Laparoscopic anterior resection for complex sigmoid diverticulitis with the difficult pelvis

Introduction

Diverticular disease is prevalent in the community with increasing incidence with the ageing population (1). Most presentations are mild simple diverticulitis that requires simple non-operative management (1). A proportion of patients will suffer from acute complex diverticulitis that failed non-operative management and subsequently require surgical intervention (2). The literature describes diverticulitis in a simplified way of simple vs complex diverticulitis. Most of this is based on computed tomography findings of presence of any complications such as phlegmon, abscess, localized contained free air or pneumoperitoneum. It is graded based on modified Hinchey classification. Whilst these are useful for non-operative management and research purposes, it does not help with operative planning. A group of patients with complex diverticulitis present with the difficult pelvis. This includes large pelvic abscess or mesenteric abscess/fibrosis stuck to the left pelvic side wall (3). The abscess/fibrosis around the pelvis and side wall often leads to tethering of important structures such as the ureters. Often a long redundant loop of diseased sigmoid colon falls into the pelvic inlet and obliterates the normal anatomical views. The disease process may also involve the rectum and mesorectum, leaving behind no virgin planes for dissection. These variations in presentation can make the minimally invasive surgery (MIS) challenging and lead to higher rates of conversion to open surgery. MIS is associated with faster bowel recovery, less pain, wound infection and incisional hernia (4,5). In the event of a MIS Hartmann’s procedure, the following reversal will be significantly easier with less adhesions (6). MIS in this acute complex diverticulitis is still limited (7), likely due to technical challenges (8).

This study presents a multidirectional approach for MIS sigmoid resection in complex diverticulitis through three different video illustrations (Video 1). The multidirectional approaches assist with the technical challenges faced in MIS of complex diverticulitis through: normalization of the pelvic anatomy by dissecting small bowel loops away from the diseased segment of colon, early identification of the left ureter (with fluorescence-guided imaging), early division of the proximal colon to allow easier manipulation of the diseased segment of colon, dissecting in the retrorectal plane and be flexible in a combination of approaches during the case. We present this article in accordance with the SUPER reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-38/rc).

Preoperative preparations and requirements

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

The computed tomography is reviewed for the anatomy with a focus on the following:

• The location of the disease—whether it is a long loopy diseased sigmoid colon in the pelvis;
• The location of the abscess/mesenteric fibrosis—proximity to the left side wall and adjacent small bowel loops;
• The rectum—whether the inflammatory disease process involves the upper rectum, signifying much difficult operation.

Step-by-step description

The surgery is performed under general anaesthesia. The patient is positioned in a modified lithotomy position on a bean bag with both arms tucked in. Prophylactic intravenous antibiotics are given. Calf compressors are applied.

Bilateral ureteric catheters with instillation of indocyanine green (ICG) 2 mL on each side are performed by urology colleagues (9).

If the patient has not had a recent colonoscopy, an on-table flexible sigmoidoscopy is performed to exclude underlying malignancy.

The four-port approach (Figure 1) is employed with Hasson entry transumbilical (10 mm) for camera, two 5 mm ports in right upper quadrant and left side of abdomen (between left lower rib and the anterior superior iliac spine) and one 12 mm port in right iliac fossa. The port placement should have adequate triangulation. The patient is in reverse Trendelenburg position with left tilt up.

Figure 1 The position of the four ports used during the case.

Step 1—assessment and access

After pneumoperitoneum is established, the diverticulitis segment of colon is assessed with respect to the adjacent anatomy. Often it is stuck to the left pelvic side wall/uterus in female patients and bladder in male patients. A loop of small intestine is often tethered to the inflamed mesentery. Sharp scissors dissection is used to mobilize the loop of small intestine away (Case 2). Energy devices are not encouraged due to the potential risk of delayed heat injury or enterotomy. After the adhesiolysis, the small bowel loops are inspected for any serosal injury and is repaired with interrupted absorbable sutures. The small bowel loops are then swept towards the right upper quadrant. This is assisted gravity by the tilt of the operating table with reverse Trendelenburg. Sometimes, the use of the gauze can be effective retracting the small bowel loops away from the field of surgery.

Step 2—lateral and medial mobilization

The fibrotic segment of colon to the left pelvic side wall often makes it difficult to manipulate and retract the bowel. The proximal aspect of the White line of Toldt is often easy to mobilise. This is mobilized from lateral to medial as much as possible. The assistant is asked to hold up this segment of the bowel. The medial aspect of the mesentery is mobilized under the superior rectal artery. Every effort is made to identify the presacral and hypogastric nerves but in the situation complex diverticulitis, this is not easy. It is advised to stay close to the superior rectal artery during dissection. Early identification of the left ureter through the ICG mode assists the dissection (Figure 2). The medial dissection should connect with the previously dissected lateral dissection. The inferior mesenteric artery is ligated with clips and divided.

Figure 2 The left ureter visualized under fluorescence-guided during medial to lateral dissection.

Step 3—division of the proximal colon

The proximal mesocolon is ligated with an energy device. The proximal colon is divided with an endoscopic stapler. This allows easy retraction of the specimen and access to the left pelvic side wall and posterior upper rectum.

Step 4—upper rectum mobilization

The posterior and right lateral upper rectum planes are usually virgin territory to explore. The posterior retrorectal space is entered. This is usually visualized as the avascular plane; so called Holy plane during total mesorectal excision dissection.

Step 5—complete pelvic side wall/anterior rectal mobilization

This part is usually the most challenging. With the other parts mobilized, the fibrosis/abscess cavity is incised sharply with scissors or using diathermy on blend setting close to the bowel to prevent thermal injury to the left ureter, uterus/bladder.

If the sigmoid mesentery is significantly adherent to the retroperitoneum that precludes safe dissection, adequate lateral mobilization to identify the left ureter allows the division of the proximal colon following a window made between the mesentery and the bowel. A mesenteric-sparing approach is chosen to ligate close to the bowel, heading towards the upper rectum (Case 3).

Step 6—division of upper rectum

With the diseased segment completely mobilized, a rectal sizer is placed through the anus to assess for rectal strictures. The mesorectum is ligated at the level of planned division. The upper rectum is divided with an endoscopic stapler.

During the surgery, some steps may interchange depending on the scenario, but early division of the proximal colon is key to provide access to the pelvis and side wall.

Step 7—left colonic conduit mobilization/end colostomy and extraction

The subsequent steps are routine. The left colon is mobilized including the splenic flexure for a tension-free colorectal anastomosis. A Pfannenstiel incision is made to extract the specimen. The purse-string can be performed either extracorporeally or intracorporeally. The type of the anastomosis constructed (end to end stapled or side to end stapler) depends on the preference of the surgeon. It is important to emphasize that the rectum should be healthy “soft” for anastomosis. An on-table scope is then performed to evaluate the colorectal anastomosis and to evaluate for air leak.

If a Hartmann’s procedure with end colostomy is planned, the left colonic conduit will be brought through the pre-marked stoma trephine site. Hartmann’s procedure is usually performed based on the patient’s comorbidities such as on immunosuppression, severe cardiorespiratory disease, intraoperative findings of unstable haemodynamics with use of inotropes and 4 quadrant faecal peritonitis.

Post-operative considerations and tasks

Enhanced recovery after surgery principles should be applied. Nasogastric tube in not routinely inserted; if used, to be removed as soon as possible. Early oral feeding is encouraged as tolerated. Indwelling urinary catheter is removed on post-operative day 1. Pelvic drain is also removed early post-operatively if placed.

In patients with primary anastomosis, clinical observations are made to ensure no clinical signs of anastomotic leak. If there is any clinical suspicions of sepsis, early computed tomography of abdomen and pelvis with rectal contrast is performed.

In patients with either a diverting loop ileostomy or patients that have end colostomy (in Hartmann’s procedure), stoma education is provided. In patients that underwent a Hartmann’s procedure, rare complications such as a rectal stump blowout can occur. It is important to washout the rectum at the end of the procedure and consider placing a rectal tube.

Tips and pearls

To tackle the case of complex diverticulitis with difficult pelvis, the following approaches should be considered:

• Restore the pelvic anatomy at the start by dissecting sharply the omentum or small bowel loops away from the diseased segment of colon.
• Early identification of the left ureter (with fluorescence-guided imaging). It is important to be aware that both ureters can be drawn into the fibrotic mesentery from the abscess. Normal locations of the ureters may not be expected.
• Early division of the proximal colon to allow easier manipulation of the diseased segment of colon.
• Dissecting in the retrorectal plane is useful as the plane is usually spared from the disease process.

Discussion

This article focuses on the surgical approaches to complex diverticulitis, especially with a challenging pelvis. In the steps described above, the main take home message is to be flexible in different approaches and can be used interchangeably during the case. The standard lateral-to-medial or medial-to-lateral may be challenging due to the fibrotic nature of the mesentery which obliterates natural dissecting planes. If one adheres strictly to only one approach, the wrong plane maybe encountered and injure important structures such as the ureter.

Early division of the proximal colon allows easy manipulation of the diseased segment of colon which often is bulky and hard to grasp. It allows visualization of the left pelvic side wall to keep the left ureter safe during dissection. This approach also allows the surgeon to decide a mesenteric-sparing approach by ligating close to the colon till the upper rectum. This technique can also be performed on the robotic platform, where the wrist articulation can assist further in the dissection, possibly leading to less conversion to open surgery (10).

Conclusions

Laparoscopic anterior resection in complex sigmoid diverticulitis with a difficult pelvis is feasible through different approaches. Early division of the proximal colon allows easy access to the pelvis and side wall.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-38/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-38/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-38/coif). Z.Q.N. serves as the unpaid Associate Editor-in-Chief of AME Surgical Journal from December 2024 to December 2026. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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