General Comments About Diverticulitis:
Diverticulosis, which is the condition of having small, outpouching of bowel/colon lining is a very common condition in Western nations, widely attributed to processed foods and lack of fiber in our diet. The muscle layers of the colon have to work harder to move the colon content, and the inner lining, called the mucosa can be pushed out at weak points of the bowel wall where the blood vessels traverse to reach the mucosa. There is no danger in the condition of diverticulosis in and of itself, however if one of the pouches gets infected, the condition become diverticulitis. Diverticulitis can often be treated with IV or oral antibiotics if it is diagnosed early. It usually manifests as left lower abdominal pain. Where complications can arise is when the diverticulitis perforates and forms abscess or even causes a free perforation of bowel content and air into the abdominal cavity. This presentation is often associated with sepsis, or bacterial infection of the blood stream and requires emergent surgical intervention.
SURGICAL PROCEDURES THAT REQUIRE HOSPITALIZATION
An inpatient stay at the hospital may be anticipated for some surgical procedures. Included in reasons to expect an inpatient stay would be the need for several days of intravenous postoperative pain control, expected delay in return of bowel function where you would require IV hydration, or a medical condition that would warrant observation at the hospital.
Open versus Robot-assisted Laparoscopic Sigmoid Colectomy
Open sigmoid colectomy is performed for emergency cases where there is a colon perforation and time is of essence. It requires standard surgical instrumentation and approached via a midline abdominal incision that provides ample access to sigmoid colon as well as most of the left side of the abdomen. Due to the emergent nature of this condition without a bowel prep (preparation of the colon by drinking a solution that will evacuate and clean the bowel content), a temporary colostomy is usually part of the procedure. A colostomy is an exteriorized bowel-end where stool can be collected in an external pouch. After this type of procedure, the colon can be re-anastomosed or “hooked” up again in 3-4 months, a procedure that is called a colostomy takedown.
Conditions where planned (elective) surgical resection of the colon could be indicated for diverticulitis:
1. Multiple recurrent bouts of diverticulitis.
2. Persistent lower abdominal pain after antibiotic treatment for diverticulitis.
3. Diverticulitis that was complicated by abscess or “micro-perforation”, but successfully treated with IV antibiotics.
4. Bleeding from diverticulitis.
5. Narrowing of the colon due to chronic diverticulitis.
When the procedure can be schedule on an elective basis, open surgery may still be the safest procedure if there have been multiple previous abdominal surgeries and a great deal of internal scar tissue is anticipated.
Fortunately, for most patients robot-assisted laparoscopic sigmoid colectomy is a good option. Laparoscopy refers to creating a tent in the abdominal cavity with carbon dioxide introduced through a tube called a “trochar”. 4 trochars are placed via which a camera and instruments are also inserted. The surgical robot (the Davinci Xi is used at Overlake Hospital where I operate), adds yet another dimension of technology to the procedure. The robotic arms are attached to the trochars and instruments are placed that I can control at a console in the same room. The Davinci robot allows me to have a great degree of control. I have 3 arms to work with and a camera that I can also control. Visualization with the robotic system’s dual lens camera is superior to a standard laparoscopic camera as it enables a 3D view. Additionally, the instruments are “wristed” so that I can suture and move the tips of the instruments with extraordinary precision and rotation ability. So, how does this benefit the patient? As we see with other minimally invasive procedures, the result is less pain and decreased time in the hospital by about a day less than an open procedure.
Risks of surgery
1. Infection- IV antibiotics are use to prevent perioperative infection, and serous infections are uncommon.
2. Bleeding- Although bleeding risk is present, meticulous dissection is performed and usual blood loss is not significant and the need for transfusion is not common.
3. The main risk of this procedure is a 2% risk of leakage at the anastomosis or “hook-up” of the two ends of the colon put together. We optimize to prevent this situation with proper bowel prep and good surgical technique.
4. There is a separate risk of anesthesia depending on the patient’s concurrent medical problems.
Robot-assisted Laparoscopic Sigmoid Colectomy Procedure
I have been doing robot-assisted surgeries since 2013 and seen the benefit of this technology for my patients, especially in the area of bowel resection procedures for the reasons just stated.
What to expect the day of procedure:
1. Pre-procedural prep:
a) Bowel prep similar to a colonoscopy bowel prep, with the addition of two antibiotics which I will prescribe at the pre-op visit.
b) In anticipation of general anesthesia, nothing to eat after midnight prior to surgery. Clear liquids up to 2 hours prior to surgery.
2. Surgery will take 3-4 hours. Robotic procedures do take a bit longer than open procedures due to the required set-up and the fine-motions that are involved with the surgery.
3. Your will be asked to present to the surgery center 1 hour prior to procedure or hospital 2 hours prior to procedure.
4. You will meet the preop nurse who will place an IV and start mediations.
5. Then the anesthesiologist and OR nurse will bring you into the operating room.
6. The anesthesiologist will provide anesthesia.
7. Sterile skin prep is applied to the surgical area once you are asleep.
8. Four small incisions are made and tubes called “trochars” are placed via which carbon dioxide is introduced to create an internal “tent” and then the camera and instruments are placed.
9. The robotic arms are attached to the trochars.
10. The diseased sigmoid colon is resected and brought out of a 2 inch incision at the lower abdomen.
11. The bowel on the left side of the abdomen is loosened and brought down to the pelvis and connected to the rectum with a special circular stapling device which completes the anastomosis or “hook up”.
12. The incisions are then closed with sutures that are dissolvable and Steri-strips (reinforced tapes) and dressings are applied.
13. You will be in the recovery room for 1 hour then transported to an inpatient room where you can be visited.
1. The anticipated hospitalization is 2-4 days.
2. IV pain medications are given the first day and night and we switch over to oral pain medications when oral fluids are tolerated well.
3. You can drink Clear liquids right after surgery. We advance your diet to Full liquids (such as soups and cream of wheat and ice cream) once you pass flatus, then Regular diet when you do well with Full liquids.
4. Dressings are removed and showering is allowed in 48 hours. Allow the Steri-strips to fall off on their own. The Steri-strips can be removed if they are still on the skin after 7 days.
5. Pain control- When you are ready to go home, a prescription for the stronger, narcotic pain medications is given as well as prescription strength ibuprofen and stool softeners. After the first few days at home, a combination of Tylenol and the prescription strength Ibuprofen can be used for less severe pain.
6. Activity- It is better that you do not stay in bed other than for sleep as getting up and walking around at home helps with blood circulation in your legs and taking deep breaths prevents pneumonia.
7. Lifting restrictions of no greater than 20 lbs for one month from the day of surgery is standard.
8. Schedule a telemedicine or in-office post- procedural visit for 10-14 days.
9. Return to work- Most people are feeling only minor discomfort by two weeks after surgery and are no longer taking narcotics, so if you have a sit-down job returning to work at that point may be possible. Lifting restrictions are no greater than 20 lbs for one month from surgery date, and my office will write a note for work to that effect if you have a physically demanding job.