Transcript Geen diatitel - stichting BG

Laparoscopic sigmoidectomy
WJHJ Meijerink MD PhD
VUmc Amsterdam, NL
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
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
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.
2.
3.
4.
All forms complicated diverticulitis associated with increased morbidity and mortality
Diverticulitis recurrent episodes with increased risk of complicated diverticulitis
All patients are at risk for perforated diverticulitis
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
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
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
Diverticulitis surgery: open or laparoscopic
Acute surgery depending from:
severity of inflammatoir mass
associated complications (fistula, abscess)
skills of surgeon
Results elective laparoscopic resection
Author
Patients
Conversion
%
OR time
(min)
H stay (days)
Morbidity %
Mortality %
Stevenson
100
8%
180 min
4 days
21%
0%
Kockerling
304
7,2 %
-----------
----------
17 %
1,1 %
Berthou
110
8,2 %
167 min
8,2 days
7,3 %
--------
Trebuchet
170
4%
141 min
8,5 days
8,2 %
0%
Buillot
179
13,9 %
223 min
----------
14,9 %
0%
Schwandner
396
6,8%
193 min
11,8 days
7,6%
0,5%
Le Moine
168
14,3%
-----------
-----------
21%
0%
Cuesta
101
12%
210 min
9 days
16%
0%
Results laparoscopic trials
author
approach
patients
OR time
(min)
Hosp stay
(days)
morbidity
Dwivedi
2002
open
88
143
8.8
23 %
lap
66
212
4.8
16
open
71
101
6.8
30
lap
61
109
3.1
8
open
80
156
12
32
lap
95
170
7
19
open
215
140
9
27
lap
56
170
4,1
9
Senagore
2002
Gonzalez
2003
Lawrence
2003
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
Σigma-trial
Laparoscopic
Open
P
Operating time (minutes)
192,50
139,16
0.0001
Blood loss (cc)
307,73
389,17
0,033
Transfusion needed
3,8% (2)
11,5% (6)
0,374
Conversion rate
Hand-assisted
9,6% (5)
Laparotomy
9,6% (5)
Splenic flexure mobilisation
57,7% (30)
67,3% (35)
0,432
Protective ileostoma
3,8% (2)
1,9% (1)
0,558
20,44
0,876
Number of trocarts
Specimen length (cm)
3
1,9% (1)
4
69,2% (36)
5
21,2% (11)
20,68
Σigma-trial
Laparoscopic
Open
P
Nasogastric tube in situ (days)
1,39
2,18
0,116
Re-insertion tube
7,7% (4)
7,7% (4)
1
Fluid
1,94
2,24
0,802
Blend
2,76
3,76
0,424
Normal
4,17
7,14
0,129
Hospital stay (days)
8,45
10,75
0,046
Systemic analgesia (days)
1,5
1,98
0,018
Minor complications
36,5% (19)
38,5% (20)
0,839
Major complications
9,6% (5)
25% (13)
0,038
Late complications
7,7% (4)
19,2% (10)
0,085
Death
0% (0)
1,9% (1)
0,315
Type of operation according to patient
32,3% right (10)
58,3% right (21)
0,427
Diet (days)
Σigma-trial
Minor complications
10
9
8
7
6
5
4
3
2
1
0
Laparoscopic
Open
Urine tract
infection
Wound
infection
Pneumonia
Other
Combination
Σigma-trial
Major complications
6
5
4
Laparoscpopic
3
Open
2
1
0
Anastomotic
leakage
Post-operative Intra-abdominal Re-operations
hemorrhage
abscesses
Other
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
Patient position
(mild) supine Loyd Davis position
vacuum mattress and gel pad
Stir-ups
arms aside
Position team
Position varies during surgery
Position trocars
1 10 mm trocar: camera
2 5 mm trocar: working instrument
3 10-12 mm trocar: working instrument
/ stapler
3
4 5 mm trocar: optional, at the level of
the incision
1
2
4
Essential choices
Oncologic vs benign (diverticulitis)
Medial vs lateral approach
Vascularisation
Essential choices
Oncologic
medial approach
ligation at origin of vessels
a. mes. inf.
a. sigmoidea
a. colica sinistra
Ultracision, ligasure, staplers
benign (diverticulitis)
lateral or medial
close to bowel
ligasure
a. sigmoidea
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!
Sigmoidectomy
Stay out of trouble
Left ureter
Spleen
Pancreatic tail
Promotory plexus
Vascularisation
1
pull omentum over stomach
2
small bowel to right
3
open left mesocolon
at level of v. mes. inf.
4
mobilise mesocolon
5
lateral peritoneum
1
1
pull omentum over stomach
2
small bowel to right
3
open left mesocolon
at level of v. mes. inf.
4
mobilise mesocolon
5
lateral peritoneum
1
2
Treiz
1
pull omentum over stomach
2
small bowel to right
3
open left mesocolon
at level of v. mes. inf.
4
mobilise mesocolon
5
lateral peritoneum
1
2
33
1
pull omentum over stomach
2
small bowel to right
3
open left mesocolon
at level of v. mes. inf.
4
mobilise mesocolon
5
lateral peritoneum
1
2
x
3
3
4
1
pull omentum over stomach
2
small bowel to right
3
open left mesocolon
at level of v. mes. inf.
4
mobilise mesocolon
5
lateral peritoneum
1
x
2
3
4
5
Benign disease
Close to bowel
1 free lateral attachments
2 Transsect proximal or distal margin
3 Cut halfway between major vessels and bowel
a.colica sinistra
a. Rectalis sup
Distale marge
Proximale marge
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
Benign disease
Close to bowel
1 free lateral attachments
2 Transsect proximal or distal margin
3 Cut halfway between major vessels and bowel
4 Lower left quadrant incision
5 Transsection of the proximal segment
6 Insertion of circular stapler
7 Close wound and restore pneumoperitoneum
8 Intracorporal anastomosis
Take home message
Laparoscopy can be safely used in elective setting
Mobilisation of splenic flexure
Medial vs lateral
Adequate (distal) resection margins