I think this procedure can only be applied to a highly selected group of patients, in only rare circumstances. It exposes the pt to the risk of general anesthesia without addressing the septic focus in the colon.

If there is a rational reason for a pt to NOT have a colon resection, then it can be considered, but in my opinion should never be offered as an alternative to definitive source control (i.e. resection) in an otherwise healthy patient.

I did that many times in selected (relatively healthy and stable) patients when the peritonitis was not diffuse. I also did that in open surgery with diffuse purulent peritonitis without doing a resection. Extensive lavage with drainage and IV A/B for one week. I am not sure that peritoneal lavage is well done when facing diffuse peritonitis. It is definitively more difficult.

After, I could then organize elective laparoscopic surgery. The only contraindication remains fecal peritonitis. No real study demonstrated that but experience of surgeons increases.

EB

Good Idea. If patient has not sign of peritonitis (High temperature, High Leucocitosis, etc), I think that this procedure is the best.

Guidelines point out that it can be done according to Hinchey's classification.

Laparoscopic exploration and washout is indicated in Hinchey stage II and III (in Hinchey II radiology guided drain is also indicated). In Hinchey stage IV faecal peritonitis only Hartmann's procedure is allowed.

No benefit unless patient has severe sepsis , multiple comorbidities, ASA 4 ,or 5,and Interventional radiologist cannot place CT guided drains because the source of sepsis is not addressed . In the rest traditional resection if possible, ostomy, and subsequent reversal is time tested management of proven benefit.

To the best of my knowledge, the treatment of reccurent diverticulitis is resection and primary anastomosis, open or laparoscopic, to avoid morbidity and perforation. If perforation occurs, treatment should be the same unless there is another cause of severe comorbidity for being more conservative. Thus, i don't see any reasonable indication and advantage for performing only a peritoneal lavage for perforated diverticulitis.

Our hospital has used laparoscopic lavage as the treatment of choice for all cases of non fecal perforated divericulitis for the last three years with very good results. It is surprising how well it works and it has revolutionised the treatment. No stoma. Much quicker mobilisation and shorter hospital stays. For us, there is no turning back to Hartmans procedure.

There is a rct published bjs. This Irish group confirmed all the above criteria and suggestions.

I would use the laparoscopic lavage if the additional surgical trauma of the resection with stoma would create a significant extra risk for the patient, while a quicker operation would be safer and act immediately in the sense of "damage control" surgery. Such situations could be those with high ASA grades or severe septic shocks. I would also use it in low Hinchey stages, single perforated diverticulum in young - fit patients in which a laparotomy and bowel resection (with or without stoma) could be an overtreatment.

Last August also EAES (european Association for Endoscopic Surgery) published guidelines that agreed that the procedure is indicated in Hinchey IIb and III patients, but also can be used in Hinchey IIa if percutaneous drainage is not an option

Please refer to:

https://www.researchgate.net/publication/228071129_Laparoscopic_approach_to_acute_abdomen_from_the_Consensus_Development_Conference_of_the_Societ_Italiana_di_Chirurgia_Endoscopica_e_nuove_tecnologie_(SICE)_Associazione_Chirurghi_Ospedalieri_Italiani_(ACOI)_Societ_Italiana_di_Chirurgia_(SIC)_Societ_Italiana_di_Chirurgia_d%27Urgenza_e_del_Trauma_(SICUT)_Societ_Italiana_di_Chirurgia_nell%27Ospedalit_Privata_(SICOP)_and_the_European_Association_for_Endoscopic_Surgery_(EAES)

Article Laparoscopic approach to acute abdomen from the Consensus De...

Despite son called "evidences" (mathematical methods to demostrated right what usually in the reality is wrong. In some our collectives we found evidences only changing statistical methods!using the same data. So what means evidences really?), I would recommend very carefull choice of surgical strategy in perforated diverticulitis . In Hinchey IIb (fistula) and III (purulent peritonitis), I have a lot of doubts that laparoscopy can perform so radical lavage like open methods. Pay attention to evidence-based medicine; it is not the absolute TRUTH, because it is based only on statistical reelaboration of numbers!!!!

Colleagues. It is 2013. Things move on and improve, and at the leading edge, the process is a jagged, imprecise, thoughtful one, if it is to be done properly. This is a good forum for the process. Understandably, some centres will be forging ahead. It is their responsibility to chart their progress and their thoughts about why they may have chosen certain patients and why not others, tracking progress and being reflective. It is the responsibility of those who are interested in this new way to critique, to add to the reflection and to contribute the the discussion of "reasonableness". I am happy to see this discussion as it is very instructive, and I am glad that the question has been posed in the first place. In 2002, I tried to look after a patient with a large diverticular abscess laparoscopically and converted. The thinking on this procedure was immature and in retrospect, there were likely things I could have one to drain the patient using the laparoscopic technique to gain access to the cavity that my radiologic colleagues thought was impossible. Since then, at our centre, some of my colleagues and I have tried and customized the approach to the patient. The discussion about "evidence" alluded to above highlights that the general safety of this procedure will be improved and have greater acceptance with some science behind it, but that like all good medicine, appropriate patient selection taking into account your intention and the appropriate contributing factors will be the overwhelming decision points in whether to go for a Hartmann's or a laparoscopic approach. Good luck, good discussion, and I hope to see a trial registered sometime soon.

The interesting fact here is the debate where clearly the movement forward will be "jagged, imprecise and thoughtful" but the question should perhaps be how? Randomised controlled trials are rarely productive in surgery and case series limited to the team. Perhaps with the heterogeneity of diverticular disease and diverticulitis this is an area where six-sigma methodologies may be useful in a multi-centre setting....trial anyone?

Ian, I don;t know that I could be a mover and shaker in this area as I now function mostly as an HPB surgeon, but I am quite interested in you idea and want to learn more. I associate SS with reducing the errors at the fringe, not in developing ways of choosing between options i what may be a chaotic system. Could you elaborate? is SS an area of special interest or competence for you - (we could all stand to learn a little)?

I read an article from Dr Wexner few years ago about this approach. We viewed it with hesitation and many questions at that time.

Now I see that it is approved by EAES.

This group of patients, generally, and not good candidates for a major open surgery. So it is tempting to have a less invasive option available. Moreover, when a colostomy may be excluded as well.

With more definite evidence based selection criteria, these patients or a subgroup of them will benefit more from surgical management.

Diverticulosis is very common and affecting about 30-60% of adult population.Diverticulitis is one of the common presentations. Hinchey's (initial classification on 1978) grades 1-2 are usually treated with antibiotics and radiological aspiration of the abscesses.Grade 3-4 are usually need intervention.The principle is if we can do the operation with similar efficacy and safety to the traditional and open one ,then why not doing it laparoscopically?.This of course requires minimal access experience and I think this approach is an excellent one for fit patients as well as for frail ,elderly patients who will make great benefits from minimal access surgery.

However the indications need to be tailored to the individual case and I think this procedure will work well for Hinchey's grade 3 and may be some cases of grade 4.Traditional Hartman's is still needed in some of these patients where no laparoscopic experience is available or it can not be managed laparoscopically.

Our hospital has good experience with early laparascopy in patients with perforated diverticular disease. Local, well limited and no stercoral peritonitis is the limiting condition for effective treatment with good and target sistemic treatment. No stoma and postponed laparoscopic resection is the treatment of choice. Good, effective and cost benefit treatment in all wiews with lower complications.

So, since I participated, I was on call when just such a patient came in. 1 week abdo pain, sudden genralized pain few hours before I saw him. suspected ruptured tic. CT showed some free air and lots of inflammation, small abscess in pelvis, likely abscess broken with no real contamination of the remainder of the belly - mostly air. l-scope, small amount of clear ascitic fluid here and there, broken walled-off abscess anterior to rectosigmoid loop in pelvis. washed pelvis, drained abscess and put another drain across the anterior lower abdomen and another up the left paracolic. pt did not do as well as hoped. fevers, worse interloop fluids by third day. drained one percutaneously. was in hospital for about 3 weeks ,then recent re-admit with rigors, nothing to find. still has one JP drain in the abscess draining light brown material. eating, home now, stable. given overall process, it was rough on the patient and the team. he has no stoma and the plan is to electively resect, but in the meantime, he is not functional and is depressed. so, did I choose wrong to offer this or did I do something wrong in the process?

Very interesting dialogue regarding not only the posed question, but also the current opinion(s) on evidence based medicine (EBM). Regarding EBM, it is my opinion that there is an obligation on researchers to apply rigorous methodological practices to their research to mitigate bias, error, and misleading or incorrect conclusions. Next, there is an even greater responsibility on the part of clinicians to apply even more rigorous interpretive standards to the conclusions of research before applying those findings to patients (e.g. real people). Research is not perfect... and like any human endeavor, motivations range from altruistic to selfish... in the end it is up to the clinicians to safeguard their patients through careful application of research findings.

Regarding the question posed... in our opinion...this treatment plan mandates careful patient selection and an acknowledgement on the part of patient and clinicians that success is not guaranteed. In our experience (albeit relatively limited), we use the laparascopic "damage control" washout for diverticular disease, in patients whom systemic toxicity & peritonitis is absent or has resolved and whom are good surgical candidates for multiple surgical sessions (we conservatively assume the washout may fail mandating a return to OR). Of note, persistent leukocytosis (low level) in the absence of systemic toxicity has been a fairly robust indicator for the procedure. Again, our experience is limited mandating continued vigilance regarding this management approach. What we have found is that many patients are willing to try to even minutely mitigate the chance of colostomy.

I anticipate more considerations to come...

I have operated a couple of diverticulitis patients with HInchey III with laparoscopic peritoneal lavage /drainage and it worked well - these people did not get a Hartmann procedure and went back home 10 days later without a stoma. However, they all came back with recurrent diverticulitis after 3-6 months. The problem with this approach is to determine whether it is meant as:

a) a definitive treatment for complicated diverticulitis - no surgery whatsoever is needed afterwards

b) a "bridge" procedure to treat the septic complication and schedule an eventual elective laparoscopic sigmoid resection three months alter.

In my experience, the correct answer is b)

We use this approach in selected patients : Patients with diffuse peritoneal signs and/or free peritoneal air/fluid  on CT undergo a laparoscopy  if they are stable. If a Hinchey 3 is found at laparoscopy , we proceed to peritoneal lavage, drainage and eventually even close the perforation ( ut a liquid fiare fiatur ) and cover it if possible  with omentum.  All patients we treated so far recovered without need of a resection but they tend to  recover slowly ; some of them stay paralytic for days, a couple needed additional percutaneous drainage of  abcesses days later.  A Hartmann could however always be avoided.  Definitive treatment was decided later on ; if  the perforation occurred during the first bout of diverticultis, a expectative treatment was proposed. 

If however a Hinchey 4 is found at laparocopy we perform a Hartmann.