Perioperative management - Sigma resection, laparoscopic

According to the current S2k guideline on diverticular disease/diverticulitis by the German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS) and the German Society for General and Visceral Surgery (DGAV) from 2013, the following indications for a sigmoid resection exist:

• Acute uncomplicated diverticulitis (Type 1a and 1b) with no response to conservative treatment
• After successfully treated uncomplicated diverticulitis in patients with risk factors for recurrence and complications (e.g., transplantation, immunosuppression, chronic systemic glucocorticoids, collagen diseases, diabetes mellitus, chronic renal insufficiency), an indication for surgery may exist.
• Acute complicated diverticulitis (Type 2a and 2b) with no response to adequate conservative therapy (IV antibiotics, possibly interventional abscess drainage) -> surgery with deferred urgency
• Successfully treated complicated diverticulitis with macroperforation/abscess (Type 2b) -> surgery in the inflammation-free interval
• Patients with diverticulitis-related abscesses that are not amenable to interventional drainage or whose clinical condition does not respond to conservative therapy within 72 hours.
• Patients with free perforation and peritonitis in acute complicated diverticulitis (Type 2c) -> emergency surgery
  • Post-diverticulitis stenosis with treatment-relevant obstruction of stool passage -> depending on clinical findings, urgent, early elective, or elective
  • Fistula formations, especially with fistulas to the urinary tract (risk of urosepsis)
• Chronic recurrent uncomplicated diverticulitis (Type 3b) only after careful risk assessment depending on individual symptoms -> surgery in the inflammation-free interval
• Diverticular bleeding (Type 4)

In the case of a clearly localized diverticular bleeding, the corresponding intestinal segment should be resected. In the case of diverticular bleeding from the sigmoid colon, a standard sigmoid resection should be performed.

• Acute bleeding if not manageable endoscopically/interventionally
• Recurrent, clinically relevant bleeding after individual benefit-risk assessment

Laparoscopic or laparoscopically-assisted surgery is preferable to open resection. This also applies to complicated forms of diverticulitis and emergency situations, where at least a minimally invasive approach should be initiated. However, appropriate expertise is required.

The classification of diverticulitis/diverticular disease valid according to the current guidelines can be found here: Guideline Classification CDD

• General contraindications for laparoscopic procedures (e.g., intolerance to pneumoperitoneum, extreme positioning, or presence of an ileus)
• Generalized peritonitis

Previous abdominal surgeries or adhesions are not contraindications for laparoscopic procedures per se, but they may justify conversion to an open procedure.

Emergency Diagnostics

• Clinical Examination
• Laboratory Tests (Inflammatory Markers)
• Abdominal Ultrasound
• Abdominal CT (with oral and rectal contrast application)

Additional Diagnostics for Elective Surgery

• Complete Colonoscopy
• Possibly Sphincter Manometry
• Pneumocolon CT if Colonoscopy is Frustrating/Impossible

• Orthograde bowel lavage with oral antibiotic administration
• Shaving of the abdominal wall
• Marking the optimal site for a potential stoma on the abdominal wall

In the OR:

• Insertion of an indwelling catheter
• Single-shot antibiotic therapy (e.g., Cefotaxime + Metronidazole)
• Trial positioning after application of supports

• Bleeding/ postoperative bleeding with administration of donor blood and possibly surgical revision
• Anastomotic insufficiency with local or generalized peritonitis leading to sepsis, reoperation, discontinuity resection, or creation of a protective ileostomy
• Intra-abdominal abscess formation
• Injury to the left ureter, iliac vessels, internal genital organs (in women), bladder, spleen, kidney, pancreas
• Primary creation of a protective ileostomy or primary discontinuity resection
• Conversion
• Change in bowel habits
• Trocar hernia
• Risk of injury to the sphincter apparatus by stapler

Intubation anesthesia with capnoperitoneum
Placement of epidural catheter for postoperative pain therapy

• Lithotomy position
• Positioning of both arms (Note: Cotton wrapping when positioning with a cloth sling)
• Cotton wrapping of the knees and proximal lower legs
• Fixation of the legs in the leg supports
• Legs adjustable via the operating table control
• Shoulder supports on both sides
• Right side support
• Trial positioning

• Surgeon to the right of the patient
• 1st assistant at the head of the surgeon
• 2nd assistant opposite
• Surgical nurse at the foot of the surgeon

Basic Instruments for Laparoscopy:

• 11 scalpel
• Dissection scissors
• Langenbeck retractor
• Suction system
• Needle holder
• Suture scissors
• Forceps
• Gas system for pneumoperitoneum
• Camera system (30-degree optics)
• Backhaus clamps
• Compresses, abdominal towels
• Swabs
• Purse-string suture and purse-string clamp
• Suture material for abdominal wall fascia (2-0 braided, absorbable), subcutis (3-0 braided, absorbable),
  skin (4-0 monofilament, non-absorbable), colon (4-0 monofilament, absorbable)
• Plaster

Trocars:

• 1 optical trocar (10/12 mm), T1
• 2 working trocars (10/12 mm), T2, T3
• 1 working trocar (5 mm), T4

Additional Instruments for Laparoscopic Sigmoid Resection:

• 2 atraumatic holding instruments
• Electric curved scissors
• Electric Overholt
• Bipolar or ultrasonic scissors (e.g., Harmonic ACE TM)
• Stick swabs
• Suction-irrigation system
• Articulating retractor
• Linear stapler
• Transluminal circular stapler
• Clamp for the spike of the stapler (head grasping forceps)
• Clip applier with vessel clips
• Easy-flow drainage, suturing, and drainage bag

Postoperative Analgesia: Continue epidural anesthesia postoperatively for 2 – 5 days. Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management). Follow the link to the current guideline Treatment of acute perioperative and post-traumatic pain.

Medical Follow-up: Monitoring in the recovery room immediately postoperatively, then transfer to the general ward should be the aim; removal of the urinary catheter on the day of surgery; early removal of the easy-flow drainage if possible.

Thrombosis Prophylaxis: In the absence of contraindications, due to the moderate thromboembolic risk (surgical procedure > 30 minutes duration), in addition to physical measures, low molecular weight heparin should be administered prophylactically, possibly in a weight- or risk-adapted dosage until full mobilization is achieved. Note: Renal function, HIT II (history, platelet control). Follow the link to the current guideline Prophylaxis of venous thromboembolism (VTE).

Mobilization: Immediate, gradual resumption of physical activity, full weight-bearing if pain-free.

Physiotherapy: Possibly breathing exercises for pneumonia prophylaxis.

Dietary Progression: On the day of surgery, drinking; on the 1st postoperative day, tea, soup, yogurt; from the 2nd postoperative day, light diet.

Bowel Regulation: Stimulation of bowel activity with parasympathomimetic (e.g., Neostigmine sc. twice daily).

Discharge: from the 4th postoperative day.

Work Incapacity: Individual – depending on the degree of convalescence.