Authors: Salomone Di Saverio Sandra Vennix Arianna Birindelli Dieter Weber Raffaele Lombardi Matteo Mandrioli Antonio Tarasconi Willem A Bemelman
Publish Date: 2016/03/22
Volume: 30, Issue: 12, Pages: 5656-5664
Abstract
Modern management of severe acute complicated diverticulitis continues to evolve towards more conservative and minimally invasive strategies Although open sigmoid colectomy with end colostomy remains the most commonly used procedure for the treatment of perforated diverticulitis with purulent/faeculent peritonitis recent major advances challenged this traditional approach including the increasing attitude towards primary anastomosis as an alternative to end colostomy and use of laparoscopic approach for urgent colectomyProvided an accurate patients selection having the necessary haemodynamic stability pneumoperitoneum is established with open Hasson technique and diagnostic laparoscopy is performed If faeculent peritonitis Hinchey IV perforated diverticulitis is found laparoscopy can be continued and a further three working ports are placed using bladeless trocars as in traditional laparoscopic sigmoidectomy with the addition of fourth trocar in left flank The feacal matter is aspirated either with largesize suction devices or in case of free solid stools these can be removed with novel application of tight sealing endobags which can be used for scooping the feacal content out and for its protected retrieval After decontamination a sigmoid colectomy is performed in the traditional laparoscopic fashion The sigmoid is fully mobilised from the retroperitoneum and mesocolon is divided up to the origin of left colic vessels Whenever mesentery has extremely inflamed and thickened oedematous tissues an endostapler with vascular load can be used to avoid vascular selective ligatures Splenic flexure should be appropriately mobilised The specimen is extracted through miniPfannenstiel incision with muscle splitting technique Transanal colorectal anastomosis is fashioned Airleak test must be performed and drains placed where appropriateThe video shows operative technique for a singlestage entirely laparoscopic washout and sigmoid colectomy with primary colorectal anastomosis in a 35yearold male patient with severe and diffuse free faeculent diverticular peritonitis Hinchey IV The patient was managed postoperatively according to enhanced recovery protocol and discharged home after 9 days following an uneventful recoveryThis case documents the technical feasibility of a minimally invasive singlestage procedure in a patient with Hinchey IV perforated diverticulitis with diffuse feacal peritonitis The laparoscopic approach facilitated an effective decontamination of the peritoneal cavity with a combination of large suction devices and aid of protected retrieval by closed endobags for effectively and completely laparoscopic removal of the solid feacal matter offering clear advantages and excellent results even in such challenging cases With necessary expertise the sigmoid resection can be thereafter safely and entirely performed laparoscopically the specimen extracted through miniPfannenstiel incision and a laparoscopic intracorporeal transanal circular primary anastomosis performedThis video and the topic of this paper have been partially presented by Dr Salomone Di Saverio MD at the 16th Congress of Trauma and Emergency Surgery in Amsterdam the Netherlands as invited Keynote speaker on “Feasibility of laparoscopy in Hinchey IV perforated diverticulitis” during the Session “Infection” on 12 May 2015 as well as during an invited Keynote speech entitled “Laparoscopy for Colorectal Emergencies” at the XIII Meeting of the Minimally Invasive and Innovation Surgery section of the Spanish Association of Surgeons in Alicante Spain on 15 May 2015SDS salo75 would like to acknowledge the merit of Prof Elio Jovine MD Head of the Department of Surgery at Maggiore Hospital of Bologna in promoting the spreading use of laparoscopy in Acute Care Surgery and in “pushing the envelope” with the most challenging laparoscopic cases Finally the authors would like to acknowledge the skills of Dr Serena Galli TSRM professional artwork designer serenitudine for manually drawing Fig 1 showing the anatomy of the levels of proximal and distal colonic resection according to the site of the vascular mesenteric ligationSDS wrote the manuscript SDS AB RL SV and DW revised and edited the manuscript and its intellectual content SDS admitted and managed the patient in ER SDS operated on the patient as the operating attending surgeon SDS AB RL AT and MM edited the video and the images SDS SV AB DW RL MM AT and WB revised critically the manuscript and the video for technical and intellectual content all Authors reviewed and approved the final draft of the manuscript
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