Laparoscopic Sigmoid Colectomy for Complicated Diverticulitis

The following video demonstrates a laparoscopic sigmoid colectomy for the treatment of complicated sigmoid diverticulitis. The patient was initially managed with intravenous antibiotics and allowed three months for the acute inflammatory process to resolve. Subsequently she was taken to operating room electively for an uncomplicated sigmoid colectomy with a primary anastomosis.

Diverticulitis, sigmoid cancer, non-resectable polyp

severe systemic illness, large inflammatory or malignant mass

Ligasure

Patient is in lithotomy position using Allen stirrups, the right arm is tucked and the patient is well secured to the operating room table. Three 5mm trocars and an Alexis Laparoscopic System is placed through a Pfannenstiel incision.

Computed tomography (CT) scan, colonoscopy

The area of inflammation is initially dissected out of the pelvis using a combination of sharp and blunt dissection with laparoscopic scissions. The peritoneal reflection is identified, and the colon can be further mobilized using electrocautery. The laparoscopic hook dissector is another useful instrument for precise mobilization of the colon off the retroperitoneum. The white line of Toldt is then incised using electrocautery, and the proximal sigmoid and left colon are mobilized by a combination of blunt dissection and electrocautery up to the splenic flexure. If additional length of the colon is required to create an anastomosis, the splenic flexure can be fully mobilized. Following resection, a primary end-to-end double-stapled anastomosis is created with a 29mm Ethicon EEA stapling device. An alternative technique would be to use a double purse string anastomosis. The integrity of the staple line is examined by insufflation using a rigid proctoscope.

Intraoperative ¢ Significant bleeding may occur from mesenteric vessels, which can be avoided by careful isolation of the mesentery, and the use of an advanced energy device. Injury to the ureter is a potential complication especially when the colon is inflamed and adhered to the abdominal wall in cases such as diverticulitis. Careful identification of the ureter is mandatory to avoid this injury, in cases of severe inflammation a ureteral stent, placed preoperatively, may be considered.

Postoperative ¢ Anastomotic leak is the most concerning postoperative complications with overall incidence of 1-5%. Symptoms include abdominal pain, fevers and tachycardia. A CT scan can be performed, and patients should be treated with intravenous antibiotics. Depending on the severity of the leak, percutaneous or operative management may be indicated.

Intraoperative ¢ Significant bleeding may occur from mesenteric vessels, which can be avoided by careful isolation of the mesentery, and the use of an advanced energy device. Injury to the ureter is a potential complication especially when the colon is inflamed and adhered to the abdominal wall in cases such as diverticulitis. Careful identification of the ureter is mandatory to avoid this injury, in cases of severe inflammation a ureteral stent, placed preoperatively, may be considered.

Postoperative ¢ Anastomotic leak is the most concerning postoperative complications with overall incidence of 1-5%. Symptoms include abdominal pain, fevers and tachycardia. A CT scan can be performed, and patients should be treated with intravenous antibiotics. Depending on the severity of the leak, percutaneous or operative management may be indicated.

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