Laparoscopic Sigmoid Colectomy for Complicated Diverticulitis

1. Laparoscopic Sigmoid Colectomy for Complicated Diverticulitis Steven D. Wexner, MD, FACS, FRCS, FRCSEd, FASCRS, FACG Chief Academic OfficerCleveland Clinic Florida Weston, Florida

2. Faculty Disclosure It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity. Steven D. Wexner, MD, FACS, FRCS, FRCSEd, FASCRS, FACG, has served as a consultant for AHRM, Century Medical (Japan), ConvaTec, EZ Surgical, Food and Drug Administration, Incontinence Devices, Inc, Karl Storz Endoscopy America, Inc, LifeBond, Mederi Therapeutics, Medtronic, Inc, NeatStitch, NiTi, Pacira Pharmaceuticals, Signalomics GmbH, and Ventrus Biosciences. He has received honoraria from Adolor, GlaxoSmithKline, LifeCell, and Oceana Therapeutics. He is a stock shareholder for CRH Medical, EZ Surgical, Intuitive Surgical, LifeBond, and NeatStitch. He has received other financial support from Covidien, Karl Storz Endoscopy America, Inc, and Unique Surgical Innovations, LLC.

3. Learning Objective • Evaluate the evidence for therapeutic options that may improve gastrointestinal recovery postsurgery and integrate these efforts toward supporting overall surgical quality measures

4. History of the Present Illness • 44-year-old male • 2 previous hospitalizations for acute diverticulitis

5. History of the Present Illness First episode: 2.5 years ago Tmax 100.5F, WBC 12,000/uL CT: uncomplicated long segment sigmoid diverticulitis Second episode: 1 month ago Tmax 101F, WBC 16,000/uL CT abdomen/pelvis: extensive inflammation of the sigmoid colon with an abscess 2.5 to 3.9 cm in size Managed with out-patient oral antibiotics

6. Past Medical History • Irritable bowel syndrome • No previous abdominal surgery • Medications: • Fenofibricacid 45 mg one tablet daily • Omega-3 fatty acids 500 mg one capsule daily • Flaxseed oil 1000 mg one tablet daily • Allergies: • Penicillin • Habits: • Tobacco: never • Alcohol use: occasional

7. Examination • Physical exam: • BMI 30.3 kg/m2 • Soft, flat, nontender, nondistended abdomen • Laboratory investigations: (all within normal limits) • Hb 12.9 mg/dL • WBC 5.8 1000/uL • Colonoscopy: 6 months ago, unremarkable • Imaging: Long segment of uncomplicated sigmoid diverticulitis

8. Preoperative Measures • 10 days prior to surgery the patient complained of left-sided abdominal pain; without fever or change in bowel habits • Oral antibiotic treatment was started and continued until day of surgery

9. Preoperative Measures • Preoperative counseling visit with colorectal surgical nurse to discuss • Surgical procedure • Principles of enhanced recovery • Preoperative fasting (midnight on day before surgery) • Mechanical bowel preparation • Medications to avoid • Pulmonary clinic to obtain • Incentive spirometer and instructions regarding its use and importance

10. Why Laparoscopy? Open Sigmoid Resection, n = 17,735 Laparoscopic Sigmoid Resection, n = 709 To read more about this study, click on the following link: http://www.ncbi.nlm.nih.gov/pubmed/14609864 LOS: Length of stay Guller U, et al. Arch Surg. 2003;138:1179-1186.

11. Advantages of Laparoscopic Colorectal Surgery Compared With Open Procedures • Reduced surgical trauma • Reduced postoperative morbidity/complications • Reduced postoperative pain • Earlier passage of flatus; earlier bowel movement • Reduced hospital stay • Lower mortality • Similar oncologic outcomes • Less use of skilled nursing after discharge For more information click on the following link: http://www.ncbi.nlm.nih.gov/pubmed/16034888 Schwenk W, et al. Cochrane Database Syst Rev. 2005;CD003145. Delaney C, et al. Ann Surg. 2008;247:819-824.

12. Enhanced Recovery Protocols (ERP) Optimize Outcomes • Improved GI recovery • Decreased length of stay • Reduced complication rates • No change in readmission rates Preadmission Education and Counseling Prophylaxis Against Thromboembolism Minimization of Bowel Trauma Avoidance of NG Tubes; Drains Goal-directed Fluid Therapy Opioid-Sparing Analgesia Enforced Early Ambulation Early Enteral Feeding Breathing Exercises Preset Discharge Criteria For more on health outcomes with enhanced recovery pathways, click on the following link: http://www.ncbi.nlm.nih.gov/pubmed/21236454 Adamina M, et al. Surgery. 2011;149(6):830-840. Lassen K, et al. Arch surg. 2009;144:961-969.

13. Laparoscopy + Fast Track Multimodal Management (LAFA-Study) Multicenter trial of 400 segmental colectomy patients randomized to 4 groups *P < 0.001 compared with other 3 treatment groups For more about the LAFA study, click here: http://www.ncbi.nlm.nih.gov/pubmed/21597360 Vlug M, et al. Ann Surg. 2011;254:868-875.

14. Surgical Procedure: Preparation • General anesthesia • Cystoscopy with prophylactic insertion of bilateral ureteric stents and foley catheter • DVT prophylaxis: • Sequential compression devices • Heparin 5000 u subcutaneous injection • Antibiotic prophylaxis: • Cefoxitin 2 g IV 30 minutes prior to incision

15. Surgical Procedure: Technique • 10 mm infraumbilical Hasson • 2 x 10 mm right lower quadrant ports • Instruments used: • 10 mm electrothermal bipolar vessel sealer • 5 mm ultrasonic device • 5 mm endoscopic scissors • 10 mm babcocks

16. Surgical Procedure: Findings • Findings: • Large (10 cm), rock-hard phlegmon in the left iliac fossa • Small bowel mesentery stuck to the colonic mesentery • Omentum draped over the colon with multiple adhesions

17. Surgical Procedure: Technique • Left colon mobilization to the mid-transverse colon • Inferior mesenteric artery and vein divided • Rectosigmoid junction cleared of fat and transected • Descending and sigmoid colon was withdrawn through infraumbilical incision (wound protector) • Descending colon to sigmoid junction was circumferentially cleared of fat and transected

18. Surgical Procedure: Technique • 33 mm anvil introduced in left colon and secured with pursestring clamp • Abdomen was reinsufflated and a circular end to end anastomosis with a 33 mm stapler was performed • Anastomosis was evaluated with flexible endoscopy

19. Surgical Procedure: Measures • Operative time: 180 minutes • Estimated blood loss: 200 mL • Fluids given: 1000 mL of normal saline • Normothermia at all times (36.3C to 37.2C) • Prophylactic ureteral stents removed in operating room at end of procedure • Drains and tubes: • Bladder catheter • No nasogastric tube • No pelvic drain

20. Postoperative Course: Day 0 • No bowel movement or flatus, no nausea or vomiting • Seated in chair • Used incentive spirometer • All vitals normal, adequate urine output • Abdomen: soft, nontender, no distention • Pain medication: • Hydromorphone IV PCA • Ketorolac IV • Acetaminophen PO

21. Postoperative Course: Day 1 No bowel movement or flatus, no nausea or vomiting Ambulated along hallway and tolerated activity well Used incentive spirometer q1h All vitals normal, adequate urine output Abdomen: soft, nontender, no distention Pain medication: Hydromorphone IV PCA Ketorolac IV Acetaminophen PO

22. Postoperative Course: Day 1 Clear liquid diet was tolerated IV fluids decreased (30 mL/hr) Bladder catheter removed

23. No bowel movement or flatus, no nausea or vomiting Ambulated along hallway > 10 times Used incentive spirometer q1h All vitals normal, adequate urine output Abdomen: soft, nontender, no distention Incisions dry, clean, and intact Postoperative Course: Day 2

24. Postoperative Course: Day 2 • Pain medication: • Hydromorphone PCA discontinued • Oxycodone offered (not used) • Ketorolac IV • Acetaminophen PO • Diet was advanced to low residue • IV fluids stopped

25. Postoperative Course: Day 3 • Passes flatus, no bowel movement, no nausea or vomiting • Abdomen: soft, nontender, no distention • Incisions dry, clean, and intact • Low residue diet was tolerated • Pain medication: acetaminophen PO • Patient was discharged in good condition

26. Postoperative Course: 6 Weeks • Feels great • Did not require PO narcotics at home • Bowel movements 1-2 BM, formed/day • Back to daily activities 1 week postoperatively • Back at work 2 weeks postoperatively • All incisions well-healed, no hernias

27. Outcomes • Time to start PO intake: 4 hours • Time to first flatus: 58 hours • Length of hospital stay: 80 hours • No complications • No ileus • No re-admission

28. Summary • Preoperative patient education and counseling • Set appropriate patient expectations • Careful perioperative planning • Minimally invasive surgery • Follow enhanced recovery principles • Coordinated multidisciplinary effort