[email protected]Dr. Carlo Augusto Sartori Dr. Carlo Augusto Sartori Castelfranco V.to (TV) Castelfranco V.to (TV) “ “ Quando e come operare la malattia diverticolare del colon” Quando e come operare la malattia diverticolare del colon” “ “ Possibilità di trattamento chirurgico laparoscopico” Possibilità di trattamento chirurgico laparoscopico”
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[email protected] Dr. Carlo Augusto Sartori Castelfranco V.to (TV) Quando e come operare la malattia diverticolare del colon Possibilità di trattamento.
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Laparoscopic colonic resections for Laparoscopic colonic resections for diverticular diseasediverticular disease
Results of a single center series of 105 pts. Results of a single center series of 105 pts. Surgical strategy and technique Surgical strategy and technique
Laparoscopic colonic resections for Laparoscopic colonic resections for diverticular diseasediverticular disease
Results of a single center series of 105 pts. Results of a single center series of 105 pts. Surgical strategy and technique Surgical strategy and technique
Mean age :Mean age : 68.3 (min.30, max.81) 68.3 (min.30, max.81)Mean age :Mean age : 68.3 (min.30, max.81) 68.3 (min.30, max.81)
Laparoscopic left colon resections for Laparoscopic left colon resections for diverticulitis. Personal experience: 105 casesdiverticulitis. Personal experience: 105 cases
Laparoscopic left colon resections for Laparoscopic left colon resections for diverticulitis. Personal experience: 105 casesdiverticulitis. Personal experience: 105 cases
Laparoscopic left colon resections for Laparoscopic left colon resections for diverticulitis. Personal experience: 105 casesdiverticulitis. Personal experience: 105 cases
Laparoscopic left colon resections for Laparoscopic left colon resections for diverticulitis. Personal experience: 105 casesdiverticulitis. Personal experience: 105 cases
Indications for surgeryIndications for surgeryIndications for surgeryIndications for surgery
- 2 or more diverticulitis episodes2 or more diverticulitis episodes 56,2% 56,2%
- 1 severe diverticulitis episode in patients < 50 years 10,5%1 severe diverticulitis episode in patients < 50 years 10,5%
- StenosisStenosis 5,7% 5,7%
- Fistula with urinary bladderFistula with urinary bladder 2,9% 2,9%
- Ileo-colic fistulaIleo-colic fistula 1,9% 1,9%
- Hinchey IHinchey I Peridiverticular abscess Peridiverticular abscess 14,3% 14,3%
- Hinchey IIHinchey II Pelvic abscess 1,9% Pelvic abscess 1,9% (percutaneous drainage and surgery)(percutaneous drainage and surgery)
- Hinchey IIIHinchey III Previous peritonitis 1,9% Previous peritonitis 1,9% (laparoscopic lavage and resection after 6-8 weeks )(laparoscopic lavage and resection after 6-8 weeks )
- PerforationPerforation 3,8% 3,8%
- Acute bleeding Acute bleeding (embolization and surgery)(embolization and surgery) 0,9% 0,9%
Patients affected by stercoral peritonitis (Hinchey IV) were excluded from present study.
Recurrent diverticulitis Recurrent diverticulitis or severe in young or severe in young patientspatients
- - Primary identification of embryonary planes Primary identification of embryonary planes and ligation of the vessels with dissection from and ligation of the vessels with dissection from right to left and from up to bottomright to left and from up to bottom
Diffuse diverticular diseaseDiffuse diverticular diseaseStandard left colectomyStandard left colectomy
Diverticular disease localized Diverticular disease localized in the sigmoid colon in the sigmoid colon Sigmoid resection with Sigmoid resection with preservation of the origin of preservation of the origin of IMA and left colic arteryIMA and left colic artery
- Lowering of the splenic flexureLowering of the splenic flexure
- Sectioning of the mesorectum and the rectumSectioning of the mesorectum and the rectum
- Service minilaparotomy, extraction of the operative Service minilaparotomy, extraction of the operative specimen and execution of the colo-rectal anastomosisspecimen and execution of the colo-rectal anastomosis
- Restoring intestinal function- Restoring intestinal function 2,1 days 2,1 days
- Oral liquid diet- Oral liquid diet 2,4 days 2,4 days
- Average hospital stay- Average hospital stay 9,2 days 9,2 days (range 7-18)(range 7-18)
Last 50 cases: average number of days effectively Last 50 cases: average number of days effectively required for hospital treatment: 5,2 days required for hospital treatment: 5,2 days (range 4-12)(range 4-12)
Average operative time for Average operative time for colectomy for diverticulitiscolectomy for diverticulitisAverage operative time for Average operative time for colectomy for diverticulitiscolectomy for diverticulitis
a.a. Anastomotic leak resolved with conservative drainageAnastomotic leak resolved with conservative drainageb.b. Group 1 vs. Group 2 – p=0.54Group 1 vs. Group 2 – p=0.54c.c. Group 1 vs. Group 3 – p=0.57Group 1 vs. Group 3 – p=0.57
Tuech et al. Surg Endosc 2001Tuech et al. Surg Endosc 2001
a.a. Hospital stay Group 1 vs. Group 2: p=0.31Hospital stay Group 1 vs. Group 2: p=0.31b.b. Hospital stay Group 1 vs. Group 3: p=0.14Hospital stay Group 1 vs. Group 3: p=0.14c.c. Inpatient rehabilitation Group 1 vs Group 2: p=0.54Inpatient rehabilitation Group 1 vs Group 2: p=0.54d.d. Inpatient rehabilitation Group 1 vs Group 3: p=0.63Inpatient rehabilitation Group 1 vs Group 3: p=0.63
18 patients- acute perforation18 patients- acute perforationLaparoscopic lavage and suctionLaparoscopic lavage and suction
++ Omental patch closure Omental patch closure7.5 days in hospital7.5 days in hospital4-34 month follow-up4-34 month follow-upSubsequent elective resection Subsequent elective resection with primary anastomosis with primary anastomosis possiblepossible
Franklin et al., Surg Endosc 1997Franklin et al., Surg Endosc 1997
90% SuccessElective resection- 4-5 days in hospital5% MorbidityBetter than LaparotomyApplicable in complex cases as well (Fistula, Abscess, Perforation)
Franklin et al., Surg Endosc 1997Franklin et al., Surg Endosc 1997
- Surgical treatment of complicated diverticular Surgical treatment of complicated diverticular disease carried out laparoscopically gives good disease carried out laparoscopically gives good results in terms of morbidity and mortality and results in terms of morbidity and mortality and confers many advantages over the traditional confers many advantages over the traditional approachapproach
- Laparoscopy requires its own specific surgical Laparoscopy requires its own specific surgical strategystrategy
- The surgical team must be expert in The surgical team must be expert in laparoscopic surgery and in colo-rectal surgerylaparoscopic surgery and in colo-rectal surgery
- EEmergency cases should be performed only mergency cases should be performed only by by experienced laparoscopic surgeonsexperienced laparoscopic surgeons
- The technique must be standardized so that The technique must be standardized so that the incidence of complications, operating time the incidence of complications, operating time and the rate of conversions to open surgery and the rate of conversions to open surgery can be minimizedcan be minimized