Laparoscopic versus open Hartmann procedure for the emergency treatment of diverticulitis: a propensity-matched analysis

Laparoscopic Hartmann's procedure for complicated diverticulitis is associated with lower superficial surgical site infections compared to open surgery with similar other outcomes: a NSQIP-based, propensity score matched analysis

BACKGROUND

Open Hartmann's procedure has traditionally been the procedure of choice to treat complicated diverticulitis. We analyzed the ACS-NSQIP database to compare outcomes in patients who underwent emergent laparoscopic Hartmann's procedure (LHP) to those who had an open Hartmann's procedure (OHP).

STUDY DESIGN

Data analyzed from 2015 to 2019 using ICD-10 codes. Patients were matched on several important covariates using a propensity score matching method (PSM). Patients were matched in a 4:1 ratio of controls to cases based on the propensity score.

RESULTS

We identified 5026, of which 456 had LHP and 4570 had OHP. PSM analysis yielded 369 LHP and 1476 OHP patients. LHP had lower rates of superficial surgical site infection (SSSI) compared to OHP (2.44% vs. 5.89%, p = 0.007). LHP had similar post-operative outcomes compared to OHP, including 30-day mortality (5.15% vs. 2.98%, p = 0.060), organ space surgical site infection (OSSSI) (14.36% vs. 12.60%, p = 0.161), wound disruption (1.36% vs. 2.44%, p = 0.349), median LOS (8 vs. 9 days, p = 0.252), readmission within 30 days (11.92% vs. 8.67%, p = 0.176), rate of reoperation (6.0 vs. 6.5%, p = 0.897), and discharge to home (76% vs. 77%, p = 0.992). LHP had longer operative times compared to OHP (median 129 vs. 118 min, p < 0.0001).

CONCLUSION

The LHP is associated with lower rates of SSSI. However, it is not associated with lower rates of mortality, OSSSI, readmissions and reoperations within 30 days. Surgical times are longer in LHP. More studies are needed to determine whether LHP offers advantages in the long-term, particularly in rates of incisional hernia and colostomy closure.

Intestinal malrotation in the adult population: Diagnosis, management, and outcomes after laparoscopic Ladd procedure

BACKGROUND

The Ladd procedure is the treatment of choice for patients with intestinal malrotation; however, the long-term outcomes of the laparoscopic Ladd procedure are not well documented. This study aimed to review the presentation, management, and outcomes of adult patients who underwent a laparoscopic Ladd procedure.

METHODS

A retrospective review was conducted to identify adult patients with malrotation who underwent a laparoscopic Ladd procedure between January 1995 and June 2022 at the Mayo Clinic in Rochester, Minnesota. Patient details and follow-up data were obtained from the electronic medical records. Patients were invited to participate in a structured phone interview to assess symptoms and quality of life (QoL).

RESULTS

A total of 44 patients underwent the laparoscopic Ladd procedure. Of the 44 patients, 42 (95.5 %) were symptomatic, with 7 (16.7 %) presenting with acute symptoms. Moreover, 8 laparoscopic procedures (13.6 %) required conversion to an open procedure. The median estimated blood loss was 20 mL (IQR, 10-50), operative time was 2.3 h (IQR, 1.8-2.8), and hospital length of stay was 2 days (IQR, 2-3). Postoperative ileus was the most common complication (18.0 %). The median follow-up was 8.00 years (IQR, 2.25-13.00), with more than 90.0 % of patients having partial or complete symptom resolution. Of note, 28 patients (63.6 %) completed phone interviews. Moreover, 1 patient (2.0 %) reported a postoperative volvulus. When asked to compare their current symptoms with those preoperatively, 78.6 % of patients noted that they were significantly better. Furthermore, 85.7 % of patients reported that their QoL was significantly better after surgery. Finally, 96.4 % of patients would recommend the procedure to a friend or family member with the same condition.

CONCLUSION

The laparoscopic Ladd procedure is a safe and effective surgical procedure for adult patients with intestinal malrotation.

LapEmerge trial: study protocol for a laparoscopic approach for emergency colon resection-a multicenter, open label, randomized controlled trial

BACKGROUND

Due to faster recovery and lower morbidity rates, laparoscopy has become the gold standard in elective colorectal surgery for both the benign and malignant forms of the disease. A substantial proportion of colorectal operations are, however, carried out in emergency settings, and most of the emergency resections are still performed open. The aim of this study is to compare the laparoscopic versus open approach for emergency colorectal surgery.

METHOD/DESIGN

This is a multicenter prospective randomized controlled trial including adult patients presenting with a condition requiring emergency colorectal resection.

DISCUSSION

Previous studies cautiously recommend wider use of laparoscopy in emergency colorectal resections, but all earlier reports are retrospective, are mostly single-center studies, and have limited numbers of patients. Laparoscopy may involve some unpredictable risks that have not yet been reported because of the infrequent use of the techniqueded to assess the safety of laparoscopy as well as the advantages and disadvantages of open compared with laparoscopic emergency surgery.

TRIAL REGISTRATION

Trial registration number:  ClinicalTrials.gov   NCT05005117 . Registered on August 12, 2021.

Comparison of the risk of postoperative wound infection in patients with rectal cancer by laparoscopic versus open Hartmann's surgery

Traditional Hartmann surgery is used when the patient is in an acute case where it might not be safe to carry out a one‐stage intestinal anastomosis. Laparoscopy has been extensively applied in the treatment of large intestine, which can significantly improve both short‐ and long‐term outcomes. While randomized, controlled studies and reviews have shown that laparoscopy is superior to that of open‐access colectomy, the impact of Hartmann's surgery on postoperative site infections has not been studied. The purpose of this study is to summarize the existing evidence to show that laparoscopy is better than open operation in the area of injury. Methods The Embase, PubMed and Cochrane Libraries were searched from the moment the database was created until November 2023. For binary results, the odds ratio was estimated, and a weighted average of consecutive results was calculated. Our findings indicate that there is a lower risk for SSIs after laparoscopic approach surgery than an open‐access procedure (OR, 0.26; 95% CI, 0.10, 0.69, p  = 0.006); Laparoscopy was associated with a reduction in the risk of dying after surgery (OR, 0.50; 95% CI, 0.30, 0.84, p  = 0.009); The operation time was not significantly different in open and laparoscope (MD, 12.23; 95% CI, −5.63, 30.09, p  = 0.18); laparoscopy was used to lower the incidence of SSI after surgery and to lower the mortality rate after surgery than by open‐access surgery. However, the time of operation did not differ significantly among the two methods. However, further controlled trials will need to be carried out to verify the results.

The Association of Polish Surgeons (APS) clinical guidelines for the use of laparoscopy in the management of abdominal emergencies. Part II

INTRODUCTION

Over the past three decades, almost every type of abdominal surgery has been performed and refined using the laparoscopic technique. Surgeons are applying it for more procedures, which not so long ago were performed only in the classical way. The position of laparoscopic surgery is therefore well established, and in many operations it is currently the recommended and dominant method.

AIM

The aim of the preparation of these guidelines was to concisely summarize the current knowledge on laparoscopy in acute abdominal diseases for the purposes of the continuous training of surgeons and to create a reference for opinions.

MATERIAL AND METHODS

The development of these recommendations is based on a review of the available literature from the PubMed, Medline, EMBASE and Cochrane Library databases from 1985 to 2022, with particular emphasis on systematic reviews and clinical recommendations of recognized scientific societies. The recommendations were formulated in a directive form and evaluated by a group of experts using the Delphi method.

RESULTS AND CONCLUSIONS

There are 63 recommendations divided into 12 sections: diagnostic laparoscopy, perforated ulcer, acute pancreatitis, incarcerated hernia, acute cholecystitis, acute appendicitis, acute mesenteric ischemia, abdominal trauma, bowel obstruction, diverticulitis, laparoscopy in pregnancy, and postoperative complications requiring emergency surgery. Each recommendation was supported by scientific evidence and supplemented with expert comments. The guidelines were created on the initiative of the Videosurgery Chapter of the Association of Polish Surgeons and are recommended by the national consultant in the field of general surgery. The second part of the guidelines covers sections 6 to12 and the following challenges for surgical practice: acute appendicitis, acute mesenteric ischemia, abdominal injuries, bowel obstruction, diverticulitis, laparoscopy in pregnancy and postoperative complications requiring a reoperation.

Laparoscopic Surgery for Acute Right-colon Diverticulitis: Video Vignette and Systematic Review With Meta-analysis of Current Evidence of Minimally Invasive Versus Conventional Surgery

BACKGROUND

Over the last decade, there has been growing diffusion of minimally invasive surgery in the setting of abdominal emergencies. However, right-colon diverticulitis is still mainly approached by conventional celiotomy.

MATERIALS AND METHODS

A video vignette is presented showing the details of an emergent laparoscopic right colectomy as performed to treat a 59-year-old woman who presented with clinical signs of peritonitis, and radiologic findings suggestive of acute right-colon diverticulitis complicated by perforation of the hepatic flexure and periduodenal abscess. We also aimed to evaluate the relative outcomes of laparoscopic versus conventional surgery by meta-analyzing the currently available comparative evidence on the argument.

RESULTS

A total of 2848 patients were included in the analysis, of which 979 patients received minimally invasive surgery and 1869 had conventional surgery. Laparoscopic surgery had a longer operating time and resulted in an abbreviated hospital stay. Overall, patients receiving laparoscopy had significantly lower morbidity than those whose surgery was undertaken by laparotomy, while there was no statistically significant difference in terms of postoperative mortality.

CONCLUSIONS

According to the existing literature, minimally invasive surgery improves the postoperative outcomes of patients receiving surgery for right-sided colonic diverticulitis.

Assessing and managing frailty in emergency laparotomy: a WSES position paper

Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.

Robotic colorectal surgery in the emergent diverticulitis setting: is it safe? A review of large national database

BACKGROUND

As robotic colorectal surgery continues to advance in conjunction with improved recovery protocols, we began implementing robotic surgery (RS) as an option for emergent diverticulitis surgery. Our hospital system utilizes the Da Vinci Xi system, and staff are required to undergo training, making emergent colorectal surgery a feasible option. However, it is essential to determine the safety with reproducibility of our experiences.

METHODS

A de-identified retrospective review was performed of Intuitive's national database which obtained data from 262 facilities from January 2018 through December 2021. This identified over 22,000 emergent colorectal surgeries. Of those, over 2500 were performed for diverticulitis in which 126 were RS, 446 laparoscopic surgery (LS), and 1952 open surgery (OS). Clinical outcome metrics including conversion rates, anastomotic leaks, intensive care unit (ICU) admissions, length of stay, mortality, and readmissions were obtained. The cohort was defined by patients who were seen in the emergency department (ED) with diverticulitis and proceeded to have a sigmoid colectomy within 24 h of ED arrival.

RESULTS

RS was associated with increased operating time (RS 262, LS 207, OS 182 min), but data has shown many benefits of emergent RS compared to OS. We identified significant decreases in ICU admission rates (OS 19.0%, RS 9.5%, p = 0.01) and anastomotic leak rates (OS 4.4%, RS 0.8%, p = 0.04), with borderline improvement in overall length of stay (OS 9.9, RS 8.9 days, p = 0.05). When compared with LS, RS showed many comparable results. However, RS witnessed a statistically significant improvement in anastomotic leak rates (LS 4.5%, RS 0.8%, p = 0.04). Importantly, there was a striking difference in conversion rates to OS. LS converted over 28.7% of cases to OS, whereas RS only converted 7.9%, p = 0.000005.

CONCLUSION

Given these findings, RS is another MIS tool that could be a safe and feasible option for the acute management of emergent diverticulitis.

Laparoscopic Hartmann Procedure—A Surgery That Still Saves Lives

Background: A Hartmann operation, which is the intervention by which the lower part of the sigmoid and the upper part of the rectum are resected with the closing of the rectal stump and end colostomy, has as its indications: advanced or complicated rectosigmoid neoplasm, moderate biological condition of the patient, peritoneal sepsis, intestinal occlusion and fragile colonic wall, especially in the context of inflammatory changes. The Hartmann procedure can save lives even at the cost of a stoma reversal failure. Methods: The cases operated with the Hartmann procedure by an open approach or laparoscopic approach in our clinic, between 1 January 2016 and 31 December 2020, were admitted in this study and their medical records were reviewed, also making a comparison between the two types of approach. Univariate statistical comparisons but also a multivariate analysis was performed. Results: We performed 985 operations for intestinal and colonic occlusion (7.15% of the total operations in the clinic), 531 (54%) were non-tumor occlusions and 454 (46%) were occlusive tumors (88 Hartmann operations). Of these, 7.3% were laparoscopically performed (7 laparoscopic Hartmann operations and 23 diagnostic laparoscopies). A total of 11 cases (18%) also had colonic perforation. We compared laparoscopic Hartmann with open Hartmann and observed the benefits of laparoscopy for postoperative morbidity and mortality. The presence of pulmonary and cardiac morbidities is associated with the occurrence of general postoperative morbidities, while peritonitis is statistically significantly associated with the occurrence of local complications that are absent after the laparoscopic approach. Conclusions: The Hartmann procedure is still nowadays an operation widely used in emergency situations. Laparoscopy may become standard for the Hartmann procedure and reversal of the Hartmann procedure, but the percentage of laparoscopy remains low due to advanced or complicated colorectal cancer, poor general condition both at the first and second intervention, and the difficulties of reversal of the Hartmann procedure.

Open versus laparoscopic Hartmann's procedure: a systematic review and meta-analysis

PURPOSE

Hartmann's procedure is traditionally performed in emergency situations where single-step procedures with immediate anastomosis may be unsafe. However, it can be associated with significant morbidity and low colostomy reversal rate. Whilst randomised controlled trials and a Cochrane review have reported strong evidence of laparoscopic over open colectomies, no such reviews have been performed for Hartmann's procedure. Hence, this paper aims to summarise the existing evidence to determine the efficacy of laparoscopic Hartmann's procedure over its open counterpart.

METHODS

Embase, Medline and Cochrane databases were searched from inception to 15 November 2020 for keywords relating to 'laparoscopy' and 'Hartmann' using strict inclusion and exclusion criteria. Odds ratio was estimated for dichotomous outcomes and weighted mean difference was estimated for continuous outcomes.

RESULTS

From the 836 articles yielded from the search strategy, 12 articles were selected for meta-analysis. Pooled analysis revealed that laparoscopic Hartmann's procedure (LHP) allows for a shorter length of stay, and a lower risk of overall surgical site infections and superficial surgical site infections. There was no significant difference in other outcomes. Single-arm analysis of LHP also showed an unprecedented high colostomy reversal rate of over 80%.

CONCLUSION

In clinically suitable patients, laparoscopic Hartmann's procedure has benefits over open Hartmann's procedure. Despite the selection bias of single-arm studies, LHP has reported a high stoma reversal rate of over 80%. Future well-controlled studies should be done to affirm the findings.

Laparoscopic versus open emergent colectomy for ischemic colitis: a propensity score-matched comparison

Introduction

Laparoscopic colectomy is rarely performed for ischemic colitis. The aim of this propensity score-matched study was to compare preoperative characteristics, intraoperative details and short-term outcomes for emergent laparoscopic colectomy versus the traditional open approach for patients with ischemic colitis.

Methods

Retrospective review of 96 patients who underwent emergent colectomy for ischemic colitis between January 2011 and December 2020 (39 via laparoscopy, 57 via laparotomy) was performed. We compared short-term outcomes after using a one-to-one ratio and nearest-neighbor propensity score matching to obtain similar preoperative and intraoperative parameters in each group.

Results

Patients in the open group experienced more surgical site complications (52.6% vs. 23.0%, p = 0.004), more intra-abdominal abscesses (47.3% vs. 17.9%, p = 0.003), longer need for ventilator support (20 days vs. 0 days, p < 0.001), more major complications (77.2% vs. 43.5%, p = 0.001), higher mortality (49.1% vs. 20.5%, p = 0.004), and longer hospital stay (32 days vs. 19 days, p = 0.001). After propensity score matching (31 patients in each group), patients undergoing open (vs. laparoscopy) had more surgical site complications (45.1% vs. 19.4%, p = 0.030) and required longer ventilator support (14 vs. 3 days, p = 0.039). After multivariate analysis, Charlson Comorbidity Index (p = 0.024), APACHE II score (p = 0.001), and Favier’s classification (p = 0.023) were independent predictors of mortality.

Conclusions

Laparoscopic emergent colectomy for ischemic colitis is feasible and is associated with fewer surgical site complications and better respiratory function, compared to the open approach.

Is laparoscopic surgery safe for elderly patients with diverticulitis? A national database study

PURPOSE

Laparoscopy is the preferred approach to elective surgery for diverticulitis and is increasingly common in the emergent setting. Although diverticulitis is most prevalent among older adults, little is known about the safety of laparoscopy for elderly patients with diverticulitis. This study aims to compare 30-day outcomes of a laparoscopic versus open approach for diverticulitis among elderly patients undergoing elective and urgent/emergent surgery.

METHODS

Patients ≥ 65 years who underwent surgery for diverticulitis from 2015 to 2019 were identified from the ACS-NSQIP database. Elective and non-elective groups were analyzed separately. Coarsened exact matching matched laparoscopic and open patients 1:1 based on preoperative factors to minimize selection bias by creating comparable cohorts. Short-term outcomes of laparoscopic versus open surgery were compared.

RESULTS

A total of 15,316 patients were included, 69.2% female and 88% White, with a mean age of 72.7 ± 6.1 years. Approximately half (50.9%) of cases were laparoscopic and 60.6% were elective. After matching, laparoscopy was associated with lower 30-day morbidity in both the elective (OR, 0.47; 95%CI, 0.38-0.58) and non-elective (OR, 0.76; 95%CI, 0.58-0.98) cohorts. Laparoscopic surgery in both cohorts was associated with fewer surgical site infections (SSIs) (elective, OR 0.43; 95%CI, 0.33-0.57; non-elective, OR, 0.66; 95%CI, 0.44-0.98) and shorter length of stay (LOS) (elective, mean difference, 1.7 days; 95%CI, 1.5-1.9; non-elective, mean difference, 1.2 days; 95%CI, 0.43-2.1).

CONCLUSION

Elderly patients undergoing both elective and non-elective laparoscopic surgery for diverticulitis have less 30-day morbidity, SSIs, and shorter LOS compared to an open approach. Therefore, laparoscopy for elderly patients is safe in elective surgery and in select emergent cases as well.

Minimally invasive surgery in emergency surgery: a WSES survey

BACKGROUND

The diffusion of minimally invasive surgery in emergency surgery still represents a developing challenge. Evidence about the use of minimally invasive surgery shows its feasibility and safety; however, the diffusion of these techniques is still poor. The aims of the present survey were to explore the diffusion and variations in the use of minimally invasive surgery among surgeons in the emergency setting.

METHODS

This is a web-based survey administered to all the WSES members investigating the diffusion of minimally invasive surgery in emergency. The survey investigated personal characteristics of participants, hospital characteristics, personal confidence in the use of minimally invasive surgery in emergency, limitations in the use of it and limitations to prosecute minimally invasive surgery in emergency surgery. Characteristics related to the use of minimally invasive surgery were studied with a multivariate ordinal regression.

RESULTS

The survey collected a total of 415 answers; 42.2% of participants declared a working experience > 15 years and 69.4% of responders worked in tertiary level center or academic hospital. In primary emergencies, only 28,7% of participants declared the use of laparoscopy in more than 50% of times. Personal confidence with minimally invasive techniques was the highest for appendectomy and cholecystectomy. At multivariate ordinal regression, a longer professional experience, the use of laparoscopy in major elective surgery and bariatric surgery expertise were related to a higher use of laparoscopy in emergency surgery.

CONCLUSIONS

The survey shows that minimally invasive techniques in emergency surgery are still underutilized. Greater focus should be placed on the development of dedicated training in laparoscopy among emergency surgeons.

Fistulating diverticular disease masquerading as a peri-anal abscess: a laparoscopic approach to management

We present a rare case of complicated sigmoid diverticulitis presenting as a peri-anal abscess from an extra-sphincteric fistulous tract. This presentation of a colocutaneous peri-anal abscess is extremely rare, with only a handful of cases described in the literature. Most are managed with an open sigmoid colectomy, however, this case was successfully managed laparoscopically. It highlights the need to consider extra-levator causes of peri-anal abscess, such as pelvic sepsis causing fistulating disease, and to consider early magnetic resonance imaging if there is clinical suspicion of underlying pathology. It also demonstrates that a safe and potentially less morbid outcome is possible via laparoscopic approach when compared to traditional open surgical approach.

Laparoscopic Versus Open Colorectal Surgery in the Emergency Setting: A Systematic Review and Meta-analysis

Objective

This systematic review and meta-analysis aimed to compare published outcomes of patients undergoing laparoscopic versus open emergency colorectal surgery, with mortality as primary outcome.

Background

In contrast to the elective setting, the value of laparoscopic emergency colorectal surgery remains unclear.

Methods

PubMed, Embase, the Cochrane Library, and CINAHL were searched until January 6, 2021. Only comparative studies were included. Meta-analyses were performed using a random-effect model. The Cochrane Risk of Bias Tool and the Newcastle-Ottawa Scale were used for quality assessment.

Results

Overall, 28 observational studies and 1 randomized controlled trial were included, comprising 7865 laparoscopy patients and 55,862 open surgery patients. Quality assessment revealed 'good quality' in 16 of 28 observational studies, and low to intermediate risk of bias for the randomized trial. Laparoscopy was associated with significantly lower postoperative mortality compared to open surgery (odds ratio [OR] 0.44; 95% confidence interval [CI], 0.35-0.54). Laparoscopy resulted in significantly less postoperative overall morbidity (OR, 0.53; 95% CI, 0.43-0.65), wound infection (OR, 0.63; 95% CI, 0.45-0.88), wound dehiscence (OR, 0.37; 95% CI, 0.18-0.77), ileus (OR, 0.68; 95% CI 0.51-0.91), pulmonary (OR, 0.43; 95% CI, 0.24-0.78) and cardiac complications (OR, 0.56; 95% CI, 0.35-0.90), and shorter length of stay. No meta-analyses were performed for long-term outcomes due to scarcity of data.

Conclusions

The systematic review and meta-analysis suggest a benefit of laparoscopy for emergency colorectal surgery, with a lower risk of postoperative mortality and morbidity. However, the almost exclusive use of retrospective observational study designs with inherent biases should be taken into account.

Minimally Invasive Management of Diverticular Disease

Traditionally, management of complicated diverticular disease has involved open damage control operations with large definitive resections and colostomies. Studies are now showing that in a subset of patients who would typically have undergone an open Hartmann's procedure for Hinchey III/IV diverticulitis, a laparoscopic approach is equally safe, and has better outcomes. Similar patients may be good candidates for primary anastomosis to avoid the morbidity and subsequent reversal of a colostomy. While most operations for diverticulitis across the country are still performed open, there has been an incremental shift in practice toward minimally invasive approaches in the elective setting. The most recent data from large trials, most notably the SIGMA trial, found laparoscopic sigmoid colectomy is associated with fewer short-term and long-term complications, decreased pain, improvement in length of stay, and maintains better cost-effectiveness than open resections. Some studies even demonstrate that robotic sigmoid resections can maintain a similar if not more reduction in morbidity as the laparoscopic approach while still remaining cost-effective. Intraoperative approaches also factor into improving outcomes. One of the most feared complications in colorectal surgery is anastomotic leak, and many studies have sought to find ways to minimize this risk. Factors to consider to minimize incidence of leak are the creation of tension-free anastomoses, amount of contamination, adequacy of blood supply, and a patient's use of steroids. Techniques supported by data that decrease anastomotic leaks include preoperative oral antibiotic and mechanical bowel prep, intraoperative splenic flexure mobilization, low-tie ligation of the inferior mesenteric artery, and use of indocyanine green immunofluorescence to assess perfusion. In summary, the management of benign diverticular disease is shifting from open, morbid operations for a very common disease to a minimally invasive approach. In this article, we review those approaches shown to have better outcomes, greater patient satisfaction, and fewer complications.

Open vs Minimally Invasive Approach for Emergent Colectomy in Perforated Diverticulitis

BACKGROUND

Traditionally, perforated diverticulitis has been managed with an open approach, with a Hartmann procedure or a colectomy with primary anastomosis. Minimally invasive surgery is associated with postoperative advantages in the elective setting and may show a benefit in the emergent setting.

OBJECTIVE

The aim of this study was to compare postoperative outcomes of open vs minimally invasive approaches for emergent perforated diverticulitis.

DESIGN

This was a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database using propensity score matching.

SETTINGS

Interventions were performed in hospitals participating in the national database.

PATIENTS

Patients who underwent emergent colectomy from 2012 to 2017 were included. Procedures were divided into Hartmann procedure and primary anastomosis. Open vs minimally invasive groups were defined by intention to treat.

MAIN OUTCOME MEASURES

Outcomes measures included length of stay and overall morbidity and mortality.

RESULTS

Of 130,616 patients, 7105 met inclusion criteria (4486 Hartmann procedure and 2619 primary anastomosis). A total of 1989 open Hartmann procedure cases were matched to 663 minimally invasive cases. The minimally invasive group underwent longer operations and had lower rates of respiratory failure. There were no differences in overall complications, mortality, length of stay, or home discharge. In the primary anastomosis group, 1027 cases were matched 1:1. The minimally invasive approach was associated with longer operative times, but reduced wound dehiscence, sepsis, bleeding, overall complications, and length of stay. No difference was detected in anastomotic leak, mortality, reoperation, or readmission rates.

LIMITATIONS

Limitations include retrospective nature, data loss, nonuniformity, selection bias, and coding errors.

CONCLUSIONS

Emergent minimally invasive primary anastomosis results in a shorter length of stay and decreased 30-day morbidity in comparison with open primary anastomosis for perforated diverticulitis. Emergent open and minimally invasive Hartmann procedures for perforated diverticulitis have comparable outcomes, perhaps because of a 40% conversion rate. See Video Abstract at http://links.lww.com/DCR/B421.

ABORDAJE ABIERTO VERSUS MNIMAMENTE INVASIVO PARA COLECTOMA DE EMERGENCIA EN DIVERTICULITIS PERFORADA

ANTECEDENTES:Tradicionalmente, la diverticulitis perforada se ha tratado con un abordaje abierto, con un procedimiento de Hartmann o una colectomía con anastomosis primaria. La cirugía mínimamente invasiva se asocia con ventajas posoperatorias en el escenario electivo y puede mostrar beneficio en el escenario emergente.OBJETIVO:El objetivo de este estudio fue comparar los resultados posoperatorios del abordaje abierto versus el mínimamente invasivo para la diverticulitis perforada emergente.DISEÑO:Ésta fue una revisión retrospectiva de la base de datos de colectomía dirigida del Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Americano de Cirujanos utilizando el pareamiento por puntaje de propensión.ESCENARIO:Las intervenciones se realizaron en los hospitales participantes en la base de datos nacional.PACIENTES:Se incluyeron pacientes que fueron sometidos a colectomía emergente de 2012 a 2017. Los procedimientos se dividieron en procedimiento de Hartmann y anastomosis primaria. Los grupos abierto versus mínimamente invasivo se definieron por intención de tratar.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado incluyeron la duración de la estancia, la morbilidad general y la mortalidad.RESULTADOS:De 130,616 pacientes, 7,105 cumplieron los criterios de inclusión (4,486 procedimiento de Hartmann y 2,619 anastomosis primaria). 1,989 casos abiertos de procedimientos de Hartmann se emparejaron con 663 casos mínimamente invasivos. El grupo mínimamente invasivo se sometió a operaciones más prolongadas y tuvo tasas más bajas de insuficiencia respiratoria. No hubo diferencias en las complicaciones generales, la mortalidad, la duración de la estancia o el alta domiciliaria. En el grupo de anastomosis primaria, 1,027 casos se emparejaron 1: 1. El abordaje mínimamente invasivo se asoció con tiempos quirúrgicos más prolongados, pero también con tasas reducidas de dehiscencia de herida, sepsis, sangrado, complicaciones generales y la duración de la estancia. No se detectaron diferencias en las tasas de fuga anastomótica, mortalidad, reintervención o reingreso.LIMITACIONES:Las limitaciones incluyen la naturaleza retrospectiva, pérdida de datos, falta de uniformidad, sesgo de selección y errores de codificación.CONCLUSIONES:La anastomosis primaria mínimamente invasiva emergente resulta en una estancia más corta y una disminución de la morbilidad a los 30 días en comparación con la anastomosis primaria abierta para la diverticulitis perforada. El procedimiento de Hartmann abierto y mínimamente invasivo de emergencia para la diverticulitis perforada tiene resultados comparables, quizás debido a una tasa de conversión del 40%. Consulte el Video Resumen en http://links.lww.com/DCR/B421.

Complicated Diverticular Disease

The modern management of colonic diverticular disease involves grouping patients into uncomplicated or complicated diverticulitis, after which the correct treatment paradigm is instituted. Recent controversies suggest overlap in management strategies between these two groups. While most reports still support surgical intervention for the treatment of complicated diverticular disease, more data are forthcoming suggesting complicated diverticulitis does not merit surgical resection in all scenarios. Given the significant risk for complication in surgery for diverticulitis, careful attention should be paid to patient and procedure selection. Here, we define complicated diverticulitis, discuss options for surgical intervention, and explain strategies for avoiding operative pitfalls that result in early and late postoperative complications.

Prognostic Factors and Management for Left Colonic Perforation: Can Hartmann's Procedure Be Preventable?

PURPOSE

To identify factors significantly associated with the mortality of patients with left colonic perforation, and to compare the outcome of Hartmann's procedure (HP) and primary repair (PR) or primary anastomosis (PA) in patients with left colonic perforation without factors associated with mortality.

METHODS

This retrospective study included patients who underwent surgery for left colonic perforation from January 2009 to February 2018. Preoperative factors related to postoperative mortality, including vital signs, laboratory findings, and intraoperative findings, were analyzed by type of operation. The chi-square, Fisher exact, and Mann-Whitney U-tests were used to analyze the data.

RESULTS

Ninety-one patients were included (36 men, 55 women), and 15 (16.5%) died postoperatively. Prognostic factors were age, leukopenia, thrombocytopenia, bleeding tendency, acute kidney injury, hemodynamic instability, and the existence of feculent ascites. Leukopenia and longer operative time were independent risk factors for mortality. Seventy-nine patients did not have leukopenia and 30 of these patients who underwent PR without diversion were excluded from the subanalysis. HP was performed in 30 patients, and PR with diversion and PA with or without diversion were performed in 19. Compared to the other operative methods, HP had no advantage in reducing hospital mortality (P=0.458) and morbidity.

CONCLUSION

Leukopenia could be an objective prognostic factor for left colonic perforation. Although HP is the gold standard for septic left colonic perforation, it did not improve the hospital mortality of the patients without leukopenia. For such patients, PR or PA may be suggested as an alternative option for left colonic perforation.

Laparoscopic Versus Open Emergent Sigmoid Resection for Perforated Diverticulitis

BACKGROUND

Potential advantages of laparoscopic sigmoidectomy for perforated diverticulitis are still under consideration. This study is designed to determine if emergent laparoscopic sigmoidectomy for perforated diverticulitis is associated with outcomes comparable to the traditional open approach.

METHODS

The American College of Surgeons-National-Surgical-Quality-Improvement-Program (ACS-NSQIP) database was queried for laparoscopic and open emergent sigmoidectomy cases for perforated diverticulitis from 2012 through 2017. Using propensity score weights, 30-day outcomes between laparoscopic and open approaches were compared in two ways: one with converted cases as a separate group and another with converted cases combined with the laparoscopic-completed group (intention-to-treat).

RESULTS

A total of 3756 cases met inclusion criteria-282 laparoscopic-completed, 175 laparoscopic-converted-to-open, and 3299 open. The laparoscopic-completed approach had significantly better outcomes than open and laparoscopic-converted cases. When combining laparoscopic-completed and laparoscopic-converted cases (intention-to-treat), the laparoscopic approach still had significantly fewer complications per patient, less unplanned intubation (p = 0.01), and acute renal failure (p = 0.005) than the open group. Laparoscopic groups had longer operating times and shorter hospital length of stay than the open group. Subgroup analysis comparing laparoscopic and open Hartmann's procedure and primary anastomosis with and without diverting stoma also showed favorable outcomes for the laparoscopic group.

CONCLUSIONS

Laparoscopic emergent sigmoid resection for perforated diverticulitis is associated with favorable outcomes compared to the open approach. Hartmann's procedure is still common and conversion rate is high. Training efforts that increase adoption of minimally invasive surgery and decrease conversion rates are justified. Randomized trials comparing laparoscopic and open approaches may allow further critical assessment of these findings.

Emergency Surgery in Acute Diverticulitis: A Systematic Review

BACKGROUND

Acute diverticulitis is a common disease with public health significance. Many studies with a high level of evidence have been published recently on the surgical management of acute diverticulitis.

OBJECTIVE

The aim of this systematic review was to define the accurate surgical management of acute diverticulitis.

DATA SOURCES

Medline, Embase, and the Cochrane Library were sources used.

STUDY SELECTION

One reviewer conducted a systematic study with combinations of key words for the disease and the surgical procedure. Additional studies were searched in the reference lists of all included articles. The results of the systematic review were submitted to a working group composed of 13 practitioners. All of the conclusions were obtained by full consensus and validated by an external committee.

INTERVENTIONS

The interventions assessed were laparoscopic peritoneal lavage, primary resection with anastomosis with or without ileostomy, and the Hartmann procedure, with either a laparoscopic or an open approach.

MAIN OUTCOME MEASURES

Morbidity, mortality, long-term stoma rates, and quality of life were measured.

RESULTS

Seventy-one articles were included. Five guidelines were retrieved, along with 4 meta-analyses, 14 systematic reviews, and 5 randomized controlled trials that generated 8 publications, all with a low risk of bias, except for blinding. Laparoscopic peritoneal lavage showed concerning results of deep abscesses and unplanned reoperations. Studies on Hinchey III/IV diverticulitis showed similar morbidity and mortality. A reduced length of stay with Hartmann procedure compared with primary resection with anastomosis was reported in the short term, and in the long term, more definite stoma along with poorer quality of life was reported with Hartmann procedure. No high-quality data were found to support the laparoscopic approach.

LIMITATIONS

Trials specifically assessing Hinchey IV diverticulitis have not yet been completed.

CONCLUSIONS

High-quality studies showed that laparoscopic peritoneal lavage was associated with an increased morbidity and that Hartmann procedure was associated with poorer long-term outcomes than primary resection with anastomosis with ileostomy, but Hartmann procedure is still acceptable, especially in high-risk patients.

Role of Emergency Laparoscopic Colectomy for Colorectal Cancer: A Population-based Study in England

OBJECTIVE

To evaluate factors associated with the use of laparoscopic surgery and the associated postoperative outcomes for urgent or emergency resection of colorectal cancer in the English National Health Service.

SUMMARY OF BACKGROUND DATA

Laparoscopy is increasingly used for elective colorectal cancer surgery, but uptake has been limited in the emergency setting.

METHODS

Patients recorded in the National Bowel Cancer Audit who underwent urgent or emergency colorectal cancer resection between April 2010 and March 2016 were included. A multivariable multilevel logistic regression model was used to estimate odds ratios (ORs) of undergoing laparoscopic resection and postoperative outcome according to approach.

RESULTS

There were 15,516 patients included. Laparoscopy use doubled from 15.1% in 2010 to 30.2% in 2016. Laparoscopy was less common in patients with poorer physical status [American Society of Anaesthesiologists (ASA) 4/5 vs 1, OR 0.29 (95% confidence interval, 95% CI 0.23-0.37), P < 0.001] and more advanced T-stage [T4 vs T0-T2, OR 0.28 (0.23-0.34), P < 0.001] and M-stage [M1 vs M0, OR 0.85 (0.75-0.96), P < 0.001]. Age, socioeconomic deprivation, nodal stage, hospital volume, and a dedicated colorectal emergency service were not associated with laparoscopy. Laparoscopic patients had a shorter length of stay [median 8 days (interquartile range (IQR) 5 to 15) vs 12 (IQR 8 to 21), adjusted mean difference -3.67 (-4.60 to 2.74), P < 0.001], and lower 90-day mortality [8.1% vs 13.0%; adjusted OR 0.78 (0.66-0.91), P = 0.004] than patients undergoing open resection. There was no significant difference in rates of readmission or reoperation by approach.

CONCLUSION

The use of laparoscopic approach in the emergency resection of colorectal cancer is linked to a shorter length of hospital stay and reduced postoperative mortality.

The role of emergency laparoscopic colectomy for complicated sigmoid diverticulits: A systematic review and meta-analysis

BACKGROUND

Nowadays sigmoidectomy is recommended as "gold standard" treatment for generalized purulent or faecal peritonitis from sigmoid perforated diverticulitis. This systematic review and meta-analysis aimed to assess effectiveness and safety of laparoscopic access versus open sigmoidectomy in acute setting.

METHODS

A systematic literature search was performed for randomized controlled trials (RCTs) and non-RCTs published in PubMed, SCOPUS and Web of Science.

RESULTS

The search yielded four non-RCTs encompassing 436 patients undergoing either laparoscopic (181 patients, 41.51%) versus open sigmoid resection (255 patients, 58.49%). All studies reported ASA scores, but only four studies reported other severity scoring systems (Mannheim Peritonitis Index, P-POSSUM). Level of surgical expertise was reported in only one study. Laparoscopy improves slightly the rates of overall post-operative complications and post-operative hospital stay, respectively (RR 0.62, 95% CI 0.49 to 0.80 and MD -6.53, 95% CI -16.05 to 2.99). Laparoscopy did not seem to improve the other clinical outcomes: rate of Hartmann's vs anastomosis, operating time, reoperation rate and postoperative 30-day mortality.

CONCLUSION

In this review four prospective studies were included, over 20 + year period, including overall 400 + patients. This meta-analysis revealed significant advantages associated with a laparoscopic over open approach to emergency sigmoidectomy in acute diverticulitis in terms of postoperative complication rates, although no differences were found in other outcomes. The lack of hemodynamic data and reasons for operative approach hamper interpretation of the data suggesting that patients undergoing open surgery were sicker and these results must be considered with extreme caution and this hypothesis requires confirmation by future prospective randomised controlled trials.

Hartmann’s Procedure for Complicated Diverticulitis: A Critical Reappraisal

Background:

Complicated diverticulitis in advanced stages (Hinchey III, IV) is an important surgical emergency for which Hartmann’s Procedure (HP) has traditionally represented the gold standard treatment. HP, however, has high mortality and morbidity and a low percentage of reanastomosis rate. Increasing efforts have therefore been made in recent years to propose alternatives.

Objective:

To critically review studies on the outcome of HPvs.alternative procedures for complicated diverticulitis Resection-Anastomosis without [RA] or with [RAS] protective stomia, Laparoscopic Lavage [LL].

Methods:

Literature search in PubMed for original and review papers in the past 20 years (up to July 2019) with keywords: Hartmann’s procedure, complicated diverticulitis.

Results:

Comparative studies on HPvs. RA/RAS overall reveal better outcomes of RA/RAS,i.e., reduced mortality, morbidity and healthcare costs. However, most studies have limitations due to lack of randomization, limited number of patients and significant impact of surgeons’ specialization and hospital setting/organization in the decision of the type of surgery to perform. These factors might induce preferential allocation of the most critical patients (advanced age, hemodynamic instability, numerous comorbidities) to HP rather than RA/RAS. LL shows promising results but has been tested in a too small number of trialsvs. HP to draw definite conclusions.

Conclusion:

Though valid alternatives to HP are being increasingly employed, consensus on the best approach to complicated diverticulitis has not yet been reached. HP is still far from representing an obsolete intervention, rather it appears to be the preferred choice in the most critical patients.

Application of Negative Pressure Wound Therapy with Instillation and Dwell Time of the Open Abdomen: Initial Experience

Recent therapeutic advances in the management of severe abdominal sepsis (SAS) have improved patient mortality and morbidity. However, SAS and its impact on multiple organ failure remain a serious, life-threatening condition with a high mortality rate. The open abdomen (OA) technique has become an effective alternative to repeat laparotomy. The use of OA negative pressure wound therapy (OA NPWT) has been a significant advancement in the management of the open abdomen. Similarly, negative pressure wound therapy (NPWT) with instillation and dwell time (NPWT-i) has been used in patients with multiple comorbidities, with an American Society of Anesthesiology Classification ≥ 2, severe traumatic wounds, diabetic foot infections, and wounds complicated by invasive infection or extensive biofilm. Controlled instillation of saline during NPWT-i may further enhance healing by facilitating automatic and contained volumetric wound irrigation and cleansing and diluting local levels of inflammatory cytokines, improving the local as well as the systemic response to infection. Although the soft tissue and intra-abdominal compartments differ anatomically, they share very similar biologic responses to infections. Therefore, from a biologic and physiologic aspect, intraperitoneal instillation therapy may play a role as an adjunctive treatment of abdominal compartment inflammation from trauma or infection. The addition of saline solution instillation to OA NPWT (OAI) in a programmed, controlled manner may offer the clinician an effective adjunctive therapy for the treatment of the complex septic abdomen. The technical aspects of instillation into the OA and a pooled multicenter case study cohort utilizing OAI with saline solution, bacitracin, or hypochlorous acid in the management of the septic abdomen is presented.

Emergency Hartmann's Procedure and Its Reversal: A Totally Laparoscopic 2-Step Surgery for the Treatment of Hinchey III and IV Diverticulitis

BACKGROUND

Hartmann's procedure (HP) followed by reversal restoration is the first choice for treatment of diffuse diverticular peritonitis. There is no unanimous consensus regarding the use of laparoscopy to treat the same condition.

METHODS

Data from 60 patients with diverticular diffuse peritonitis who underwent urgent HP followed by laparoscopic reversal were retrospectively analyzed. Patients were divided into 2 groups according to the open or laparoscopic HP (OHP, 24 patients; LHP, 36 patients). Outcomes were measured in terms of functional recovery, morbidity, mortality, and length of hospital stay.

RESULTS

HPs showed no differences among the groups in terms of operative time, blood loss, and length of intensive care unit stay. Overall morbidity was significantly lower in LHP than in OHP, corresponding to 33.3% and 66.7% respectively ( P = .018). The incidence of both surgical and medical complications was higher in OHP than in LHP (41.7% vs 22.2% [ P = .044] and 45.8% vs 24.3% [ P = .023], respectively). Mortality was 16.6% for each group. LHP showed a faster return to bowel movements and a shorter hospital stay than OHP. The secondary intestinal reversal was possible in 92% of cases, successfully completed laparoscopically in 91.3%. No patients of LHP group required a conversion to open intestinal reversal.

CONCLUSION

LHP for treatment of diverticular diffuse peritonitis showed significantly lower morbidity, faster recovery, shorter hospital stay, and higher rates of successful laparoscopic reversal when compared with OHP.

The Growing Utilization of Laparoscopy in Emergent Colonic Disease

Emergent colonic disease has traditionally been managed with open procedures. Evaluation of recent trends suggests a shift toward minimally invasive techniques in this disease setting. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2014 was used to examine clinical data from patients who emergently underwent open colectomy (OC) and laparoscopic colectomy (LC). Multivariate regression was utilized to analyze preoperative characteristics and determine risk-adjusted outcomes with intent-to-treat and as-treated approach. Of 10,018 patients with emergent colonic operation, 90 per cent (9023) underwent OC whereas 10 per cent (995) underwent LC. Laparoscopic utilization increased annually, with LC composing 10.9 per cent of emergent colonic operations in 2014 compared with 9.3 per cent in 2012. Compared with LC, patients treated with OC had higher rates of overall morbidity (odds ratio 2.01, 95% confidence interval 1.74–2.34, P < 0.01) and 30-day mortality (odds ratio 1.79, 95% confidence interval 1.30–2.46, P < 0.01). Subset analysis of emergent patients without preoperative septic shock revealed consistent benefits with laparoscopy in overall morbidity, 30-day mortality, ileus, and surgical site infection. In select patients with hemodynamic stability, emergent LC appears to be a safe and beneficial operation. This study reflects the growing preference and utilization of minimally invasive techniques in emergent colonic operations.

Comparative Analysis of Laparoscopic and Open Approaches in Emergency Abdominal Surgery

The objective of this study was to evaluate usage and outcomes of emergency laparoscopic versus open surgery at a single tertiary academic center. Over a three-year period 165 patients were identified retrospectively using National Surgical Quality Improvement Program results. Appendectomies and cholecystectomies were excluded. Open and laparoscopic approaches were compared regarding preoperative and operative characteristics, the development of postoperative complications, 30-day mortality, and length of hospital stay. Indications for operation were similar between groups. Patients who underwent open surgery had more severe comorbidities and higher ASA class. Laparoscopy was associated with reduced complication rates, operative time, length of stay, and discharges to skilled nursing facilities on univariate analysis. In a multivariate model, surgical approach was not associated with the development of complications. Older age, dependent status, and dyspnea were predictors of conversion from attempted laparoscopic to open approaches.

Hartmann's reversal: a comparative study between laparoscopic and open approaches

BACKGROUND

A reversal of Hartmann's procedure can be performed using either a laparoscopic or open approach. However, laparoscopic reversal (LR) of Hartmann's procedure is challenging. This study was designed to compare the results between open and laparoscopic approaches.

METHODS

This was a retrospective study of prospectively collected data. We analysed 29 patients who received Hartmann's reversal at Korea University Anam Hospital between April 2007 and September 2014. All patients underwent either LR (n = 17) or open reversal (OR, n = 12).

RESULTS

Patient characteristics were similar between the LR and OR groups. There was also no difference in mean operation time (212.5 versus 251.8 min), diversion ileostomy, length of hospital stay, postoperative analgesic days, time to diet resumption (3.9 versus 6.2 days) or complication rate. Although the time to resuming a solid diet was not different between the two groups (P = 0.053), bowel movement occurred faster in LR patients (LR versus OR, 1.8 versus 2.8 days, P = 0.020). Patients in the LR group also had less blood loss during surgery (114.1 versus 594.2 mL, P = 0.026). There were no mortalities in this study.

CONCLUSION

LR of Hartmann's procedure resulted in faster bowel function recovery than the open method. Laparoscopic approaches are feasible even for patients who received an open Hartmann's procedure.

Risk Factors for Surgical Site Infection in Open and Laparoscopic Hartmann Closure: A Multivariate Analysis

BACKGROUND

Hartmann reversal is a high-morbidity procedure. The aim of this study is to identify risk factors for surgical site infection (SSI) in the era of laparoscopy.

MATERIALS AND METHODS

A query of the National Surgical Quality Improvement Program database was done. Patients undergoing open or laparoscopic Hartmann reversals were identified. Risk factors for and the incidence of SSI were assessed in both groups.

RESULTS

A total of 7970 patients were identified and 1431 (18%) were done laparoscopically. The SSI rate in the overall population was 13.6%, with 14.9% in those undergoing open surgery and 8% with laparoscopic procedures. Obese patients and smokers had the highest incidences of SSI (18% and 17.5%, respectively). Open surgery (odds ratio=1.8, P<0.001) and obesity (odds ratio=1.6, P<0.001) significantly correlated with higher SSI rates.

CONCLUSIONS

Patients undergoing Hartmann closure are at risk for SSI. Our findings indicate that laparoscopy can significantly reduce SSI, particularly in obese patients.

Complicated diverticular disease: Position statement on outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage and laparoscopic approach. Consensus document of the Spanish Association of Coloproctology and the Coloproctology Section of the Spanish Association of Surgeons

The Spanish Association of Coloproctology (AECP) and the Coloproctology Section of the Spanish Association of Surgeons (AEC), propose this consensus document about complicated diverticular disease that could be used for decision-making. Outpatient management, Hartmann's procedure, laparoscopic peritoneal lavage, and the role of a laparoscopic approach in colonic resection are exposed.

Laparoscopic Approach in Colonic Diverticulitis: Dispelling Myths and Misperceptions

BACKGROUND/AIM

Diverticular disease is a first-class health care problem and one of the most common gastrointestinal disorders in western industrialized countries, causing significant morbidity and mortality. In this review of the literature, we aim to assess the feasibility and effectiveness of the laparoscopic approach in both elective and emergency setting of diverticular disease.

MATERIALS AND METHODS

A bibliographic search of articles was performed using the electronic database Medline from PubMed. Of 341 articles identified, 279 were excluded, resulting in 62 full-text articles for review. Our final review included 16 articles.

RESULTS

The 16 articles included in the final review consisted of 6 retrospective studies, 5 prospective studies, 2 randomized controlled trials, 1 systematic review and meta-analysis, and 2 systematic reviews. Seven articles considered elective laparoscopic sigmoid resection, 7 articles evaluated laparoscopic peritoneal lavage, and 2 articles considered emergency laparoscopic sigmoid resection for perforated diverticulitis. The elective laparoscopic approach is feasible and safe. Laparoscopic peritoneal lavage has emerged as a safe and effective minimally invasive procedure for the treatment of perforated diverticulitis. Furthermore, in selected patients, emergency laparoscopic sigmoidectomy could also be feasible for perforated diverticulitis with generalized peritonitis.

CONCLUSIONS

Laparoscopic approach can be a safe and effective option in both elective and emergency setting of diverticular disease. Large, prospective, randomized studies should be conducted to confirm these findings.

Laparoscopy for Benign Diseases of the Colon

Laparoscopic surgery has revolutionized the delivery of care to the surgical patient undergoing colorectal resection. Since the first laparoscopic-assisted colectomy in 1991, significant advances have been made in minimally invasive colorectal surgery. For many benign conditions, laparoscopic colectomy has been proven to be safe and effective, and in some instances superior when compared with open surgery. Complex laparoscopic resections such as those for diverticulitis and inflammatory bowel disease have also been shown to have equivalent outcomes when compared with open surgery. Short-term benefits of a minimally invasive approach include less pain, decreased rates of wound infection and postoperative morbidity, faster return of bowel function, and shorter length of stay. Improvements in long-term complications have also been noted with lower incidence of incisional hernias and small bowel obstructions secondary to adhesions. As surgeons become more facile with laparoscopic resection, more complex cases such as those for complicated diverticulitis and reoperative surgery for inflammatory bowel disease can be completed with shorter operative times and decreased cost.

Open versus laparoscopic approach in the treatment of abdominal emergencies in elderly population

AIM

To evaluate the role of laparoscopy in the treatment of surgical emergency in old population.

PATIENTS AND METHODS

Over-70 years-old patients submitted to emergency abdominal surgery from January 2013 to December 2014 were collected and grouped according to admission diagnoses. These accounted small bowel obstruction, colonic acute disease, appendicitis, ventral hernia, gastro-duodenal perforation, biliary disease. In each group it was analyzed the operation time (OT), the morbidity rate and the mortality rate comparing open and laparoscopic management using T-test and Chi-square test.

RESULTS

159 over 70-years-old patients underwent emergency surgery in the General and Emergency surgery Operative Unit (O.U.) of the Policlinic of Palermo. 75 patients were managed by a laparoscopic approach and 84 underwent traditional open emergency surgery. T-Test for OT and Chi-square test for morbidity rate and mortality rate showed no differences in small bowel emergencies (p=0,4; 0,250,9; p>0,95) and in gastro-duodenal perforation (p=0,9; p>0.9; p>0.95). In cholecystitis, laparoscopy group showed lower OT (T-Test: p= 0,0002) while Chi-square test for morbidity rate (0,1

CONCLUSIONS

The collected data showed the feasibility of laparoscopic management as an alternative to open surgery in surgical emergencies in elderly population.

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Key Words

• surgery
• laparoscopy
• elderly
• emergency

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MESH Headings

• Abdomen/surgery
• Aged
• Digestive System Diseases/surgery
• Emergency Treatment
• Hernia, Ventral/surgery
• Humans
• Laparoscopy

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Affiliation(s)

G. COCORULLO Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
N. FALCO Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
R. TUTINO Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
T. FONTANA Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
G. SCERRINO Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
G. SALAMONE Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
L. LICARI Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy
G. GULOTTA Department of Surgical, Oncological and Oral Sciences, University of Palermo, General Surgery and Emergency Operative Unit, Policlinico Universitario “P. Giaccone”, Palermo, Italy

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Real-Time Measurement of the Tool-Tissue Interaction in Minimally Invasive Abdominal Surgery: The First Step to Developing the Next Generation of Smart Laparoscopic Instruments

Introduction Analysis of force application in laparoscopic surgery is critical to understanding the nature of the tool-tissue interaction. The aim of this study is to provide real-time data about manipulations to abdominal organs. Methods An instrumented short fenestrated grasper was used in an in vivo porcine model, measuring force at the grasper handle. Grasping force and duration over 5 small bowel manipulation tasks were analyzed. Forces required to retract gallbladder, bladder, small bowel, large bowel, and rectum were measured over 30 seconds. Four parameters were calculated-T(hold), the grasp time; T(close), time taken for the jaws to close; F(max), maximum force reached; and F(rms), root mean square force (representing the average force across the grasp time). Results Mean F(max) to manipulate the small bowel was 20.5 N (±7.2) and F(rms) was 13.7 N (±5.4). Mean T(close) was 0.52 seconds (±0.26) and T(hold) was 3.87 seconds (±1.5). In individual organs, mean F(max) was 49 N (±15) to manipulate the rectum and 59 N (±13.4) for the colon. The mean F(max) for bladder and gallbladder retraction was 28.8 N (±7.4) and 50.7 N (±3.8), respectively. All organs exhibited force relaxation, the F(rms) reduced to below 25 N for all organs except the small bowel, with a mean F(rms) of less than 10 N. Conclusion This study has commenced the process of quantifying tool-tissue interaction. The static measurements discussed here should evolve to include dynamic measurements such as shear, torque, and retraction forces, and be correlated with evidence of histological damage to tissue.

Pushing the envelope: laparoscopy and primary anastomosis are technically feasible in stable patients with Hinchey IV perforated acute diverticulitis and gross faeculent peritonitis

INTRODUCTION

Modern management of severe acute complicated diverticulitis continues to evolve towards more conservative and minimally invasive strategies. Although open sigmoid colectomy with end colostomy remains the most commonly used procedure for the treatment of perforated diverticulitis with purulent/faeculent peritonitis, recent major advances challenged this traditional approach, including the increasing attitude towards primary anastomosis as an alternative to end colostomy and use of laparoscopic approach for urgent colectomy.

TECHNIQUE

Provided an accurate patients selection, having the necessary haemodynamic stability, pneumoperitoneum is established with open Hasson technique and diagnostic laparoscopy is performed. If faeculent peritonitis (Hinchey IV perforated diverticulitis) is found, laparoscopy can be continued and a further three working ports are placed using bladeless trocars, as in traditional laparoscopic sigmoidectomy, with the addition of fourth trocar in left flank. The feacal matter is aspirated either with large-size suction devices or, in case of free solid stools, these can be removed with novel application of tight sealing endobags, which can be used for scooping the feacal content out and for its protected retrieval. After decontamination, a sigmoid colectomy is performed in the traditional laparoscopic fashion. The sigmoid is fully mobilised from the retroperitoneum, and mesocolon is divided up to the origin of left colic vessels. Whenever mesentery has extremely inflamed and thickened oedematous tissues, an endostapler with vascular load can be used to avoid vascular selective ligatures. Splenic flexure should be appropriately mobilised. The specimen is extracted through mini-Pfannenstiel incision with muscle splitting technique. Transanal colo-rectal anastomosis is fashioned. Air-leak test must be performed and drains placed where appropriate.

RESULTS

The video shows operative technique for a single-stage, entirely laparoscopic, washout and sigmoid colectomy with primary colorectal anastomosis in a 35-year-old male patient with severe and diffuse free faeculent diverticular peritonitis (Hinchey IV). The patient was managed post-operatively according to enhanced recovery protocol and discharged home after 9 days, following an uneventful recovery.

CONCLUSIONS

This case documents the technical feasibility of a minimally invasive single-stage procedure in a patient with Hinchey IV perforated diverticulitis with diffuse feacal peritonitis. The laparoscopic approach facilitated an effective decontamination of the peritoneal cavity, with a combination of large suction devices and aid of protected retrieval by closed endobags for effectively and completely laparoscopic removal of the solid feacal matter, offering clear advantages and excellent results even in such challenging cases. With necessary expertise, the sigmoid resection can be thereafter safely and entirely performed laparoscopically, the specimen extracted through mini-Pfannenstiel incision, and a laparoscopic intracorporeal transanal circular primary anastomosis performed.

Laparoscopic treatment of complicated colonic diverticular disease: A review

Up to 10% of acute colonic diverticulitis may necessitate a surgical intervention. Although associated with high morbidity and mortality rates, Hartmann’s procedure (HP) has been considered for many years to be the gold standard for the treatment of generalized peritonitis. To reduce the burden of surgery in these situations and as driven by the accumulated experience in colorectal and minimally-invasive surgery, laparoscopy has been increasingly adopted in the management of abdominal emergencies. Multiple case series and retrospective comparative studies confirmed that with experienced hands, the laparoscopic approach provided better outcomes than the open surgery. This technique applies to all interventions related to complicated diverticular disease, such as HP, sigmoid resection with primary anastomosis (RPA) and reversal of HP. The laparoscopic approach also provided new therapeutic possibilities with the emergence of the laparoscopic lavage drainage (LLD), particularly interesting in the context of purulent peritonitis of diverticular origin. At this stage, however, most of our knowledge in these fields relies on studies of low-level evidence. More than ever, well-built large randomized controlled trials are necessary to answer present interrogations such as the exact place of LLD or the most appropriate sigmoid resection procedure (laparoscopic HP or RPA), as well as to confirm the advantages of laparoscopy in chronic complications of diverticulitis or HP reversal.

Surgeon Volume Correlates with Reduced Mortality and Improved Quality in the Surgical Management of Diverticulitis

BACKGROUND

Volume has been shown to be an important determinant of quality and cost outcomes.

METHODS

We performed a retrospective study of patients who underwent surgery for diverticulitis using the University HealthSystem Consortium database from 2008–2012. Outcomes evaluated included minimally invasive approach, stoma creation, intensive-care admission, post-operative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized into four categories by mean annual volumes: very-high (VHVS) (>31), high (HVS) (13–31), medium (MVS) (6–12), and low (LVS) (≤5).

RESULTS

A total of 19,212 patients with a mean age of 59 years, 54 % female makeup, and 55 % rate of private insurance were included. Similar to the unadjusted analysis, multivariable analysis revealed decreasing odds of stoma creation, complications, ICU admission, reoperation, readmission, and inpatient mortality with increasing surgeon volume. Additionally, compared with LVS, a higher surgeon volume was associated with higher rates of the minimally invasive approach. Median length of stay and costs were also notably lower with increasing surgeon volume.

CONCLUSION

Quality and the use of minimally invasive technique are tightly associated with surgeon volume. Further studies are necessary to validate the direct association of volume with outcomes in surgery for diverticulitis.

Emergent Laparoscopic Colectomy Is an Effective Alternative to Open Resection for Benign and Malignant Diseases: a Meta-Analysis

The aim of this study is to compare the perioperative outcomes between laparoscopic and open resections performed for colonic emergencies. A systematic search of the literature identified previously published comparative studies regarding emergent laparoscopic colectomy (ELC) and emergent open colectomy (EOC). Meta-analysis was performed utilizing a pooled odds ratio (OR) for dichotomous variables and a weighted mean difference (WMD) for continuous variables with 95 % confidence intervals (CIs). Eleven studies involving 752 patients were identified. Although operation time was noted to be significantly shorter for EOC, patients post-ELC had significantly lower overall morbidity (OR 0.44; 95 % CI 0.30, 0.66; P < 0.0001). Meanwhile, recovery time for post-ELC patients was significantly shorter, as was the length of hospital stay (WMD -2.78 days; 95 % CI -3.17, -2.38; P < 0.00001), the time to regular dietary habits (WMD -1.32 days; 95 % CI -2.51, -0.13; P = 0.03), and the time to recover bowel movement (WMD -0.55 days; 95 % CI -0.89, -0.22; P = 0.001). Reoperation rate and mortality were found to be comparable between ELC and EOC. The R0 resection rate and the number of lymph nodes harvested were also comparable between ELC and EOC for malignant diseases. Whether for benign or malignant disease, ELC is a safe and feasible procedure for colonic emergencies compared with EOC, despite being relatively time-consuming.

Acute laparoscopic and open sigmoidectomy for perforated diverticulitis: a propensity score-matched cohort

Background

Hartmann’s procedure for perforated diverticulitis can be characterised by high morbidity and mortality rates. While the scientific community focuses on laparoscopic lavage as an alternative for laparotomy, the option of laparoscopic sigmoidectomy seems overlooked. We compared morbidity and hospital stay following acute laparoscopic sigmoidectomy (LS) and open sigmoidectomy (OS) for perforated diverticulitis.

Methods

This retrospective cohort parallel to the Ladies trial included patients from 28 Dutch academic or teaching hospitals between July 2010 and July 2014. Patients with LS were matched 1:2 to OS using the propensity score for age, gender, previous laparotomy, CRP level, gastrointestinal surgeon, and Hinchey classification.

Results

The propensity-matched cohort consisted of 39 patients with LS and 78 patients with OS, selected from a sample of 307 consecutive patients with purulent or faecal perforated diverticulitis. In both groups, 66 % of the patients had Hartmann’s procedure and 34 % had primary anastomosis. The hospital stay was shorter following LS (LS 7 vs OS 9 days; P = 0.016), and the postoperative morbidity rate was lower following LS (LS 44 % vs OS 66 %; P = 0.016). Mortality was low in both groups (LS 3 % vs OS 4 %; P = 0.685). The stoma reversal rate after Hartmann’s procedure was higher following laparoscopy, with a probability of being stoma-free at 12 months of 88 and 62 % in the laparoscopic and open groups, respectively (P = 0.019). After primary anastomosis, the probability of reversal was 100 % in both groups.

Conclusions

In this propensity score-matched cohort, laparoscopic sigmoidectomy is superior to open sigmoidectomy for perforated diverticulitis with regard to postoperative morbidity and hospital stay.

Electronic supplementary material

The online version of this article (doi:10.1007/s00464-015-4694-8) contains supplementary material, which is available to authorized users.