WJHJ Meijerink MD PhD VUmc Amsterdam, NL

1. Laparoscopic sigmoidectomy WJHJ Meijerink MD PhD VUmc Amsterdam, NL

2. Diverticulitis Diverticulose affects 1/3 of population > 45 yrs 10-25% of these patients develops acute diverticulitis 1/3 of patients with acute diverticulitis will have a complicated diverticulitis Classification according to Hinchey

3. Diverticulitis Complicated diverticulitis associated with significant morbidity and mortality Majority of published literature: mortality 6-17% in complicated diverticulitis mortality 22-39% in free perforation or fecal peritonitis perforation in 50-70% first manifestation of complicated diverticulitis

4. Diverticulitis Golden rule of diverticulitis: Profylactic surgery to prevent complications of recurrent diverticulitis after 2 episodes of clinically documented diverticulitis, (1 episode in young patients) Sequellae of conservative treated acute diverticulitis (fistula, stenosis, etc.) 1. All forms complicated diverticulitis associated with increased morbidity and mortality 2. Diverticulitis recurrent episodes with increased risk of complicated diverticulitis 3. All patients are at risk for perforated diverticulitis 4. Risk of recurrent diverticulitis and colostomy is eliminated with elective surgery 1/3 of patients will develop 2nd episode 1/3 of them will develop a subsequent episode Recurrent episodes thought to be associated with increased risk of complications and mortallity

5. Diverticulitis Perforated diverticulitis high mortality (up to 20-25%) free perforation fecal peritonitis All other forms of diverticulitis perocolic abscess fistula obstruction phlegmon bleeding low mortality equal to elective surgery (0 - 2.6%) (Profylactic sigmoidresection low mortality rate 1 - 2.4%) But > 50-70% of patients with perforated diverticulitis no previous history and: recurrent diverticulitis after sigmoid resection: 2.6 - 10.4% Reasons to rethink the rules????? Chapman J et al. Ann Surg 2005 Kaiser AM. Ann Surg 2006

6. Elective sigmoid resection indications • (Am Soc Colorect Surg) • Hinchey I and II after percutaneous drainage of the abscess • Young patients after one well documented episode of diverticulitis • Elderly patients after two episodes of diverticulitis • Diverticulitis with fistula (vagina, bladder or external) • Diverticulitis with stenosis • Diverticular disease with lower tract bleeding

7. Diverticulitis surgery: open or laparoscopic Acute surgery depending from: severity of inflammatoir mass associated complications (fistula, abscess) skills of surgeon

8. Results elective laparoscopic resection

9. Results laparoscopic trials

10. Σigma-trial Laparoscopic versus open elective sigmoid resection in patients with symptomatic diverticulitis. A prospective double blind multi centre trial B.R. Klarenbeek, A.A.F.A. Veenhof, W.T. van den Broek, D.L. van der Peet, E.S.M. de Lange, W.A. Bemelman, R. Bergamaschi, P. Heres, A.M. Lacy, M.A. Cuesta

11. Σigma-trial

12. Σigma-trial

13. Σigma-trial Minor complications

14. Σigma-trial Major complications

15. Σigma-trial • Less major complications • Shorter hospital stay • Less pain • Better SF-36 scores • Limitations due to physical health • Limitations due to emotional problems • Social functioning • Pain • Less bloodloss • Longer operating time

16. Patient position (mild) supine Loyd Davis position vacuum mattress and gel pad Stir-ups arms aside

17. Position team Position varies during surgery

18. Position trocars • 1 10 mm trocar: camera • 5 mm trocar: working instrument • 10-12 mm trocar: working instrument / stapler • 5 mm trocar: optional, at the level of the incision 3 1 2 4

19. Essential choices Oncologic vs benign (diverticulitis) Medial vs lateral approach Vascularisation

20. Essential choices Oncologic benign (diverticulitis) medial approach lateral or medial ligation at origin of vessels close to bowel a. mes. inf. a. sigmoidea a. sigmoidea a. colica sinistra Ultracision, ligasure, staplers ligasure

21. Mobilisation of splenic flexure Not always necessary enough length tension free But standard mobilisation 15-20 min extra time experience never doubt about length / tension Full mobilisation: medial approach Partial mobiliation: lataral approach incl. omentum!

22. Sigmoidectomy Stay out of trouble Left ureter Spleen Pancreatic tail Promotory plexus Vascularisation

23. 1 pull omentum over stomach 2 small bowel to right open left mesocolon at level of v. mes. inf. 4 mobilise mesocolon 5 lateral peritoneum 1

24. 1 pull omentum over stomach 2 small bowel to right open left mesocolon at level of v. mes. inf. 4 mobilise mesocolon 5 lateral peritoneum 1 2 Treiz

25. 1 pull omentum over stomach 2 small bowel to right open left mesocolon at level of v. mes. inf. 4 mobilise mesocolon 5 lateral peritoneum 1 3 2 3

26. 1 pull omentum over stomach 2 small bowel to right open left mesocolon at level of v. mes. inf. 4 mobilise mesocolon 5 lateral peritoneum 1 x 3 2 3 4

27. 1 pull omentum over stomach 2 small bowel to right open left mesocolon at level of v. mes. inf. 4 mobilise mesocolon 5 lateral peritoneum 1 x 2 3 4 5

28. Benign disease Close to bowel free lateral attachments Transsect proximal or distal margin Cut halfway between major vessels and bowel a.colica sinistra a. Rectalis sup

29. Distale marge Proximale marge

30. Distale marge Overgang rectum - sigmoid Teniae! Indien recidief diverticulitis, bijna altijd onvoldoende distale marge Proximale marge Moeilijker te bepalen Op overgang naar soepele deel colon Niet streven naar volledige resectie divertikels

31. Benign disease Close to bowel free lateral attachments Transsect proximal or distal margin Cut halfway between major vessels and bowel Lower left quadrant incision Transsection of the proximal segment Insertion of circular stapler Close wound and restore pneumoperitoneum Intracorporal anastomosis

32. Take home message Laparoscopy can be safely used in elective setting Mobilisation of splenic flexure Medial vs lateral Adequate (distal) resection margins