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Advantages of Laparoscopy for Diverticulitis

Advantages of Laparoscopy for Diverticulitis. Steven D. Wexner, M.D., FACS, FRCS, FRCS (Ed) Cleveland Clinic Florida Chairman, Department of Colorectal Surgery Chief of Staff, Cleveland Clinic Florida

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Advantages of Laparoscopy for Diverticulitis

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  1. Advantages of Laparoscopy for Diverticulitis Steven D. Wexner, M.D., FACS, FRCS, FRCS (Ed) Cleveland Clinic Florida Chairman, Department of Colorectal Surgery Chief of Staff, Cleveland Clinic Florida Professor of Surgery, Ohio State University Health Sciences Center at the Cleveland Clinic Foundation Clinical Professor of Surgery, University of South Florida College of Medicine

  2. Cleveland Clinic FloridaWeston

  3. Advantages of Laparoscopy: Diverticulitis • Advantages • Operative time • Morbidity • Hospital Length of Stay • Special considerations • Presence of complications • Conversion • Advantages for elderly • Advantages for obese • Cost

  4. Laparoscopy: Diverticulitis

  5. Modified Hinchey* Grading System I. Pericolic abscess IIA. Distant abscess amenable to percutaneous drainage IIB. Complex abscess associated with fistula III. Generalized purulent peritonitis IV. Fecal peritonitis *Adv Surg 1978

  6. Case-Controlled Series *p<0.05 **p<0.001 Advantages of less morbidity and shorter hospitalization

  7. Laparoscopy: DiverticulitisRetrospective/prospective results – Hospital Stay

  8. Laparoscopy: Diverticulitis Retrospective/Prospective Results - Morbidity The more complicated the diverticular disease, the tendency for higher morbidity and longer lengths of hospital stay *p<0.001 **p<0.05

  9. Laparoscopy: Diverticulitis - Comparative Studies *p<0.05 **p<0.001

  10. Laparoscopy: Diverticulitis • 1/95-1/98: 1118 patients • Laparoscopic colorectal surgery study group • 509 sigmoid colectomies • 304 diverticulitis • 249 (81.9%) • Peridiverticulitis • Recurrent inflammation • Stenosis • 26 Hinchey I • 9 Hinchey II • 2 Hinchey III Köckerling et al., Surg Endosc 1999

  11. Laparoscopy: Diverticulitis Stage Conversion Mean operative time Morbidity (n (%)) (min (range)) (%) Total 22/304 (7.2) 164 (65-410) 17 Chronic 12/249 (4.8) 159 (65-395) 14.8 Hinchey I-IV 10/55 (18.2) 182 (90-410) 28.9 I 8/26 (30.7) 183 (100-410) 33.3 II 1/9 (11.1) 198 (90-320) 37.5 III/IV 0/2 (0) 110 (100-120) 50 Köckerling et al., Surg Endosc 1999

  12. Mean age, 59.5 years Mean age, 69.5 years Mean age, 67.9 years Mean age, 54.3 years Mean age, 65.9 years Mean age, 67.7 years Laparoscopy: DiverticulitisComparative Study n = 18 # patients Sher et al, Surg Endosc. 1997

  13. Laparoscopy: Diverticulitis - Comparative Studies Morbidity Morbidity (%) 43 29* 29 13 0 0 Hinchey IIAand IIB OverallLate experience experience * P<0.05 Sher et al, Surg Endosc. 1997

  14. 10† 9* 7* 5 5 Laparoscopy: Diverticulitis Open vs. LaparoscopyHospital stay Days * p<0.05 †p<0.01 Sher et al, Surg Endosc. 1997

  15. Open vs. Laparoscopy *p<0.05 **p<0.001

  16. Laparoscopy: Elderly Laparoscopic Open p value n= 22 n = 24 Mean age (yrs) 77.2 (75-82) 78 (76-84) NS Gender (M:F) 10:12 10:14 NS Operative time (min) 234 136 NS IV analgesia (days) 5.4 8.2 0.001 Morbidity (%) 18 50 0.02 Mortality 0 0 NS Inpatient rehabilitation 6 15 0.01 Hospitalization (days) 13.1 20.2 0.003 Teuch et al. Surg Endosc 2000

  17. Costs: open vs. Laparoscopy *p<0.05 a = Total direct cost/case

  18. Laparoscopy: Diverticulitis • There is good evidence (Level 2) that laparoscopy for diverticulitis results in earlier discharge

  19. Laparoscopy: Diverticulitis • Despite longer operative time, the morbidity rate for the laparoscopic approach to diverticulitis in the most recent studies is equivalent or better than the open approach (Level 2 evidence)

  20. Laparoscopy: Diverticulitis Conclusion • Elective laparoscopy for diverticular disease confers many advantages over the traditional approach • Based upon these data, laparoscopy is our preferred approach to the treatment of sigmoid diverticulitis

  21. Practice Parameters for Sigmoid Diverticulitis The Standards Committee of The American Society of Colon and Rectal Surgeons The laparoscopic approach is appropriate in selected patients. Level of Evidence III, Grade of Recommendation A Laparoscopic colectomy may have advantages over open laparotomy, including less pain, smaller scar, and shorter recovery. There is no increase in early or late complications. Cost and outcome are comparable to open resection. Laparoscopic surgery is acceptable in the elderly and seems to be safe in selected patients with complicated disease Rafferty et al, DCR 2006

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