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Pushing the envelope: laparoscopy and primary anastomosis are technically feasible in stable patients with Hinchey IV perforated acute diverticulitis and gross faeculent peritonitis.
Surg Endosc. 2016 12; 30(12):5656-5664.SE

Abstract

INTRODUCTION

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 colectomy.

TECHNIQUE

Provided 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 large-size 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 mini-Pfannenstiel incision with muscle splitting technique. Transanal colo-rectal anastomosis is fashioned. Air-leak test must be performed and drains placed where appropriate.

RESULTS

The video shows operative technique for a single-stage, entirely laparoscopic, washout and sigmoid colectomy with primary colorectal anastomosis in a 35-year-old male patient with severe and diffuse free faeculent diverticular peritonitis (Hinchey IV). The patient was managed post-operatively according to enhanced recovery protocol and discharged home after 9 days, following an uneventful recovery.

CONCLUSIONS

This case documents the technical feasibility of a minimally invasive single-stage 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 mini-Pfannenstiel incision, and a laparoscopic intracorporeal transanal circular primary anastomosis performed.

Authors+Show Affiliations

General Surgery and Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center - AUSL Bologna Local Health District, Bologna, Italy. salo75@inwind.it.Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands.General Surgery and Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center - AUSL Bologna Local Health District, Bologna, Italy.Royal Perth Hospital, Perth, Australia.General Surgery and Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center - AUSL Bologna Local Health District, Bologna, Italy.General Surgery and Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center - AUSL Bologna Local Health District, Bologna, Italy.General Surgery and Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Regional Emergency Surgery and Trauma Center - AUSL Bologna Local Health District, Bologna, Italy.Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands.

Pub Type(s)

Case Reports
Journal Article
Video-Audio Media

Language

eng

PubMed ID

27005295

Citation

Di Saverio, Salomone, et al. "Pushing the Envelope: Laparoscopy and Primary Anastomosis Are Technically Feasible in Stable Patients With Hinchey IV Perforated Acute Diverticulitis and Gross Faeculent Peritonitis." Surgical Endoscopy, vol. 30, no. 12, 2016, pp. 5656-5664.
Di Saverio S, Vennix S, Birindelli A, et al. Pushing the envelope: laparoscopy and primary anastomosis are technically feasible in stable patients with Hinchey IV perforated acute diverticulitis and gross faeculent peritonitis. Surg Endosc. 2016;30(12):5656-5664.
Di Saverio, S., Vennix, S., Birindelli, A., Weber, D., Lombardi, R., Mandrioli, M., Tarasconi, A., & Bemelman, W. A. (2016). Pushing the envelope: laparoscopy and primary anastomosis are technically feasible in stable patients with Hinchey IV perforated acute diverticulitis and gross faeculent peritonitis. Surgical Endoscopy, 30(12), 5656-5664.
Di Saverio S, et al. Pushing the Envelope: Laparoscopy and Primary Anastomosis Are Technically Feasible in Stable Patients With Hinchey IV Perforated Acute Diverticulitis and Gross Faeculent Peritonitis. Surg Endosc. 2016;30(12):5656-5664. PubMed PMID: 27005295.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Pushing the envelope: laparoscopy and primary anastomosis are technically feasible in stable patients with Hinchey IV perforated acute diverticulitis and gross faeculent peritonitis. AU - Di Saverio,Salomone, AU - Vennix,Sandra, AU - Birindelli,Arianna, AU - Weber,Dieter, AU - Lombardi,Raffaele, AU - Mandrioli,Matteo, AU - Tarasconi,Antonio, AU - Bemelman,Willem A, Y1 - 2016/03/22/ PY - 2015/12/17/received PY - 2016/03/09/accepted PY - 2016/3/24/pubmed PY - 2017/7/18/medline PY - 2016/3/24/entrez KW - Acute diverticulitis KW - Colorectal surgery KW - Colostomy KW - Faecal peritonitis KW - Hinchey classification KW - Laparoscopy KW - Minimally invasive surgery KW - Perforated diverticulitis KW - Peritonitis KW - Primary anastomosis SP - 5656 EP - 5664 JF - Surgical endoscopy JO - Surg Endosc VL - 30 IS - 12 N2 - INTRODUCTION: 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 colectomy. TECHNIQUE: Provided 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 large-size 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 mini-Pfannenstiel incision with muscle splitting technique. Transanal colo-rectal anastomosis is fashioned. Air-leak test must be performed and drains placed where appropriate. RESULTS: The video shows operative technique for a single-stage, entirely laparoscopic, washout and sigmoid colectomy with primary colorectal anastomosis in a 35-year-old male patient with severe and diffuse free faeculent diverticular peritonitis (Hinchey IV). The patient was managed post-operatively according to enhanced recovery protocol and discharged home after 9 days, following an uneventful recovery. CONCLUSIONS: This case documents the technical feasibility of a minimally invasive single-stage 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 mini-Pfannenstiel incision, and a laparoscopic intracorporeal transanal circular primary anastomosis performed. SN - 1432-2218 UR - https://www.unboundmedicine.com/medline/citation/27005295/Pushing_the_envelope:_laparoscopy_and_primary_anastomosis_are_technically_feasible_in_stable_patients_with_Hinchey_IV_perforated_acute_diverticulitis_and_gross_faeculent_peritonitis_ L2 - https://dx.doi.org/10.1007/s00464-016-4869-y DB - PRIME DP - Unbound Medicine ER -