Suprapubic single-port approach for complicated diverticulitis

Abstract

Background: Laparoscopic sigmoidectomy is the gold standard for elective surgical treatment of diverticulitis. A periumbilical single-port technique reduces the size of the access wound, usually to 3-4 cm. However, in the presence of large phlegmon or fistulae, the risk of conversion is higher and the extraction site might be enlarged. A suprapubic Pfannenstiel incision reduces the risk of incisional hernia compared to umbilical access and might provide the possibility to perform sigmoidectomy with a hybrid technique. The aim of the present study was to investigate the feasibility of laparoscopic sigmoidectomy through a single suprapubic transverse access for large diverticular phlegmon.

Methods: Consecutive patients with a diverticular inflammatory mass ≥ 5 cm, with or without sigmoid-vesical fistula, were considered candidates for laparoscopic sigmoidectomy through a 5-cm single-port suprapubic (SPSP) access, extended (if required) to match the size of the inflammatory mass.

Results: Twenty patients underwent SPSP sigmoidectomy at our institution in April 2014-April 2017. All procedures were completed by SPSP access, with no intraoperative complications or need for additional trocar placement. Eight patients had a sigmoid-vesical fistula (bladder sutured in three patients). The splenic flexure was mobilized in nine patients. Median operative time was 178 min and median hospital stay was 5.5 days (iqr 4-6). Postoperative complications occurred in four patients and included one subcutaneous hematoma, one urinary tract infection, and two superficial wound infections. After a median follow-up time of 25 months (interquartile range 15-38), all patients experienced complete resolution of symptoms, with no incisional hernias reported.

Conclusions: SPSP sigmoidectomy for diverticulitis is feasible and effective, minimizing the size of the access wound and avoiding increased risk of hernia. This approach might be especially valuable for the management of large diverticular phlegmon and sigmoid-vesical fistula.

Keywords: Diverticulitis; Pelvic mass; Single-port laparoscopy; Suprapubic incision.