Laparoscopic Approach in Complicated Diverticular Disease

Alejandro Canelas, MD, Esteban Grzona, MD, Emmanuel Sadava, MD, Maximiliano Bun, MD, Mariano Laporte, MD, Nicolás Rotholtz, MD. Colorectal Surgery Section. Hospital Alemán. Buenos Aires – Argentina.

INTRODUCTION: Studies have shown clear benefits of the use of laparoscopic colectomy in diverticular disease. However, this is not defined in patients with complicated disease. The aim of this paper is to analyze the results of laparoscopic colectomy in complicated diverticular disease and secondarily to determine feasibility of emergency laparoscopic sigmoid colectomy in patients Hinchey III / IV.

METHODS AND PROCEDURES: Patients who underwent laparoscopic colectomy for diverticular disease between July 2000 to June 2010 were included. The series was divided into two groups. G1: patients with complicated disease (abscess, perforation, fistula, or stenosis), and G2: patients undergoing surgery for recurrent diverticulitis. Univariate analysis was made between the two groups. Furthermore sigmoidectomies without ostomy in Hinchey III / IV (G1A) versus other complicated diverticular (G1B) were compared.

RESULTS: 205 patients were included; G1: 56 (27%) and G2: 149 (73%). G1 consists of: 8 (14%) pericolonic abscesses or severe inflammatory sequelae, 12 (21%) Hinchey II, 16 (29%) Hinchey III / IV, 12 (22%) Fistulas (9 colovesical / 3 colocutaneous), and 8 (14%) stenosis. Procedures performed in G1 were: 49 (87%) sigmoidectomies; 5 (9%) with proximal ileostomy and 2 (4%) Hartmann’s procedures.
Patients in G2 presented more previous episodes of diverticulitis (G1: 1.5 ± 1.4 vs. G2: 2.6 ± 1.3, p <0.05). G1 had longer operating time G1 (G1: 203 ± 66 vs. G2: 159 ± 58 minutes, p <0.05) and higher conversion rate [G1: 11/56 (20%) vs. G2: 5/149 (3.3 %), p <0.05]. There were no differences in complications. G1 had longer hospital stay (G1: 4.7 ± 3.1 vs. G2: 3 ± 1.8 days, p <0.05) and more postoperative complications [G1: 14/56 (25%) vs. G2: 18/149 (12%), p = 0.04], but there were no differences in major complications.
Comparing G1A (n = 10) vs. G1B (n = 39) vs. G2 (n = 149) G1B had longer operative time (G1A: 159 ± 35 vs. G1B: 205 ± 65 vs. G2: 159 ± 58 minutes, p <0.05). There were no differences in intraoperative complications between the groups. G1B showed higher conversion rate [G1A: 0/10 (0%) vs. G1B: 11/39 (28.2%) vs. G2: 5/149 (3.3%), p <0.05] and increased hospital stay G1A (G1A: 5.1 ± 4.1 vs. G1B: 4.1 ± 2.2 vs. G2: 3 ± 1.8 days, p <0.05). No differences in postoperative complications were identified.

CONCLUSION: The laparoscopic approach in complicated diverticular disease is safe.
Laparoscopic sigmoid resection without ostomy in Hinchey III / IV is feasible with acceptable results.