Perioperative management - Sigmoid resection, tubular, for diverticulitis, robotically assisted

The sigmoid resection is the surgical treatment option for sigmoid diverticulitis. The indications are classically divided into absolute and relative (or elective) indications and are now oriented towards complications, course, and quality of life, less towards the mere number of episodes.

Absolute Indications (Emergency Surgery)

Immediate surgery required for:

• Free Perforation with generalized peritonitis
  → CDD IIc
• Therapy-Refractory Sepsis
• Uncontrollable Bleeding from the sigmoid
• Intestinal Ischemia or Necrosis
• Acute Ileus due to diverticulitis

Relative / Elective Indications

Surgery after resolution of the acute episode (after 6 weeks):

• Complicated Diverticulitis
  • Covered Perforation / Abscess
    • especially in:
    • Abscess > 3–5 cm
    • Recurrence after drainage
  • Fistulas
    • colovesical (air in urine, recurrent urinary tract infections)
    • colovaginal
    • colocutaneous
  • Stenosis with passage disturbance
  • Recurrent Bleedings
• Uncomplicated Diverticulitis
  • Recurrent Episodes with:
    • significant impairment of quality of life
    • short episode-free intervals
  • Therapy-Resistant Course
  • Chronic-Recurrent Inflammation ( “smoldering diverticulitis”)

Special Indications

• Immunosuppressed Patients
  (e.g., transplant recipients, long-term steroid therapy)
• Younger Patients with severe course (now assessed more cautiously than before)

No Longer Valid Old Indications

•  “Surgery after the 2nd episode” → no longer recommended
• ✔️ Decision today individualized according to the above principles

Principles of Sigmoid Resection for Diverticulitis

• Removal of the inflamed segment
• Anastomosis in the inflammation-free descending colon
• As elective and minimally invasive as possible (laparoscopic/robotic)

Here is a clear table of the CDD classification (Classification of Diverticular Disease), as it is commonly used in the German-speaking area (DGAV/DGVS) (S3 guideline AWMF):

Note:

• CDD 1 = uncomplicated
• CDD 2 = acutely complicated
• CDD 3 = chronic
• CDD 2c = absolute surgical indication
• Not the number of episodes, but complications & quality of life are decisive

The current guidelines with the valid classification of diverticulitis/diverticular disease can be found here:LINK

The general contraindications for the robotic procedure are based on the general contraindications for minimally invasive procedure. This concerns:

Contraindications for the creation of a pneumoperitoneum e.g.

• due to severe systemic disease,
• or a manifest ileus with massive intestinal distension
• all clinical situations with an abdominal compartment syndrome
• massive adhesive abdomen (hostile abdomen)

In addition, relative contraindications should be considered, in which preoperative optimization may be possible, such as:

• Severe coagulation disorders (Quick < 50%, PTT > 60 sec., platelets < 50/nl),
• pronounced portal hypertension with caput medusae

Note: Abdominal previous operations or adhesions are per se no contraindication for a minimally invasive procedure, but can justify a conversion to the open procedure.

• Clinical examination
• Laboratory examination: surgical routine: CBC, CRP, electrolytes, blood sugar, coagulation, kidney values, liver values, bilirubin, blood group) 
• Abdominal ultrasound
• current abdominal CT
• Complete colonoscopy
• Possibly sphincter manometry
• Pneumocolon CT in case of unsuccessful / impossible colonoscopy

Further preoperative ancillary diagnostics (if necessary):

• ECG
• Lung function testing if indicated by history
• ABG in COPD/COLD
• Cardiac echo with EF in suspected heart failure

Preoperative Preparation on Ward

• Body care: shower the evening before (antiseptics)
• Shaving: nipples up to and including genitals
• Premedication by anesthesia
• Preoperative bowel preparation: The current data situation speaks for an antegrade bowel lavage with synchronous administration of topical antibiotics.
• On the morning of the surgery, enema.
• Thrombosis prophylaxis  (usually “Clexane 40”), anti-thrombosis stockings

 Cave: Preoperative checking and adjustment of therapy with anticoagulants:

• The perioperative therapy with Aspirin can be continued.
• Clopidogrel (ADP inhibitor) should be paused at least 5 days beforehand.
• Vitamin K antagonists should be paused 7-10 days under control of the INR.
• NOAC (new oral anticoagulants)  should be paused 2-3 days preoperatively
• Always, if necessary, after consultation with the treating cardiologist

Bridging:

• For vitamin K antagonists, bridging with short-acting heparins if INR outside the target range
• For NOACs, due to the short half-life, bridging can usually be omitted. In case of very high occlusion/stroke risk: Bridging under inpatient conditions with UFH

 Preoperative Preparation in the OR:

• Insertion of an indwelling catheter
• CVC placement: usually during anesthesia induction.
• If necessary, artery during induction
• Perioperative antibiotic therapy with e.g. Unacid

Important points of the informed consent:

• Indication, planned surgical procedure, aftercare, possible alternatives
• Bleeding / Secondary bleeding / Administration of donor blood
• Drainage insertion, catheter insertion
• Possible need for surgical revision due to a complication
• Anastomotic insufficiency with local or generalized peritonitis and consequences of sepsis, reoperation, open abdominal treatment, discontinuity resection creation of a protective ileostomy or a Hartmann situation
• Intra-abdominal abscess formation with need for interventional or surgical measures
• Wound infection
• Burst abdomen
• Incisional hernia / Trocar hernia
• Injury to adjacent structures (left ureter, iliac vessels, urinary bladder, spleen, kidney, pancreas, small intestine, further colon sections)
• Injury to the sphincter apparatus by the stapler
• Need for surgical extension
• Possibility / Need for creation of a stoma (protective ileostomy vs. terminal stoma as worst case scenario)
• Conversion to a laparotomy
• Change in bowel habits
• In case of entry into the small pelvis: Impotentia coeundi in men, fecal incontinence and bladder emptying disorders due to injury to the inferior hypogastric nerves, injury to the internal genitals in women