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patients with satisfactory immunological competency, without comorbidities, and
evident parietal discontinuities of the involved colonic tract.
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3 Laparoscopic Sigmoidectomy
After 30years from the rst laparoscopic colectomy, this technique has progressively gained a prominent role in the surgical management of diverticular disease,
mainly, thanks to reducing postoperative complications with equal effectiveness
compared to the open approach. However, the evidence of the laparoscopic sigmoidectomy is well dened in elective settings. Conversely, its role in the context of
complicated acute diverticulitis is still unclear and remains a topic of discussion.
A minimally invasive approach is associated with a lower rate of respiratory
complications. The less postoperative pain allows a greater thoracic excursion and,
consequently, improved alveolar ventilation. Furthermore, laparoscopy determines
a lower intensive inammatory response that facilitates regenerative processes, such
as faster healing and lower ileus. All these factors lower the duration of hospitalization than open surgery [45–47].
Like in elective settings, it has been demonstrated that the laparoscopic colonic
resection is associated with lower surgical and medical postoperative complications, also in complicated diverticulitis [48]. In a recent study by Lee etal., 3756
cases undergoing emergent sigmoidectomy for perforated diverticulitis were analyzed. Of them, 282 were laparoscopic-completed, 175 laparoscopic-converted-toopen, and 3299 open. They found that the laparoscopic-completed approach had
signicantly better outcomes than open and laparoscopic-converted cases. In the
intention-to-treat analysis, the laparoscopic-completed approach had signicantly
fewer complications, less unplanned intubation, and acute renal failure than the
open group. Furthermore, laparoscopic groups presented shorter hospital lengths of
stay although with longer operating times. Interestingly, when comparing laparoscopic and open colonic resections, the laparoscopic group showed favorable outcomes. So far, the authors have promoted minimally invasive surgery in perforated
diverticulitis, suggesting the need for randomized studies to dene an optimal operative approach in patients requiring emergency surgery for diverticular perforation [48].
There is no doubt that laparoscopic resections must be considered when patient’s
clinical conditions are permissive (hemodynamical stability), and there is no severe
and diffuse peritoneal contamination, such as Hinchey’s IV fecal peritonitis [40,
49–51]. Abraha etal. conducted a meta-analysis from three randomized studies
comparing open vs. laparoscopic colonic resections with an overall population of
392 patients. The authors showed no signicant differences in mean hospitalization,
30-day mortality, surgical complications, early and late morbidity, major and minor
complications, intraoperative blood loss, time for reintroducing liquid and solid
diet, and recurrence of diverticulitis. On the other hand, the postoperative pain and
the perceived quality of life in patients undergoing laparoscopic resection were signicantly better than the open approach, albeit with a very low level of evidence.
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However, important risks of attrition, detection, and performance bias were highlighted among studies, which were inhomogeneous in discriminating open and
laparoscopic sigmoidectomies, both in the emergency and elective regimes. As a
result, the authors were unable to support or reject the safety and efcacy of laparoscopic surgery over traditional surgery in acute diverticulitis [46]. Elgawki et al.
highlighted the importance of a minimally invasive approach to the surgical management of acute diverticulitis, reporting the outcomes on 260 patients undergoing
laparoscopic sigmoid colectomy in emergency. Hinchey’s I diverticulitis (88%) was
the most relevant percentage, while only 9% of the overall cohort of patients presented purulent peritonitis. The authors reported a very low rate of intraoperative
complications (1%), constituted by anastomotic failure attributable to stapler defect,
small bowel, and urinary bladder injuries. Furthermore, they identied a conversion
rate of 6%, an anastomotic leak rate of 1.9%, overall 30-day morbidity of 3.8%, and
30-day mortality of 0.7%. Considering these encouraging results, the authors concluded that, in the hands of experienced surgeons, laparoscopic colonic resection for
sigmoid diverticulitis might be considered the “gold-standard” treatment for patients
with Hinchey’s grades I–II.At the same time, for Hinchey III, further studies are
necessary to prove its efcacy. However, no comparison was made. The study was
limited to a simple cas series report [52]. Similarly, in their meta-analysis of 14
studies for a total population of 918 patients, Lin etal. supported the superiority of
the laparoscopic approach over open surgery in acute complicated diverticulitis due
to a reduction in morbidity and mortality [53].
A keypoint for a successful outcome of a laparoscopic sigmoidectomy is the
surgeon’s expertise and the high specialization of the hospital [54]. In a survey conducted by De Simone etal., it emerges that the therapeutic strategies of acute diverticulitis are often subordinated to the surgeon’s experience. The authors suggest
using the laparoscopic approach in Hinchey’s grades 3 and 4 acute diverticulitis in
hemodynamically stable patients, whereas adequate materials and personnel are
present [55]. A laparoscopic resection requires more expensive equipment and longer operative time than the laparotomic approach [56]. However, a shorter hospital
stay, reduced consumption of painkillers, and a faster return to normal activities
may balance the overall costs between the two approaches. Klarenbeek etal. conducted an economic evaluation of the randomized control “SIGMAtrial,” comparing elective laparoscopic sigmoid resection to open ones in patients with symptomatic
diverticulitis, identifying a not statistically signicant difference (total healthcare
costs: 9969 euro vs. 9366 euro). Thus, the authors stated that, as clinical outcomes
favored laparoscopic resection, elective sigmoidectomy should be preferably
approached laparoscopically [57]. Unfortunately, no studies have been published
about cost-effectiveness in emergency settings, where many other factors can inuence the decision-making process, and healthcare costs might have limited
importance.
Primary anastomosis with or without proximal diversion should be considered in
the settings of an appropriate patient’s physiology and tissue quality, as it is associated with reduced morbidity and mortality [58]. Several randomized studies have by
now demonstrated that resection with primary anastomosis is a safe alternative to
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non-restorative colon resection in selected patients with purulent or fecal diverticular peritonitis [59–62]. In a retrospective study on 415 patients undergoing laparoscopic sigmoid resection without diversion, Dreifuss et al. identied 73 cases
(20.8%) of perforated diverticulitis. In these settings, laparoscopic sigmoidectomy
for perforated diverticulitis has morbidity, anastomotic leak, and mortality rates
similar to elective ones [63]. Furthermore, recent evidence has shown that laparoscopic colonic resection may be more difcult in Hinchey grade II and III.The
longer exposition to inammation may determine a more edematous, friable, and
thicker mesentery rather than Hinchey grade IV.In a recent study by Pellinoet al., it
has been described that laparoscopic sigmoidectomy could be easier than open surgery also in hemodynamically stable patients suffering from Hinchey grade 3 and 4
diverticulitis, when performed by expert surgeons. Interestingly, the authors report
a recanalization rate of 88% in patients undergoing laparoscopic Hartmann’s compared to 62% of patients undergoing traditional surgery, probably due to the lower
presence of adhesions and easier execution of the operation. Consequently, the
authors stated that colonic resection with primary laparoscopic anastomosis in perforated diverticulitis is technically feasible in hemodynamically stable patients.
However, patient selection and additional factors, including surgeon expertise and
hospital resources, are crucial and require careful consideration [47].
If the primary anastomosis is unsafe for the treatment of complicated diverticulitis, a laparoscopic Hartmann’s procedure has been described [64]. Agaba etal.
reported seven patients with an average operative time of 154min and an average
length of stay of 6days. All patients were reversed approximately 2–3months later
through a laparoscopic approach [65]. Although little has been published, some
studies have compared laparoscopic and open approaches for the reversal of the
Hartmann’s procedure [66]. Overall, these small series support laparoscopy during
Hartmann’s reversal to be technically feasible and safe with outcomes like those
seen with open surgery. In a multicenter retrospective study on 2937 patients with
diverticular perforation undergoing emergent sigmoid colon resection with a colostomy, Moghadamyeghaneh etal. identied a rate of minimally invasive surgery of
11.4% with a 38.6% conversion rate to open. Interestingly, the authors demonstrated
that the open approach to sigmoidectomy was associated with higher morbidity
compared to the laparoscopic approach (67.2% vs. 56.8%), although no signicant
differences in risk of reoperation (8.5% vs. 3.9%) or intra-abdominal abscess
(11.6% vs. 10.2%). Furthermore, patients who had an open Hartmann’s procedure
presented signicantly higher respiratory complications and unplanned intubations
rates, with longer hospitalization length than the mini-invasive approach. Even
though important limitations, the authors were able to conclude that a mini-invasive
approach to emergent Hartmann’s procedure for perforated diverticulitis is feasible
and is associated with decreased morbidity and hospitalization length [45].
Although the literature seems to be favorable to laparoscopic surgery also in the
emergency settings, we should be aware of the important limits of the considered
studies, mainly deriving from patients’ selection bias, the absence of a clinical stratication of the acute diverticulitis, the small number of population-based registries
analyzed, and the frequent retrospective nature. In most cases, laparoscopic groups
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included elective sigmoidectomy with patients who are undoubtedly more t for
surgery than the open group. Only in 2018, it has been launched a multicentric randomized study called “LaCeS feasibility trial” (Laparoscopic versus Open
Colorectal Surgery in the Acute Setting) from England; the rst one aimed to assess
the feasibility, safety, and acceptability of performing a large-scale denitive phase
III randomized controlled trial with a comparison of emergency laparoscopic with
open surgery for acute colorectal pathology [67].
In conclusion, even though the laparoscopic sigmoidectomy for acute complicated diverticulitis is technically feasible in stable hemodynamic patients with adequate clinical reserves, this procedure should be preferably performed by experienced
surgeons in specialized centers. Furthermore, a primary anastomosis could be considered if the patient’s conditions allow it.
4 Robotic Colonic Resection
The mini-invasive treatment of diverticulitis could be arduous due to the chronically
inamed tissues, distorted anatomic planes, and increased tendency to bleeding,
which increases the risk of injury on other organs. In these difcult conditions, the
disadvantages of laparoscopy are represented by lower ergonomics in conned
spaces, rigid instrumentation, decreased freedom of motion, tremor effect, 2-D
visualization, and reduced depth perception. These factors may limit a proper dissection and, consequently, its use. The robotic approach has several advantages and
disadvantages than the conventional laparoscopy [68, 69] (Table1).
The robotic technique has constantly been gaining popularity in colorectal surgery. Unfortunately, only a few studies focusing on robotic colonic resection in
patients with diverticulitis have been published.
Robotic surgery can be safe and feasible for noncomplicated and complicated
diverticulitis. XIa etal. compared robotic-assisted surgery for complicated and noncomplicated diverticulitis: they demonstrated that the complicated group was related
Table 1 Advantages and disadvantages of the robotic surgery
Advantages Disadvantages
1. Surgeon-controlled camera and stable camera platform 1. Reduced haptic feedback
2. High denition and 3D vision with tenfold magnication 2. Use of larger ports
3. Conversion of surgeon’s coarse movements to accurate
movements of the robot
4. Filter to eliminate tremor 4. Repeating the docking
5. Improved strength of action 5. Costs
6. Articulating instruments improving maneuverability and
facilitate ne dissection
7. Extended length of instrumentation (helpful in obese
patients and close pelvis)
8. A third operating arm controlled by the surgeon
9. Improved operative comfort with more ergonomic position
of the surgeon
3. Greater number of ports
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to a higher conversion rate (3.1% vs. 22.2%), a longer mean operative time (171min
vs. 196min), and a higher ostomy rate (9.4% vs. 33.3%). Instead, no signicant
differences were identied regarding estimated blood loss, length of postoperative
stay, complication rate, time to return normal bowel function, and readmission
rate [68].
Among studies comparing robotic and laparoscopic colectomy for diverticulitis,
data are very heterogeneous, mainly in conversion rate, complications rate, length
of postoperative stay, and operative time. Al-Temimi etal. compared robotic and
laparoscopic elective colectomy for diverticulitis in a multivariate analysis [70].
They observed that the robotic approach was associated with a better overall morbidity, shortened length of stay, and lower conversion rate. Instead, the operation
time resulted longer. These ndings were similar in other reports [71–74].
A longer operative time associated with robotic surgery probably has multifactorial reasons. The most important one may be represented by the limited experience
of the attending surgeons. It has been demonstrated that the presence of a dedicated
team is associated with decreased operative times [71, 72, 75, 76]. Another important aspect that must be considered is the type of the used robot. Most of the studies
show results referring to the Da Vinci Si, the oldest one. With the new version, the
Da Vinci Xi, many limits have been overcome. The Da Vinci Xi is enriched with the
Integrated Table Motion®: this device allows to change the patient positioning during the different phases of the procedure without moving the robotic trocars. So far,
it could be possible to perform the splenic exure takedown without recurring to the
“hybrid” “technique or redocking. That requires undoubtedly less time [75, 77].
As far as the conversion rate is concerned, the literature gives us opposite results.
Beltzer etal. compared robotic (n=60) and laparoscopic (n=46) sigmoid resections for uncomplicated, complicated, or recurrent diverticular disease. The authors
did not nd signicant differences in terms of operative time (130 versus 118min),
anastomotic leakage (6.7% versus 6.5%), need for a stoma (6.7% versus 4.3%),
conversion (1.7% versus 0%), reoperation (8.3% versus 15.2%), overall complications (30.0% versus 30.4%), and mortality (1.7% versus 0%) rates [76]. Conversely,
Al-Temimi etal. and Maciel etal. identied lower conversion rates: 7.5% vs. 14.3%
and 0 vs.14.55%, respectively [70, 73, 74]. On the contrary, Elliott etal. and Ogilvie
JW etal. found lower conversion rates for the laparoscopic resections than robotic
ones [71, 78].
There is no clear superiority from robotic surgery over laparoscopy regarding
morbidity and major complication rates. In their small cohort of patients, Elliott
etal. found that robotic resection for colonic diverticulitis with stula had operative
time, complication, and readmission rates very similar to laparoscopy [78].
Comparably, in a matched cohort of elective sigmoid resection for diverticular diseases, Ogilvie etal. had demonstrated that laparoscopic and robotic-assisted surgery
resulted in a clinically equivalent return to bowel function, length of stay, postoperative pain, and morbidity [71]. Cassini etal. analyzed 156 consecutive patients with
a history of complicated diverticulitis undergoing elective mini-invasive colonic
resections: 92 fully laparoscopic (FL) and 64 robotic hybrid approaches (RHA).
They found that overall postoperative morbidity and major postoperative morbidity
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rates were higher in FL (21.6% vs. 12.3% and 13% vs. 4.6%, respectively).
Interestingly, no signicant differences were recognized in mean operative time,
mean intraoperative blood loss, mean hospital stay, and mortality. Conversely, the
surgeon’s compliance was notably increased in the robotic arm [79]. In a retrospective propensity score-matched analysis on a multicentric database performed by
Raskin etal., more than 12,000 sigmoidectomies, split in 9.9% robotic, 28.9% open,
and 61.2% laparoscopic approaches, were analyzed. The authors found that robotic
surgery was associated with signicantly lower postoperative complication rates
and postoperative ileus than the LS group. However, no other signicant differences
were identied between robotic and laparoscopic groups [72]. The postoperative
length of hospital stay (LOS) is closely related to the conversion and complication
rates. In this case, the results are extremely heterogeneous [80].
Robotic colorectal surgery is related to increased costs compared to laparoscopy.
The very high cost of the robotic equipment, its maintenance, and each upgrade/
addition undoubtedly represents the main obstacle to the full spread of the robotic
technique. Furthermore, the presence of a single globally employed company in the
eld of robotic surgery might determine a barrier to the decrease in costs. Probably,
increased competition among companies will be able to reduce overall costs. Some
authors have speculated that a shorter hospital stay, a lower complication rate, and a
reduced need for intensive care unit support associated with the robotic surgery may
limit the expensiveness of the robot. However, that must still be demonstrated [70,
74, 81]. More recent studies have shown similar costs between total hospitalization
of robotic colorectal surgery compared with laparoscopy [82].
In short, robotic colonic resection is feasible and safe in the elective management
of diverticular disease and is related to similar short-term outcomes compared with
laparoscopic technique. However, additional studies are needed to evaluate the role
of robotic surgery over laparoscopic surgery for the management of left-sided diverticulitis, mainly in the context of emergency.
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