Laparoscopic Surgery for Diverticular Disease

Steve Wexner

Powerpoint File

Introduction:
The resection of benign colonic disease employing a laparoscopic approach is now well-established. Laparoscopy for diverticulitis can be particularly challenging due to the profound inflammation that is frequently encountered. This inflammation obscures normal tissue planes rendering identification of normal anatomical structures such as the left ureter and the left internal iliac vein very difficult, placing them at increased risk of injury during the dissection.

The loss of tactile sensation and the inability to use digital blunt dissection add to the complexity of the laparoscopic procedure in diverticulitis patients. Finally, especially in the hands of the novice, the operation can take a long time. Despite these shortcomings, a number of publications have confirmed the feasibility and safety of laparoscopic or laparoscopic-assisted approaches in the treatment of diverticulitis. Moreover, the overall benefits of the laparoscopic procedure are frequently seen in appropriately selected patients.

Results:
Laparoscopy vs. laparotomy:
There are no prospective, randomized trials comparing the results of open and laparoscopic sigmoid colectomies for diverticular disease; however, there are a multitude of comparative, non-randomized reports, and retrospective reports that present impressive data. Purkayastha et al. (1) conducted a meta-analysis of non-randomized trials that compared laparoscopic to open surgery for diverticular disease. The meta-analysis included 12 comparative studies published between 1996 and 2004 which included 19,608 patients (1,192 had laparoscopic surgery and 18,416 had open surgery). Laparoscopic surgery resulted in reduced infective (p = 0.01), pulmonary (p < 0.001), gastrointestinal tract (p = 0.03), and cardiovascular complications (p = 0.0008). Operative time was longer with laparoscopic surgery (p = 0.04), and length of stay was significantly shorter (p < 0.0001). The authors concluded that in spite of a longer operative time, laparoscopy for diverticular disease reduces the overall complication rate, and shortens the hospital stay.
Cost:
Recently, Senagore et al. (2) reported their results comparing direct cost structure of elective open and laparoscopic resection for sigmoid diverticulitis. Sixty-one patients had a laparoscopic colectomy and 71 underwent open procedures. The operating time was similar (109min in the laparoscopic group vs. 101min in the open group) but the laparoscopic group had a significantly shorter length of stay and fewer pulmonary and wound complications. Conversion to open colectomy occurred in 6.6% of the patients, and readmission occurred in 3 (4.9%) laparoscopic and 4 (5.6%) open surgery patients. The mortality rate was 1.6% in the laparoscopic group and there was no mortality in the open colectomy group. Direct cost per case was significantly lower for laparoscopic procedures ($3,458 ± 437) than for open colectomies ($4321 ± 501; p<0.05). The authors concluded that laparoscopic colectomy is a cost–effective means of electively managing sigmoid diverticular disease.
Emergency:
Few authors have reported their experience with the use of laparoscopy in emergency settings. O’Sullivan et al (3) reported the use of laparoscopic peritoneal lavage in conjunction with parenteral fluids and antibiotic therapy in the management of 8 patients with generalized purulent peritonitis (Hinchey III) secondary to perforated diverticular disease. These patients were treated with laparoscopic peritoneal lavage and intravenous fluids and antibiotics, with complete recovery and resumption of normal diet within 5-8 days; during a 12-48 month follow-up, none of the patients required subsequent surgical intervention. Franklin et al (4) reported their experience treating 43 patients with acute complicated diverticulitis, including emergency cases. These patients included 8 with colonic diverticular perforation (Hartmann’s procedure in 6, omental patch closure in 2), 18 patients who underwent diagnostic laparoscopy with drainage and lavage only without resection, 4 patients with laparoscopic colonic resection for recurrent bleeding, 6 patients who underwent laparoscopic resection and reanastomosis for colonic fistula and finally, 7 patients who underwent laparoscopic resection and colostomy for colonic obstruction. The morbidity rate was 37% and there was no mortality. The authors felt that the laparoscopic approach led to improvement in postoperative patient status, decreasing the risk of wound infection, atelectasis, and the overall length of hospital stay in these patients. However, laparoscopy is not routinely indicated in emergency setting, and should be performed only in selected patients and by experienced surgeons.
Summary:
Laparoscopic management of sigmoid diverticular disease has emerged as an important adjunct to the armamentarium of surgical options for this disease process. Although there are no prospective randomized studies directly comparing laparoscopic and open colectomy for diverticulitis, the comparative studies provide compelling data. The magnitude of benefits achieved with laparoscopic colectomy in the hands of experienced laparoscopic colon surgeons has been routinely and repeatedly demonstrated.

References:

1. Purkayastha S, Constantinides VA, Tekkis PP, Athanasiou T, Aziz O, Tilney H, Darzi AW, Heriot AG. Laparoscopic vs. open surgery for diverticular disease: a meta-analysis of nonrandomized studies. Dis Colon Rectum. 2006; 49: 446-63.
2. Senagore AJ, Duepree HJ. Delaney CP, Dissanaike S, Brady KM, Fazio W. Cost structure of laparoscopic and open sigmoid colectomy for diverticular disease: similarities and differences. Dis Colon Rectum. 2002; 45: 485-490.
3. O’Sullivan GC, Murphy D, O’Brien MG, Ireland A. Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Am J Surg 1996; 17: 432-4.
4. Franklin ME Jr., Dorman JP, Jacobs M, Plasencia G. Is laparoscopic surgery to complicated colonic diverticular disease? Surg Endosc 1997; 11: 1021-5.