Emergency Laparoscopic Sigmoidectomy for Perforated Diverticulitis with Generalised Peritonitis: A Systematic Review

Abstract

Background: Laparoscopic sigmoidectomy for diverticulitis has initially been confined to the elective setting. However, open acute sigmoidectomy for perforated diverticulitis is associated with high morbidity rates that might be reduced after laparoscopic surgery. The aim of this systematic review was to assess the feasibility of emergency laparoscopic sigmoidectomy for perforated diverticulitis. Methods: We performed a systematic search of PubMed, EMBASE and CENTRAL. All studies reporting on patients with perforated diverticulitis (Hinchey III-IV) treated by laparoscopic sigmoidectomy in the acute phase were included, regardless of design. Results: We included 4 case series and one cohort study (total of 104 patients) out of 1,706 references. Hartmann's procedure (HP) was performed in 84 patients and primary anastomosis in 20. The mean operating time varied between 115 and 200 min. The conversion rate varied from 0 to 19%. The mean length of hospital stay ranged between 6 and 16 days. Surgical re-intervention was necessary in 2 patients. In 20 patients operated upon without defunctioning ileostomy, no anastomotic leakage was reported. Three patients died during the postoperative period. Stoma reversal after HP was performed in 60 out of 79 evaluable patients (76%). Conclusions: Acute laparoscopic sigmoidectomy for the treatment of perforated diverticulitis is feasible in selected patients provided they are handled by experienced hands.

The Multidisciplinary Management of Acute Complicated Diverticulitis

“…Several small retrospective cohort studies and case series have been published, but no RCTs comparing the laparoscopic and open approach in the acute setting exist [63], mostly because of concerns about the clinical characteristics of ACD that, potentially, negatively affects outcomes of the laparoscopic approach. In the acute setting, the distended bowel, inflammatory dense adhesions, and the contamination of the abdominal cavity caused by perforated ACD often raise concerns on the safety and feasibility of the approach.…”

“…Small retrospective series have demonstrated emergency laparoscopic sigmoidectomy in ACD to be safe and feasible, with significant advantages in terms of low conversion, reintervention, morbidity, and mortality rates, as well as faster recovery, and higher stoma reversal rates [64]. Although the published studies are limited by their small size, heterogeneity of participants and outcome variables, obvious selection bias, and lack of open control group, it is still stated that the approach is feasible in selected patients and experienced hands [64], as was also concluded in a recent propensity score-matched analysis [65].…”

“…Although the published studies are limited by their small size, heterogeneity of participants and outcome variables, obvious selection bias, and lack of open control group, it is still stated that the approach is feasible in selected patients and experienced hands [64], as was also concluded in a recent propensity score-matched analysis [65]. Furthermore, the benefit of laparoscopic HP might be a decrease in abdominal wall complications, such as incisional hernias [65].…”

“…Overall, no mortality and significantly better postoperative outcomes were found in the laparoscopic group, in terms of less frequent prolonged ileus (12.8 vs. 32%), shorter time to oral intake (3 vs. 6 days) and shorter length of stay (5 vs. 8 days) [67]. Moreover, Vennix et al [63] performed a systematic review of 4 case series and 1 cohort study, in which a total of 104 patients underwent emergency laparoscopic resection for perforated diverticulitis (84 Hartmann, 20 primary anastomoses). Mean operating time varied between 115 and 200 min, conversion rate varied from 0 up to 19%, mean hospital stay ranged between 6 and 16 days, surgical reintervention was necessary in 2 patients, no anastomotic leak was reported, and 3 patients died postoperatively.…”

“…Moreover, concerns have been raised on the risk of damage to the vulnerable and distended small bowel, as well as the hypothetical risk of increased bacteremia and hypercapnia, caused by pneumoperitoneum [63, 65]. Despite the fact that there is no strong evidence proving or disproving these concerns, laparotomy and HP are still the most commonly used procedures [28, 63]. The role of sigmoid resection with PA versus HP has been discussed in several studies [73, 74].…”