Surgery for complicated diverticulitis. Another lesson learned from the past

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CASE:

A 53-year-old male with no relevant history came to the emergency room claiming that he had been suffering from abdominal pain for the last 15 days. It was located mostly at the lower abdomen, and in the last few days the patient had developed a fever.

Physical examination revealed tenderness and pain at the left lower abdomen, and the laboratory results were 9.9 X 103 mm3 WBC with a RCP of 14 millligrams by decalitre.

A CT Scan was ordered and a thickened sigmoid colon with several diverticula was found; this was accompanied by a bi-lobar collection smaller than 5cm that was in contact with a portion of small bowel (also inflamed). No free liquid or pneumoperitoneum was found.

TREATMENT:

The patient was admitted to the hospital and underwent conservative therapy with close follow up. The clinical course was favorable and he was discharged. One month later, while awaiting a colonoscopy, the acute diverticulitis relapsed twice, requiring readmission.

Once again, antibiotics and nutritional support were administered. The CT Scan revealed similar findings to those in the previous episode. A sigmoidoscopy was carried out. There were no mucosal lesions and a biopsy ruled out IBD.

Laparoscopic surgical treatment was provided, as this was a complicated case of acute diverticulitis with various readmissions in a short period of time. The patient was placed in the supine position with open legs. The leading surgeon stood to the right of the patient with one assistant on each side of the patient.

A total of 4 trocars were used. A 12 mm port was placed at the umbilicus for a 30o scope. Two working ports  were placed for the leading surgeon, a 5mm port at the right flank and a 12mm port at the right iliac fossa. The last was a 5 mm  trocar on the left flank for the assistant surgeon.

A loop of small bowel was attached to the sigmoid colon, the first maneuver was to individualize it. We recommend using scissors to dissect and avoid unexpected thermal injuries. There were many inflammatory changes. The tissues were fused and delicate the abscess was located and drained this is a laborious phase of the surgery and the surgeon must be patient.

Changing the approach to a mobilization of the small bowel from the pelvis made it possible to progress using blunt dissection and the scissors the surgeon lifted the small bowel to expose the plane with his left hand while dissecting with the right hand. This strategy made it possible to mobilize a large amount of the compromised bowel. Now a medial approach was taken by accommodating the gut towards the right of the patient. Cranial traction made it possible to identify a correct plane.

Placing a gauze is helpful to clarify the planes if individualization is not possible the surgeon must consider resection of the small bowel. In this case it was not necessary the next goal of the surgery is to mobilize the sigmoid colon. The hook was used to accomplish a lateral to medial dissection.

The surgeon performed traction of the colon with its left hand, exposing the avascular plane. The colon and its mesentery were fragile. The surgeon decided to perform blunt dissection close to the sigmoid-rectal junction this created a tunnel to pass a ribbon and achieve traction and more secure dissection.

Thanks to the lateral mobilization a small window was identified a the mesenterium above the IMV it was opened, connecting both dissections this made it possible to identify the ureter and the gonadal vessels in order to respect them. Suction can be used to verify that the mesentery has been correctly individualized, exposing the IMV a grey EndoGIA? was used to section it.

The sigmoid colon was redundant and was attached to the pelvis. Mobilization was carefully performed using the scissors and suction. Remember that at this point the surgeon must be aware of the ureter and the iliac vessels.

Once the plane was clear the LigaSure? was used to complete the individualization of the colon and to prepare the colon for further division. At this phase the assistant surgeon performed cranial traction of the colon and exposed its posterior wall a blue cartridge of EndoGIA? was used to section the colon just below the rectosigmoid junction. Lateral mobilization was completed, releasing a sufficient amount of colon to perform a tension free anastomosis. Splenic flexure mobilization was not required.

A small Pfannenstiel incision was made and a protective bag was placed. The colon was exteriorized and the proximal margin was sectioned. The anvil was settled and reintroduced into the abdominal cavity.

Pelvic lavage was carried out before the anastomosis was created. Introduction of the mechanical suture through the rectal stump was difficult. To prevent it from breaking, the trocar was exteriorized through the anterior rectal wall.

The anvil was attached to create the anastomosis. We always check that the colon is tension free and untwisted.

A couple of Vicryl knots were made, involving the lateral aspects of the anastomosis, to release tension. Finally a drain was placed for postoperative surveillance

OUTCOME:

Surgery took 155 minutes, with no conversion to open approach, vascular or urological lesions. Oral intake started on the 3rd postoperative day; there were no leaks or collections. The patient was discharged 6 days after the surgery. Pathological examination ruled out neoplasia and Crohn`s disease. The last follow up took place 6 years after the procedure and there was no relapse or chronic complications.

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