Laparoscopic Lavage in the Management of Hinchey III/IV Diverticulitis

Abstract

Diverticulitis manifestations may cover a spectrum of mild local inflammation to diffuse feculent peritonitis. Up to 35% of patients presenting with diverticulitis will have purulent (Hinchey grade III) or feculent (Hinchey grade IV) contamination of the abdomen, with a high-associated morbidity and mortality. Surgical management may involve segmental resection with or without restoration of bowel continuity. However, emergency resection for diverticulitis can be associated with high mortality rates, as well as low stoma reversal rates at 1 year. Therefore, laparoscopic peritoneal lavage has been proposed for use in selected patients with purulent peritonitis. The topic of laparoscopic peritoneal lavage for the treatment of perforated diverticulitis in the literature has been controversial. Our review of the recent data show that laparoscopic lavage may be safe and feasible in select patients with similar rates of mortality and major morbidity. There is, however, a concern regarding an associated higher rate of postoperative abscess and early reintervention risk.

Management of Diverticulitis

“…These results were posited to be due to hernia and wound dehiscence complications in the resection group . More research is required to delineate the type of patient, hospital setting, and surgeon combination that may benefit from laparoscopic lavage over sigmoid resection …”

Effectiveness of NOTES versus traditional techniques on surgical outcomes in adults with diverticulitis: a systematic review protocol

“…Traditional management is guided by the level of severity, with Hinchey I–II being largely treated with analgesia and broad spectrum antibiotics, and in some cases radiologically guided drainage of pericolic abscesses depending on antibiotic response 10 . Hinchey III–IV diverticulitis is typically managed with surgical resection of the affected section of bowel, with or without a primary anastomosis, through an open, laparoscopic, or robotic approach 11 . Complicated diverticulitis, when treated conservatively, has been shown to have a recurrence rate of up to 50% 12 .…”

“…10 Hinchey III-IV diverticulitis is typically managed with surgical resection of the affected section of bowel, with or without a primary anastomosis, through an open, laparoscopic, or robotic approach. 11 Complicated diverticulitis, when treated conservatively, has been shown to have a recurrence rate of up to 50%. 12 Emergency intervention can be indicated in patients who have clinical or radiological findings consistent with perforation or those who have failed to respond to conservative treatment of complicated diverticulitis, and who have signs of worsening intra-abdominal sepsis.…”