Surgical treatment of Hinchey III diverticulitis is still controversial, with debate between the proponents of laparoscopic lavage and those proponents of sigmoid resection. In this latter group there is debate between the laparoscopic and open approaches and between anastomosis and colostomy. Laparoscopy may be challenging in the setting of acute inflammation but allows peritoneal lavage, drainage of abscesses and bowel resection, offering enhanced patient recovery and reduced morbidity. A recent meta-analysis of 3 randomized controlled trials comparing laparoscopic lavage versus surgical resection concludes that laparoscopic lavage is associated with reduced operating time, shortened postoperative stay and a lower surgical reintervention rate at 12 months. By contrast, postoperative mortality rate at the index operation and 90 postoperative days, surgical reintervention during the index hospitalization and at 90 days, and Clavien-Dindo grade I-III complications favoured emergency sigmoid resection although they did not achieve statistical significance. Laparoscopic lavage was associated with a significant increase in postoperative intra-abdominal abscess formation within 90 days, which may explain the higher unplanned reintervention rate in the laparoscopic lavage group. Laparoscopic lavage is non-inferior to sigmoid resection although in this group of patients may be necessary an increased number of late procedures related to ongoing sepsis, mainly due to intra-abdominal abscess. Patients undergoing these unplanned procedures may be exposed to increased morbidity. The video presents the case of a patient with acute diverticulitis Hinchey III who was initially treated with laparoscopic lavage and had persistent sepsis. 3 days after the index surgery, a laparoscopic sigmoidectomy with colostomy was performed. After the unplanned procedure the patient had a normal postoperative course with discharge in the 5th postoperative day. Surgical treatment of Hinchey III acute diverticulitis is still controversial. Laparoscopic lavage seems a useful tool in selected patients but it may be associated with an increased need for unplanned procedures that may increase morbidity.
Published
Mar 2021
Case A 75 year-old man with a medical history of atrial fibrillation and laparoscopic radical prostatectomy for prostate adenocarcinoma. He came to the Emergency Department due to melena and hemodynamic instability with a blood test which found a Hemoglobin level of 7.9 g/dL. And emergent upper endoscopy showed early gastric neoplasia (type IIa + IIc) with a biopsy compatible with gastric adenocarcinoma. A CT scan showed a tumor in the right kidney with no signs of locally advanced gastric cancer. Thus a minimally invasive subtotal gastrectomy with D2 lymphadenectomy was scheduled. Treatment Surgery started with a lymphadenectomy of the greater curvature, with dissection of the gastroepiploic artery and vein. (Later, dissection of the pylorus and postpyloric section with an EndoGIA was performed. Lymphadenectomy of the left gastric artery, celiac trunk, hepatic artery and splenic artery followed. D2 lymphadenectomy with preservation of the ganglionar stations 1 and 2 was performed. Once this was done, the vascularization of the gastric stump was assessed with 5mg of ICG inserted through a central catheter, and the decision to section the stomach in a well-perfused portion of the gastric stump was made, as this would be the site of the gastrojejunal anastomosis. A end-to-side anastomosis was created using an Orvil®. The mesenteric defect was then closed. Outcome The patient had an uneventful postoperative evolution and started oral intake on the first day after surgery. He was discharged on the 4th postoperative day. Pathology reported a T2N0 (0/18) gastric adenocarcinoma. Conclusions Even though leakage after a subtotal gastrectomy with gastrojejunal anastomosis is uncommon, when a leak occurs the consequences are devastating, both in the oncologic long-term as well as in terms of function, morbidity and mortality. The use of tools such as ICG, which provide a guide for safer anastomosis, are useful and may help to further reduce this dreadful complication.
Published
Dec 2019
Case A 27-year-old female patient with no medical history. She came to the emergency room due to pain and abdominal distension for several hours without any other symptoms. A blood analysis was performed in which leukocytosis was found. The rest of the parameters were normal. An x-ray of the abdomen was performed, showing a distension of the colon suggesting a sigmoid volvulus, so it was decided to complete the study with a CT Scan. The CT Scan objectified two abrupt changes in gauge at the level of the sigma, with the swirl sign and subsequent dilation of the colon being compatible with a sigma volvulus. The liver was displaced to the left by the dilation of the colon, occupying the right hypochondrium. A colonoscopy was performed to resolve the volvulus and then a complete colonoscopy to study the colon, finding an erythematous mucosa 30 to 50 cm from the anal verge and a dilated proximal colon with no other anomalies. Once the study was completed and the acute episode was resolved, it was decided to perform a laparoscopic sigmoidectomy. Treatment A total of 4 trocars were used. A 12mm trocar was placed in the supra umbilical position for a 30° scope. A 12 mm trocar was placed at the right iliac fossa and a 5 mm trocar was placed at the right flank, serving as working channels for the leading surgeon. A 5mm trocar was placed at the left flank as an auxiliary channel for the assistant and for the surgeon if necessary. First we could see that the distal sigma was normal. Upon ascending to the proximal sigma, the first change of caliber was seen. We continued to explore the colon, observing the second change of caliber with respect to the volvulation area. We see how the sigma and transverse colon were increased in caliber with respect to previous volvulation episodes. Then we mobilized the colon that was occupying the right hypochondrium, displacing the liver. We could see how the mesocolon was thickened, possibly related to the torsion zone in the volvulus.We finally mobilized the small bowel, leaving the right hypochondrium free. Once we had placed all the structures in their normal anatomical positions, a regulated sigmoidectomy was initiated. We then proceeded to expose the mesenteric vessels for proper section, from medial to lateral. The dissection starts with an incision of the peritoneum in the mesentery. A cautery is used to open the peritoneum along this line, opening the plane cranially up to the origin of the inferior mesenteric artery. We continue the dissection, taking care not to injure the iliac vessels or the left ureter. Blunt dissection is used to lift the vessels away from the retroperitoneum. Then the dissection of the inferior mesenteric artery ends. The vessels were transected with scissors between endoclips. We continued to section the rest of the mesocolon with Ligasure. At this time we could see how the liver and stomach had regained their normal position. We observed that the colon was again underneath the liver so we proceeded to anatomize the colon and the small bowel once again, always being careful not to cause injuries. Step by step we reduced the colon to its normal position. With the colon anatomized and the liver in the right position we can see how the hepatic flexure and the ascending colon are correctly positioned. We returned to the left side +to continue the redundant colon resection. We released the mesocolon from medial to lateral using Ligasure. Then we released the distal colon up to the promontory. The rectal resection is performed using an elliptical dissection pattern from right lateral, to posterior and left lateral to anterior. We used an electrocautery and at this point we also used the LigaSure to section the mesocolon. Once the rectum had been properly dissected an EndoGIA™ stapler was used to divide the rectum with one firing. Finally we sectioned the rest of the mesocolon using ligasure and verified that the proximal colon reached the pelvis with no tension to make the anastomosis. After this, the specimen was exteriorized through a Pfannenstiel incision in the hypogastrium. We cut the proximal colon, completing the sigmoidectomy. We made a lateral to end colorectal anastomosis using an EEA stapler, checking beforehand that it was not twisted and had no tension. Finally we completed the surgery. Outcome The surgery took 150 minutes. The patient had a favorable postoperative period with no complications. She was started on oral intake 24 hours after the surgery and left hospital on the 3rd postoperative day.
Published
Jan 2017
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