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.
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.
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.
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.
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SDS (@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 ligation.
SDS 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 E.R.; 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.
Salomone Di Saverio, Sandra Vennix, Arianna Birindelli, Dieter Weber, Raffaele Lombardi, Matteo Mandrioli, Antonio Tarasconi and Willem A. Bemelman have no conflicts of interest or financial ties to disclose.
Dr. Salomone Di Saverio, Dr. Sandra Vennix, Willem Bemelman and Elio Jovine are investigators of the LADIES trial (NCT01317485).
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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 30, 5656–5664 (2016) doi:10.1007/s00464-016-4869-y
- Acute diverticulitis
- Perforated diverticulitis
- Hinchey classification
- Faecal peritonitis
- Minimally invasive surgery
- Primary anastomosis
- Colorectal surgery