We present the case of a 60-year-old male patient with a history of recurrent acute sigmoid diverticulitis episodes. Comorbidities were limited to suspected obstructive sleep apnea (OSAS). The patient did not exhibit pneumaturia, fecaluria, or recurrent urinary tract infections. Colonoscopy revealed sigmoid diverticulosis, while contrast-enhanced abdominal CT demonstrated a large sigmoid diverticulum adhered to the posterior bladder wall, suggestive of a pre-fistulous state.

Given the clinical presentation, we opted for surgical intervention, performing a robot-assisted hemicolectomy using the Da Vinci system. The surgery involved ligation of the inferior mesenteric artery and vein, followed by the mobilization of the left colon up to the splenic flexure. Subsequent meticulous dissection was carried out to separate the sigmoid colon from the bladder, to which it was tenaciously adhered. This revealed a diverticulum that had eroded the bladder wall down to the muscular layer. We resected the diverticulum from the sigmoid colon, leaving a portion adhered to the bladder wall.

The rectum was resected up to the peritoneal reflection using a linear stapler. To remove the remaining diverticulum fragment adhered to the bladder wall, the bladder was filled with a solution of physiological saline and methylene blue, facilitating safer dissection and visualization of potential suture lines. The fragment was cautiously dissected from the bladder wall, with no evidence of fistulas. The bladder wall was subsequently reinforced with a continuous suture using Stratafix PDS 2/0.

Following the removal of the surgical specimen, a termino-terminal colorectal anastomosis was created using a circular stapler. Postoperatively, the patient experienced an uneventful recovery, maintaining a urinary catheter until the 5th postoperative day with no signs of hematuria or fecaluria. Following catheter removal, diuresis was normal and spontaneous.

This case highlights the successful management of a complicated sigmoid diverticulum with robotic-assisted surgery, emphasizing the importance of meticulous dissection and bladder wall reinforcement in such cases.

This case study highlights the efficacy of robotic-assisted hemicolectomy in managing sigmoid diverticulum cases, showcasing the distinct advantage of enhanced surgical precision offered by the Da Vinci system compared to traditional laparoscopic or open surgery. The robotic platform enables surgeons to achieve greater surgical dexterity and control, facilitating meticulous dissection and intricate procedures such as ligation of vessels and mobilization of the colon. This heightened level of precision is particularly beneficial when dealing with complex anatomical structures, ensuring thorough and accurate interventions. The ability to perform fine, controlled movements with the robotic arms allows for improved visualization and manipulation of tissues, contributing to a more refined surgical outcome.
In reference to the presented case, the indications for performing this procedure extend to all cases of acute or chronic diverticulitis necessitating surgical resolution. The enhanced precision and maneuverability afforded by the robotic platform make it a valuable choice for addressing a broad spectrum of diverticulitis cases, ensuring optimal outcomes in both acute and chronic scenarios.
The contraindications for this procedure align with general contraindications associated with laparoscopic surgery, encompassing the overall health conditions of the patient. Factors such as cardiovascular instability, severe respiratory compromise, and coagulopathy, among other general contraindications to laparoscopy, would also apply to the robotic-assisted hemicolectomy using the Da Vinci system. Patient-specific conditions and overall fitness must be carefully assessed to determine the appropriateness of the robotic approach, ensuring safety and efficacy in line with established surgical guidelines.
The setup for the procedure followed the conventional positioning for left hemicolectomy with the Da Vinci robotic system. The arrangement of the robotic arms and trocars adhered to established practices for this specific surgery, and the procedural nuances are further elucidated in the accompanying video documentation. An essential tip in enhancing the dissection of the diverticulum adhered to the bladder wall involved filling the bladder with methylene blue. This technique serves a dual purpose by delineating the boundaries of the dissection and unveiling potential bladder fistulas.
The preoperative workup for this procedure involves a comprehensive anatomical assessment of the patient through various imaging modalities. Magnetic resonance imaging (MRI), computed tomography (CT), and cystography are employed to meticulously study the anatomy and detect any potential colovesical fistulas. These diagnostic tools provide detailed insights into the extent of diverticular disease, the relationship between the sigmoid colon and adjacent structures, and the presence of any pathological connections with the bladder. This thorough preoperative evaluation is crucial for surgical planning, guiding the surgical team in anticipating challenges and optimizing the approach for a successful robotic-assisted hemicolectomy.
The meticulous preoperative study of anatomy and precise diagnosis is paramount for the execution of this surgery. However, the adaptability and visual acuity of the robotic system enable the surgical team to navigate unforeseen challenges or alterations in anatomy, ensuring flexibility in addressing different pathologies during the procedure.
Robotic surgery brings notable advantages, including an enhanced field of view with 3D visualization, greater precision in surgical maneuvers, and optimal stability of movements. These factors contribute to a more accurate and controlled procedure. However, it's worth noting that the primary drawback lies in the slightly higher cost compared to conventional laparoscopic surgery. Despite this, the benefits offered by robotic surgery, in terms of precision and clinical outcomes, often justify the selection of this advanced technology.
Complications associated with this procedure are comparable to those encountered in laparoscopic or open surgery and encompass potential issues such as bleeding, anastomotic fistula, or vesical fistula. Additionally, there is a risk of intestinal perforation and complications related to pneumoperitoneum. While these complications are inherent to abdominal surgeries, the use of the robotic system does not inherently introduce new risks. Diligent preoperative planning and adherence to best surgical practices help mitigate these potential complications, ensuring a safe and effective outcome for the patient.
There are no conflicts of interest to disclose related to this procedure
No additional acknowledgments or contributions are applicable for individuals who do not qualify for authorship status.
Ali F, Raskin E. Robotic Surgery for Complicated Diverticular Disease. Clin Colon Rectal Surg. 2021;34(5):297-301. doi:10.1055/s-0041-1729863 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8416326/#:~:text=Advantages%20of%20a%20Robotic%20Approach&text=Specific%20to%20sigmoid%20colectomy%20for,12.5%25).


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