Perioperative management - Sigmoidectomy, laparoscopic - general and visceral surgery
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Indications
The current S2k guideline on diverticular disease/diverticulitis of the German Association of Gastroenterology, Digestive and Metabolic Disorders (DGVS) and the German Society of General and Visceral Surgery (DGAV) from 2013 lists the following indications for sigmoidectomy:
- Acute uncomplicated diverticulitis (type 1a and 1b) not responding to conservative management
- Patients with successfully managed uncomplicated diverticulitis, but at risk for recurrence and complications (e.g., transplantation, immunosuppression, chronic systemic glucocorticoids, collagenosis, diabetes, chronic kidney disease)
- Acute complicated diverticulitis (type 2a and 2b) without response to adequate conservative therapy (i.v. antibiotics, possibly percutaneous abscess drainage) àurgent surgery
- Successfully managed complicated diverticulitis with gross perforation/abscess (type 2b) àelective surgery after successful control of the inflammation
- Patients with diverticular abscess not amenable to percutaneous drainage or not responding to conservative treatment within 72h
- Acute complicated diverticulitis (type 2c) with free-air perforation and fecal peritonitis àemergency surgery
- Postdiverticular stenosis with obstruction of fecal passage mandating surgery àdepending on clinical findings either emergent, urgent, scheduled or elective
- Fistula formation, especially in urinary tract fistulas (risk of urosepsis)
- Chronic recurrent, uncomplicated diverticulitis (type 3b) depending on individual complaints and only after careful risk assessment àelective surgery after successful control of the inflammation
- Diverticular bleeding (type 4)
In case of clearly identifiable diverticular bleeding, the corresponding segment of the colon should be resected. In case of diverticular bleeding from the sigmoid, standard sigmoidectomy should be performed.
- Acute bleeding not manageable by endoscopy/intervention
- Recurrent clinically significant bleeding after individual risk-benefit assessment of the patient
Laparoscopic/laparoscopically-assisted surgery is preferred over open resection. This also applies to complicated diverticulitis as well as emergencies, where the operation should at least be started as a minimally invasive procedure. Adequate expertise is mandatory.
The valid classification of diverticular disease/diverticulitis according to the current guidelines may be found here : Review of current classifications for diverticular disease and a translation into clinical practice
Contraindications
- General contraindications for laparoscopic procedures (e.g., intolerance of pneumoperitoneum, extreme patient positioning or presence of ileus)
- Generalized peritonitis
Previous abdominal operations and intestinal adhesions are not necessarily a contraindication for laparoscopic procedures, but may justify conversion to open surgery
Preoperative diagnostic work-up
Emergency diagnostic work-up
- Physical examination
- Laboratory studies (inflammation parameters)
- Abdominal ultrasonography
- Abdominal CT imaging (with oral and rectal contrast enhancement)
Additional diagnostic work-up in elective surgery
- Total colonoscopy
- Possibly sphincter manometry
- Virtual colonoscopy, if endoscopy is unsuccessful/impossible
Special preparation
- Oral colonic lavage with antibiotics
- Shaving of the abdominal wall
- Marking the best location for a possible stoma on the abdominal wall
In the operating room:
- Foley catheter
- Single shot antibiotics (e.g., cefotaxime + metronidazole)
- Trial positioning after mounting the patient supports on the OR table
Informed consent
- Bleeding/ secondary bleeding with need for allogeneic blood transfusion and possible revision surgery
- Anastomotic failure with local or generalized peritonitis and subsequent sepsis, reoperation, Hartmann procedure, and construction of a protective ileostomy
- Intraabdominal abscess formation
- Injury to: Left ureter, iliac vessels, internal genitals (in women), bladder, spleen, kidney, pancreas
- Primary protective ileostomy or primary Hartmann operation
- Conversion
- Changes in bowel habits
- Trocar site incisional hernia
- Risk of stapler injury to the sphincter
Anesthesia
Positioning
Operating room setup
Special instruments and fixation systems
Postoperative management
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