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T.S. Ro d r iguez
This approach has a low mortality rate—despite patient comorbidity and disease
severity. Benefi ts include stoma avoidance and the lower rate of wound complications such as dehiscence and wound infection, with the high risk of incisional hernia. If during laparoscopy a fecal peritonitis is found (Hinchey IV), the patient
should undergo a Hartmann procedure.
References
1. Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med. 2007;357:2057–66.
2. Constantinides AV, Heriot A, et al. Operative strategies for diverticular peritonitis. A decision
analysis between primary resection and anastomosis versus Hartmann’s procedures. Ann Surg.
2007;245:94–103.
3. Outcome Trenti L, Biondo S, et al. Generalized peritonitis due to perforated diverticulitis:
Hartmann’s procedure or primary anastomosis? Int J Colorectal Dis. 2011;26:377–84.
4. Gooszen AW, Gooszen HG, Veerman W, et al. Operative treatment of acute complications of
diverticular disease: primary or secondary anastomosis after sigmoid resection. Eur J Surg.
2001;167:35–9.
5. Myers E, Hurley M, O'Sullivan GC, et al. Laparoscopic peritoneal lavage for generalized peri-
tonitis due to perforated diverticulitis. Br J Surg. 2008;95:97–101.
Chapter 83
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Case on Anastomotic Leakage After
Taken Down Hartmann Procedure
Niels de Korte
Keywords Diverticulitis • Sigmoid resection • Hartmann procedure • Leakage
anastomosis • Peritonitis
Diagnosis and Indication for Surgery
A 70-year-old female patient presented with a 3-month history of abdominal pain,
weight loss, and diarrhea. Fifteen years before, a Hartmann procedure had been
performed for a perforated diverticulitis. Three months postoperatively the colostomy had been taken down without complications. Her additional history included
chronic atrial fi brillation.
A CT angiography was performed on suspicion of abdominal angina, but showed
no signs of stenosis in the visceral vessels. There was however evidence of a signifi cant stenotic segment at the level of the anastomosis at the promontory (Fig. 83.1 ).
A contrast enema was performed showing a stenotic segment. A sigmoidoscopy
showed no tumor at the level of anastomosis. Because endoscopic dilatations were
not effective, patient was scheduled for a resection of the segment.
Operation
A laparotomy was performed through the old scar. On palpation, a stenotic segment of
colon was felt at the site of the anastomosis. A resection of the stenotic segment was
performed in which the distal part of the resection was about 7 cm proximal of the
pelvic fl oor. The splenic fl exure was mobilized to achieve a tension-free anastomosis.
N. de Korte , M.D.
Department of Surgery , Spaarne Hospital , Hoofddorp , The Netherlands
e-mail: ndekorte@yahoo.com
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_83,
© Springer International Publishing Switzerland 2014
459
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Fig. 83.1 Stenosis at the
anastomosis, after take down
of a Hartmann procedure
Fig. 83.2 CT scan, leakage
of anastomosis with rectal
contrast outside the colon
N. de Korte
The anastomosis was performed in a side-to-end fashion using the double- stapled
technique with a 31 CEEA stapler. A drain was left in the presacral space.
Postoperative Course: Identifi cation and Treatment
of Complication
After the 10th postoperative day, the patient developed fever and abdominal pain. A
CT scan with rectal and intravenous contrast showed a large amount of air subdiaphragmatic and the evidence of contrast and air leakage at the site of the anastomosis (Fig. 83.2 ). No abscesses were visible.
83 Case on Anastomotic Leakage After Taken Down Hartmann Procedure
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Under diagnosis of leakage of the anastomosis, a relaparotomy was performed.
During operation, an abscess was found at the site of the anastomosis and an anastomotic leakage of about one-third of the circumference was observed. The anastomosis was taken down and an end-colostomy was created.
The patient developed signs of abdominal sepsis with multiple organ failure. She
was admitted to the ICU, mechanical ventilated, and hemodialysis was started
because of acute renal insuffi ciency (ARI). Broad-spectrum antibiotics were iv
administered. After 2 days she could we weaned off the mechanical ventilator, and
hemodialysis could be stopped after 1 week.
After 14 days, she left the hospital and after 3 months a follow-up at the outpatient department showed she was doing fi ne. Her colostomy is functioning well. She
expressed no desire to attempt restoring bowel continuity.
Discussion
Anastomotic leakage is the most dreaded complication after colorectal surgery.
Incidence in the literature varies from 1 to 26 %, with lower anastomosis carrying a
higher risk of failure [ 1 ]. The literature on the management of anastomotic leakage is
scarce and controversial. Historically, the dismantling of the anastomosis and colostomy creation proved to be a safe option, especially in the presence of diffuse peritonitis or ischemia at the level of the anastomosis. The fact that in 70–100 % of these
patients the colostomy is never taken down [ 1 , 2 ] has led to the development of treat-
ment options where the anastomosis is not dismantled. Some series have reported
favorable results using the concept of creating a de-functioning stoma above the
anastomosis and local drainage [ 3 ]. In these series, this is used for patients having
small defects in the anastomosis, only local contamination, and no vascular compromise. Closure of the anastomotic defect using Transanal Endoscopic Microsurgery
[ 4 ] or fi brin glue [ 5 ] has been described in small series as having good results.
Summing up, the procedure of choice in treating an anastomotic leakage is infl uenced by numerous factors including the patient’s general condition on reoperation,
degree of peritonitis, comorbidity, vascular status of bowel ends, age, and the extent
of leakage. In the present case, because of the patient’s age, her septic profi le at
reoperation and the extent of dehiscence, the anastomosis was taken down, creating
a defi nitive colostomy.
References
1. Khan AA, Wheeler JM, Cunningham C, et al. The management and outcome of anastomotic
leaks in colorectal surgery. Colorectal Dis. 2008;10:587–92.
2. Maggiori L, Bretagnol F, Lefèvre JH, et al. Conservative management is associated with a
decreased risk of defi nitive stoma after anastomotic leakage complicating sphincter-saving
resection for rectal cancer. Colorectal Dis. 2011;13:632–7.
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3. Wind J, Koopman AG, van Berge Henegouwen MI, et al. Laparoscopic reintervention for
anastomotic leakage after primary laparoscopic colorectal surgery. Br J Surg.
2007;94:1562–6.
4. Beunis A, Pauli S, Van Cleemput M. Anastomotic leakage of a colorectal anastomosis treated
by transanal endoscopic microsurgery. Acta Chir Belg. 2008;108:474–6.
5. Testi W, Vernillo R, Spagnulo M, et al. Endoscopic treatment of intestinal anastomotic leakage
in low anterior resection of the rectum by using fi brin adhesive. Our experience. Minerva Chir.
2002;57:683–8.
N. de Korte
Chapter 84
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Case on Complication After Sacrocolpopexy
Chan Yuan
Keywords Vaginal prolapse • Sacrocolpopexy • Bleeding • Rectal perforation •
Ileostomy
Diagnosis and Indication for Surgery
A 65-year-old female was operated on because of prolapse of the vagina, causing
defecation problems. Twenty years ago she underwent an appendectomy and a hysterectomy because of uterus fi broid 10 years previously.
Operation
A laparoscopic sacrocolpopexy was intended, yet because of multiple adhesions
intra-abdominally, a conversion to laparotomy became required. After dissection of
the rectum and apex of vagina, a polypropylene mesh was sutured to the vaginal
apex and that at the level of the sacrum promontory.
Postoperative Course: Identifi cation and Treatment
of Complication
Patient had a diffi cult postoperative course. Postoperative thrombosis of the left
iliac vein occurred and the use of coumarin was started (Fig. 84.1 ). Because of a
bowel obstruction and rectal blood loss, a MRI was performed. A large hematoma
C. Yuan , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_84,
© Springer International Publishing Switzerland 2014
463
464
https://t.me/med1917
Fig. 84.1 CT scan showing
the thrombosis left iliac vein
Fig. 84.2 MRI, bleeding in
the rectal wall after
sacrocolpopexy
C. Yuan
was found in the rectal wall, ulcerating through the wall (Fig. 84.2 ). After 3 days
of conservative treatment, a new CT scan showed suspect for rectal perforation
(Fig. 84.3 ); hence, the surgeon decided to perform a relaparotomy. As conse-
quence of the previous operations, extensive adhesions were found in the lower
abdomen. Pelvic hematoma was drained and an ileostomy performed to deviate
the feces. By palpation it seemed that the perforation caused an important circumferential defect of the rectum. The initial plan was to leave the ileostomy for at
least a period of 6 months, so the hematoma and infl ammation of the pelvis could
subside. Yet, after 3 months the ileostomy was causing important care problems
with continuous leakage and high production including dehydration. A proctoscopy showed that at least the last 8 cm of the rectum were normal. Through a laparotomy a rectosigmoid resection of a stenosed and fi brotic traject was performed
with a distal colorectal anastomosis, result being the ileostomy closed. To deviate
the feces, a colostomy proximal to the anastomosis was created. After 6 months,
the control of the anastomosis by enema (Fig. 84.4 ) showed a good patent anasto-
mosis without leakage, and the colostomy could be closed. After 2 months a stenosis of the anastomosis was found—being digitally dilated under anesthesia. The
patient is currently continent for feces and has no recurrence of the vaginal
prolapse.
84 Case on Complication After Sacrocolpopexy
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Fig. 84.3 CT scan, rectal
wall perforation after
bleeding (contrast outside
rectum)
465
Fig. 84.4 Enema, control of
the anastomosis, no leakage
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C. Yuan
Discussion
An explanation for this complication could probably be that during conversion to
laparotomy, a lesion was made at the rectal wall. Treatment with coumarin because
of the iliac vein thrombosis could have induced bleeding of a rectal wall leading to
rectal perforation. The deviating ileostomy worked properly by diverting the feces,
but it was too short and continually caused problems and leaks. After low anterior
resection, the anastomosis healed without problems and fi nally the colostomy could
be reversed. Slawik et al. studied the outcome of laparoscopic ventral rectopexy and
vaginal sacrocolpopexy [ 1 ] for the treatment of recto-genital prolapse in 80 patients
and found complications in 21 %: fecal impaction 4 %, wound infection 2 %, bleeding 2 %, leakage 1 %. Ganatra et al. reviewed the current status of laparoscopic
sacrocolpopexy for vaginal vault prolapse (VVP) and multicompartmental Pelvic
Organ Prolapse [ 2 ]. In comparison with the vaginal sacrocolpopexy—up-to-now
the gold standard—abdominal sacrocolpopexy (ASC) seems to be superior to VVP
for having fewer incidences of recurrent prolapse and less dyspareunia. They
reported outcomes from 11 series with more than 1,000 patients. Mean operative
time was 158 min with a 2.7 % conversion rate and a 1.6 % early reoperation rate.
With a mean follow-up of 24.6 months there was, on average, a 94.4 % satisfaction
rate, a 6.2 % prolapse reoperation rate, and a 2.7 % mesh erosion rate.
References
1. Slawik S, Soulsby R, Carter H. Laparoscopic ventral rectopexy, posterior colporrhaphy and
vaginal sacrocolpopexy for the treatment of recto-genital prolapse and mechanical outlet
obstruction. Colorectal Dis. 2008;10:138–43.
2. Ganatra AM, Rozet F, Sanchez Salas R, et al. The current status of laparoscopic sacrocolpo-
pexy: a review. Eur Urol. 2009;55:1089–103.
Chapter 85
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Case on Ischemia–Necrosis of the
Sigmoid After Repair of a Ruptured
Juxtarenal Aneurysm
Jorg de Bruin
Keyword Aorta aneurysm • Juxtarenal aneurysm • Aortic prosthesis • Renal
cooling • Acute renal insuffi ciency • Sigmoid ischemia
Diagnosis and Indication for Surgery
A 62-year-old patient was presented to our emergency department with nausea,
lower back, and abdominal pain. He had a history of hypertension, dyslipidemia,
and repair of a traumatic rupture of an Achilles tendon. The pain had started 18 h
before presentation and was progressive over time. On physical examination, he
was in shock, had tachycardia, and a large pulsatile mass in the abdomen. Ultrasound
revealed an aneurysm of 7.2 cm in diameter. Computerized tomography scanning
showed a ruptured juxtarenal abdominal aortic aneurysm with a retroperitoneal haematoma (Fig. 85.1 ).
Operation
The patient was transferred to the operating room and underwent open repair of the
juxtarenal aneurysm. The clamp had to be placed suprarenal with renal cooling of
both kidneys during the clamping time; however, the anastomosis could be made
infrarenal. The anastomosis distally was adjacent to the bifurcation. An aortafemoral bypass was made on the left side due to stenosis of the iliac segment. Blood
J. de Bruin , M.D.
Department of Surgery , VU Medical Center , Amsterdam , The Netherlands
e-mail: jl.debruin@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_85,
© Springer International Publishing Switzerland 2014
467
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