ORIGINAL ARTICLE
Hand-assisted Laparoscopic Colectomy for Colovesical Fistula Associated With Diverticular Disease Rona Spector, MD,* Vyacheslav Bard, MD,* Oded Zmora, MD,w Shmuel Avital, MD,z and Nir Wasserberg, MD*
Abstract: To evaluate the feasibility and short-term outcome of hand-assisted laparoscopic colectomy (HALC) for the treatment of colovesical fistula complicating diverticulitis, we reviewed the files of all 34 patients who underwent surgery for diverticular colovesical fistula in 1999 to 2010 at a major tertiary medical center. Twenty-one were treated with HALC and 13 with open colectomy. There were no differences in demographic parameters among the groups. HALC and open colectomy had similar operating time. HALC was associated with a significantly shorter hospital stay compared with open colectomy (5 vs. 8 d, P = 0.001). HALC proved to be technically feasible and safe in this setting. It provided benefits of tactile feedback and manual manipulation as in open colectomy while maintaining the advantages of a minimal invasive approach. Key Words: hand-assisted laparoscopic colectomy, colovesical fistula, diverticulitis
(Surg Laparosc Endosc Percutan Tech 2014;24:251–253)
D
iverticular disease may be complicated by the formation of an internal fistula. Colovesical fistula is the most common type, accounting for 65% of all diverticular disease–associated fistulas.1 It often presents a therapeutic challenge because the accompanying inflammatory process and distorted anatomy make dissection and mobilization difficult. Conventional open surgical management of isolated colovesical fistula consists of resection of the involved bowel segment, usually the sigmoid colon, with either primary anastomosis or diversion.1,2 The involved urinary bladder can often be treated by simple decompression using a standard transurethral catheter. With larger fistulas, the visible defect in the bladder wall may require local closure.3 At its advent, laparoscopic surgery was considered inappropriate for the treatment of diverticular fistulas because the lack of tactile sensation and retraction was not amenable to the complexity of the repair, the large stiff phlegmon, and the dense adhesions. In addition, it posed a risk of damage to adjacent organs and of spillage of bowel content during fistula dissection.4 Recently, however, more extensive experience and improvements in technique and equipment have increased the popularity of laparoscopic colon surgery, and it is now widely practiced in the Received for publication July 16, 2012; accepted January 27, 2013. From the Departments of *Surgery B, Rabin Medical Center, Beilinson Campus, Petach Tikva; wShiba Medical Center, Tel Hashomer; and zMeir Medical Center, Kfar Saba, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. The authors declare no conflicts of interest. Reprints: Nir Wasserberg, MD, Department of Surgery B, Rabin Medical Center, Beilinson Campus, Petach, Tikva 49 100, Israel (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
treatment of both benign and malignant diseases, including inflammatory conditions. Several studies have shown it to be equally safe and efficient to open colectomy.5–7 Hand-assisted laparoscopic colectomy (HALC) was introduced to overcome some of the limitations of laparoscopic colon surgery in complex cases.8,9 HALC provides the surgeon with tactile feedback, allowing for safe and simple retraction and dissection.10 It has been found to yield at least similar operative and postoperative results to formal laparoscopic colectomy.11–13 The aim of the present study was to assess the use of HALC in the intricate surgical treatment of colovesical fistula complicating diverticulitis.
METHODS All patients who underwent colonic resection for colovesical fistula at a tertiary medical center in 1999 to 2010 were identified by review of a prospectively collected database, complemented by a code search and chart review. The following data were collected: demographics, type of surgery, bowel section involved, incision length, conversion, operative time, hospital length of stay, time to bowel movement, and complications.
Management All patients at our center with a suspected colovesical fistula undergo contrast-enhanced computed tomography to confirm the diagnosis. Complete or partial colonoscopy is performed, and the surgeon selects the specific treatment approach on the basis of the preoperative evaluation and his/her preference. Surgery is not performed until at least 6 weeks after an acute diverticulitis attack.
HALC Technique For the HALC procedure, patients are placed in the low-lithotomy position, and regular or illuminated ureteral stents are inserted. A 5 to 6 cm midline, periumbilical incision is made, and a LAP Disc (Ethicon Endosurgery, Cincinnati, OH) is inserted. A trocar with an angled camera is then introduced through the LAP Disc. After laparoscopic inspection, a 12 mm suprapubic operative port and a 10 mm camera port are placed at the right lower quadrant. The camera is moved to the camera port, and the surgeon places his/her left hand in the abdominal cavity through the LAP Disc. The patient is then positioned in a steep Trendelenburg position with a slight right tilt. For left-sided resections, we favor the lateral to medial approach. The surgeon retracts the colon medially by hand and, using a Harmonic scalpel (Ethicon Endosurgery), separates its lateral peritoneal attachments up to the splenic flexure. The left ureter and the fistula area are identified. The bowel is dissected away from the bladder using sharp dissection and the finger-fracture technique. The mesentery is divided with
Volume 24, Number 3, June 2014
www.surgical-laparoscopy.com |
251
Surg Laparosc Endosc Percutan Tech
Spector et al
a vascular Endo-GIA stapler (Ethicon Endosurgery) and a Harmonic scalpel. The sigmoid colon is then transected distally using the Endo-GIA stapler, and the bowel is exteriorized through the hand port and resected proximally. The continuity of the colon is achieved by creating a primary intracorporeal end-to-end anastomosis with a circular stapler. The integrity of the anastomosis is checked with the bubble test. The bladder is decompressed with a urinary catheter, which is removed after cystography on postoperative day 10.
Analysis For the present study, patients were divided by type of surgery: HALC, or open colectomy. Differences in mean variables between the groups were analyzed by the t test and w2 test, as appropriate. A P value of
Hand-assisted Laparoscopic Colectomy for Colovesical Fistula Associated With Diverticular Disease Rona Spector, MD,* Vyacheslav Bard, MD,* Oded Zmora, MD,w Shmuel Avital, MD,z and Nir Wasserberg, MD*
Abstract: To evaluate the feasibility and short-term outcome of hand-assisted laparoscopic colectomy (HALC) for the treatment of colovesical fistula complicating diverticulitis, we reviewed the files of all 34 patients who underwent surgery for diverticular colovesical fistula in 1999 to 2010 at a major tertiary medical center. Twenty-one were treated with HALC and 13 with open colectomy. There were no differences in demographic parameters among the groups. HALC and open colectomy had similar operating time. HALC was associated with a significantly shorter hospital stay compared with open colectomy (5 vs. 8 d, P = 0.001). HALC proved to be technically feasible and safe in this setting. It provided benefits of tactile feedback and manual manipulation as in open colectomy while maintaining the advantages of a minimal invasive approach. Key Words: hand-assisted laparoscopic colectomy, colovesical fistula, diverticulitis
(Surg Laparosc Endosc Percutan Tech 2014;24:251–253)
D
iverticular disease may be complicated by the formation of an internal fistula. Colovesical fistula is the most common type, accounting for 65% of all diverticular disease–associated fistulas.1 It often presents a therapeutic challenge because the accompanying inflammatory process and distorted anatomy make dissection and mobilization difficult. Conventional open surgical management of isolated colovesical fistula consists of resection of the involved bowel segment, usually the sigmoid colon, with either primary anastomosis or diversion.1,2 The involved urinary bladder can often be treated by simple decompression using a standard transurethral catheter. With larger fistulas, the visible defect in the bladder wall may require local closure.3 At its advent, laparoscopic surgery was considered inappropriate for the treatment of diverticular fistulas because the lack of tactile sensation and retraction was not amenable to the complexity of the repair, the large stiff phlegmon, and the dense adhesions. In addition, it posed a risk of damage to adjacent organs and of spillage of bowel content during fistula dissection.4 Recently, however, more extensive experience and improvements in technique and equipment have increased the popularity of laparoscopic colon surgery, and it is now widely practiced in the Received for publication July 16, 2012; accepted January 27, 2013. From the Departments of *Surgery B, Rabin Medical Center, Beilinson Campus, Petach Tikva; wShiba Medical Center, Tel Hashomer; and zMeir Medical Center, Kfar Saba, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. The authors declare no conflicts of interest. Reprints: Nir Wasserberg, MD, Department of Surgery B, Rabin Medical Center, Beilinson Campus, Petach, Tikva 49 100, Israel (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
treatment of both benign and malignant diseases, including inflammatory conditions. Several studies have shown it to be equally safe and efficient to open colectomy.5–7 Hand-assisted laparoscopic colectomy (HALC) was introduced to overcome some of the limitations of laparoscopic colon surgery in complex cases.8,9 HALC provides the surgeon with tactile feedback, allowing for safe and simple retraction and dissection.10 It has been found to yield at least similar operative and postoperative results to formal laparoscopic colectomy.11–13 The aim of the present study was to assess the use of HALC in the intricate surgical treatment of colovesical fistula complicating diverticulitis.
METHODS All patients who underwent colonic resection for colovesical fistula at a tertiary medical center in 1999 to 2010 were identified by review of a prospectively collected database, complemented by a code search and chart review. The following data were collected: demographics, type of surgery, bowel section involved, incision length, conversion, operative time, hospital length of stay, time to bowel movement, and complications.
Management All patients at our center with a suspected colovesical fistula undergo contrast-enhanced computed tomography to confirm the diagnosis. Complete or partial colonoscopy is performed, and the surgeon selects the specific treatment approach on the basis of the preoperative evaluation and his/her preference. Surgery is not performed until at least 6 weeks after an acute diverticulitis attack.
HALC Technique For the HALC procedure, patients are placed in the low-lithotomy position, and regular or illuminated ureteral stents are inserted. A 5 to 6 cm midline, periumbilical incision is made, and a LAP Disc (Ethicon Endosurgery, Cincinnati, OH) is inserted. A trocar with an angled camera is then introduced through the LAP Disc. After laparoscopic inspection, a 12 mm suprapubic operative port and a 10 mm camera port are placed at the right lower quadrant. The camera is moved to the camera port, and the surgeon places his/her left hand in the abdominal cavity through the LAP Disc. The patient is then positioned in a steep Trendelenburg position with a slight right tilt. For left-sided resections, we favor the lateral to medial approach. The surgeon retracts the colon medially by hand and, using a Harmonic scalpel (Ethicon Endosurgery), separates its lateral peritoneal attachments up to the splenic flexure. The left ureter and the fistula area are identified. The bowel is dissected away from the bladder using sharp dissection and the finger-fracture technique. The mesentery is divided with
Volume 24, Number 3, June 2014
www.surgical-laparoscopy.com |
251
Surg Laparosc Endosc Percutan Tech
Spector et al
a vascular Endo-GIA stapler (Ethicon Endosurgery) and a Harmonic scalpel. The sigmoid colon is then transected distally using the Endo-GIA stapler, and the bowel is exteriorized through the hand port and resected proximally. The continuity of the colon is achieved by creating a primary intracorporeal end-to-end anastomosis with a circular stapler. The integrity of the anastomosis is checked with the bubble test. The bladder is decompressed with a urinary catheter, which is removed after cystography on postoperative day 10.
Analysis For the present study, patients were divided by type of surgery: HALC, or open colectomy. Differences in mean variables between the groups were analyzed by the t test and w2 test, as appropriate. A P value of
