJHJ Meijerink MD PhD VUmc Amsterdam, NL
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Diverticulitis Diverticulose affects 1/3 of
population gt 45 yrs 10-25 of these patients
develops acute diverticulitis 1/3 of patients
with acute diverticulitis will have a
complicated diverticulitis Classification
according to Hinchey
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Diverticulitis Complicated diverticulitis
associated with significant morbidity and
mortality Majority of published literature
mortality 6-17 in complicated
diverticulitis mortality 22-39 in free
perforation or fecal peritonitis perforation
in 50-70 first manifestation of complicated
diverticulitis
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Diverticulitis Golden rule of diverticulitis Pr
ofylactic surgery to prevent complications of
recurrent diverticulitis after 2 episodes of
clinically documented diverticulitis, (1 episode
in young patients) Sequellae of conservative
treated acute diverticulitis (fistula, stenosis,
etc.) 1. All forms complicated diverticulitis
associated with increased morbidity and
mortality 2. Diverticulitis recurrent episodes
with increased risk of complicated
diverticulitis 3. All patients are at risk for
perforated diverticulitis 4. Risk of recurrent
diverticulitis and colostomy is eliminated with
elective surgery 1/3 of patients will develop
2nd episode 1/3 of them will develop a subsequent
episode Recurrent episodes thought to be
associated with increased risk of complications
and mortallity
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Diverticulitis Perforated diverticulitis high
mortality (up to 20-25) free perforation fecal
peritonitis All other forms of diverticulitis
perocolic abscess fistula obstruction phlegmo
n bleeding low mortality equal to elective
surgery (0 - 2.6) (Profylactic
sigmoidresection low mortality rate 1 -
2.4) But gt 50-70 of patients with perforated
diverticulitis no previous history and
recurrent diverticulitis after sigmoid resection
2.6 - 10.4 Reasons to rethink the
rules????? Chapman J et al. Ann Surg
2005 Kaiser AM. Ann Surg 2006
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• Elective sigmoid resection indications
• (Am Soc Colorect Surg)
• Hinchey I and II after percutaneous drainage of
  the abscess
• Young patients after one well documented
  episode of diverticulitis
• Elderly patients after two episodes of
  diverticulitis
• Diverticulitis with fistula (vagina, bladder or
  external)
• Diverticulitis with stenosis
• Diverticular disease with lower tract bleeding

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Diverticulitis surgery open or laparoscopic
Acute surgery depending from severity of
inflammatoir mass associated complications
(fistula, abscess) skills of surgeon
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Results elective laparoscopic resection
Author Patients Conversion OR time (min) H stay (days) Morbidity Mortality
Stevenson 100 8 180 min 4 days 21 0
Kockerling 304 7,2 ----------- ---------- 17 1,1
Berthou 110 8,2 167 min 8,2 days 7,3 --------
Trebuchet 170 4 141 min 8,5 days 8,2 0
Buillot 179 13,9 223 min ---------- 14,9 0
Schwandner 396 6,8 193 min 11,8 days 7,6 0,5
Le Moine 168 14,3 ----------- ----------- 21 0
Cuesta 101 12 210 min 9 days 16 0
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Results laparoscopic trials
author approach patients OR time (min) Hosp stay (days) morbidity
Dwivedi 2002 open 88 143 8.8 23
Dwivedi 2002 lap 66 212 4.8 16
Senagore 2002 open 71 101 6.8 30
Senagore 2002 lap 61 109 3.1 8
Gonzalez 2003 open 80 156 12 32
Gonzalez 2003 lap 95 170 7 19
Lawrence 2003 open 215 140 9 27
Lawrence 2003 lap 56 170 4,1 9
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Sigma-trial
Laparoscopic versus open elective sigmoid
resection in patients with symptomatic
diverticulitis. A prospective double blind multi
centre trial B.R. Klarenbeek, A.A.F.A. Veenhof,
W.T. van den Broek, D.L. van der Peet, E.S.M. de
Lange, W.A. Bemelman, R. Bergamaschi, P. Heres,
A.M. Lacy, M.A. Cuesta
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Sigma-trial
Laparoscopic Open P
Operating time (minutes) 192,50 139,16 0.0001
Blood loss (cc) 307,73 389,17 0,033
Transfusion needed 3,8 (2) 11,5 (6) 0,374
Conversion rate Hand-assisted 9,6 (5)
Laparotomy 9,6 (5)
Splenic flexure mobilisation 57,7 (30) 67,3 (35) 0,432
Protective ileostoma 3,8 (2) 1,9 (1) 0,558
Number of trocarts 3 1,9 (1)
4 69,2 (36)
5 21,2 (11)
Specimen length (cm) 20,68 20,44 0,876
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Sigma-trial
Laparoscopic Open P
Nasogastric tube in situ (days) Nasogastric tube in situ (days) Nasogastric tube in situ (days) Nasogastric tube in situ (days) 1,39 2,18 0,116
Re-insertion tube Re-insertion tube     7,7 (4) 7,7 (4) 1
Diet (days) Diet (days) Fluid Fluid 1,94 2,24 0,802
    Blend Blend 2,76 3,76 0,424
    Normal Normal 4,17 7,14 0,129
Hospital stay (days) Hospital stay (days)     8,45 10,75 0,046
Systemic analgesia (days) Systemic analgesia (days) Systemic analgesia (days) Systemic analgesia (days) 1,5 1,98 0,018
Minor complications       36,5 (19) 38,5 (20) 0,839
Major complications       9,6 (5) 25 (13) 0,038
Late complications       7,7 (4) 19,2 (10) 0,085
Death       0 (0) 1,9 (1) 0,315
Type of operation according to patient Type of operation according to patient Type of operation according to patient Type of operation according to patient 32,3 right (10) 58,3 right (21) 0,427
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Sigma-trial
Minor complications
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Sigma-trial
Major complications
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Sigma-trial

• Less major complications
• Shorter hospital stay
• Less pain
• Better SF-36 scores
• Limitations due to physical health
• Limitations due to emotional problems
• Social functioning
• Pain
• Less bloodloss
• Longer operating time

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Patient position
(mild) supine Loyd Davis position vacuum
mattress and gel pad Stir-ups arms aside
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Position team
Position varies during surgery
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Position trocars

• 1 10 mm trocar camera
• 5 mm trocar working instrument
• 10-12 mm trocar working instrument / stapler
• 5 mm trocar optional, at the level of the
  incision

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1
2
4

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Essential choices Oncologic vs benign
(diverticulitis) Medial vs lateral
approach Vascularisation
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• Essential choices
• Oncologic benign (diverticulitis)
• medial approach lateral or medial
• ligation at origin of vessels close to bowel
• a. mes. inf. a. sigmoidea
• a. sigmoidea
• a. colica sinistra
• Ultracision, ligasure, staplers ligasure

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Mobilisation of splenic flexure Not always
necessary enough length tension free But
standard mobilisation 15-20 min extra
time experience never doubt about length /
tension Full mobilisation medial
approach Partial mobiliation lataral approach
incl. omentum!
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Sigmoidectomy
Stay out of trouble Left ureter Spleen
Pancreatic tail Promotory plexus Vascularisation
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• 1 pull omentum over stomach
• 2 small bowel to right
• open left mesocolon
• at level of v. mes. inf.
• 4 mobilise mesocolon
• 5 lateral peritoneum

1
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• 1 pull omentum over stomach
• 2 small bowel to right
• open left mesocolon
• at level of v. mes. inf.
• 4 mobilise mesocolon
• 5 lateral peritoneum

1
2
Treiz
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• 1 pull omentum over stomach
• 2 small bowel to right
• open left mesocolon
• at level of v. mes. inf.
• 4 mobilise mesocolon
• 5 lateral peritoneum

1
3
2
3
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• 1 pull omentum over stomach
• 2 small bowel to right
• open left mesocolon
• at level of v. mes. inf.
• 4 mobilise mesocolon
• 5 lateral peritoneum

1
x
3
2
3
4
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• 1 pull omentum over stomach
• 2 small bowel to right
• open left mesocolon
• at level of v. mes. inf.
• 4 mobilise mesocolon
• 5 lateral peritoneum

1
x
2
3
4
5
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• Benign disease
• Close to bowel
• free lateral attachments
• Transsect proximal or distal margin
• Cut halfway between major vessels and bowel

a.colica sinistra
a. Rectalis sup
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Distale marge Proximale marge
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Distale marge Overgang rectum -
sigmoid Teniae! Indien recidief diverticulitis,
bijna altijd onvoldoende distale
marge Proximale marge Moeilijker te bepalen Op
overgang naar soepele deel colon Niet streven
naar volledige resectie divertikels
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• Benign disease
• Close to bowel
• free lateral attachments
• Transsect proximal or distal margin
• Cut halfway between major vessels and bowel
• Lower left quadrant incision
• Transsection of the proximal segment
• Insertion of circular stapler
• Close wound and restore pneumoperitoneum
• Intracorporal anastomosis

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Take home message Laparoscopy can be safely
used in elective setting Mobilisation of splenic
flexure Medial vs lateral Adequate (distal)
resection margins