Article

Stapled diverticulectomy for solitary caecal diverticulitis

Scarborough General Hospital, Woodlands Drive, Scarborough, North Yorkshire YO12 6QL, UK. .
Annals of The Royal College of Surgeons of England (Impact Factor: 1.27). 11/2012; 94(8):235-6. DOI: 10.1308/003588412X13373405387131
Source: PubMed
ABSTRACT
Caecal diverticulitis is an uncommon phenomenon in western countries. The clinical diagnosis is often difficult as it mimics other acute abdominal conditions like appendicitis, colitis or neoplasia. Diagnosis is often made at operation. Operative strategy has been controversial and there is no broad consensus emerging. We report the case of a 71-year-old woman, known to have chronic obstructive pulmonary disease, who presented acutely with right iliac fossa pain. A clinical diagnosis of appendicitis was made. At laparoscopy, a solitary, inflamed, gangrenous caecal diverticulum was found. A laparoscopic stapled diverticulectomy was performed. The patient made a steady post-operative recovery. Histology confirmed diverticulitis. We conclude that stapled diverticulectomy for solitary caecal diverticulitis is a safe and effective surgical strategy when confronted with this scenario.

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e235
ONLINE CASE REPORT
Ann R Coll Surg Engl 2012; 94: e235–e236
doi 10.1308/003588412X13373405387131
Ann R Coll Surg Engl 2012; 94: e235–e236
KEYWORDS
Caecal diverticulitis – Laparoscopic – Diverticulectomy
Accepted 21 August 2012; published online 5 November 2012
CORRESPONDENCE TO
Raphael Uwechue, Surgical Registrar, Scarborough General Hospital, Woodlands Drive, Scarborough, North Yorkshire YO12 6QL, UK
T: +44 (0)1723 368 111; F: +44 (0)1723 377 223; E: uzouwechue@gmail.com
Stapled diverticulectomy for solitary caecal
diverticulitis
RU Uwechue, ER Richards, M Kurer
Scarborough and North East Yorkshire Healthcare NHS Trust, UK
ABSTRACT
Caecal diverticulitis is an uncommon phenomenon in western countries. The clinical diagnosis is often difficult as it
mimics other acute abdominal conditions like appendicitis, colitis or neoplasia. Diagnosis is often made at operation. Opera-
tive strategy has been controversial and there is no broad consensus emerging. We report the case of a 71-year-old woman,
known to have chronic obstructive pulmonary disease, who presented acutely with right iliac fossa pain. A clinical diagnosis of
appendicitis was made. At laparoscopy, a solitary, inflamed, gangrenous caecal diverticulum was found. A laparoscopic stapled
diverticulectomy was performed. The patient made a steady post-operative recovery. Histology confirmed diverticulitis. We
conclude that stapled diverticulectomy for solitary caecal diverticulitis is a safe and effective surgical strategy when confronted
with this scenario.
Caecal diverticulitis was rst described by Potier in 1912. It
is a well recognised pathological entity yet it is still uncom-
mon in Western society. It has a higher prevalence in Asian
populations.
1
Presentation is commonly with a history of right-sided
abdominal pain and a clinical examination indistinguish-
able from appendicitis. Caecal diverticulitis is frequently
diagnosed at laparoscopy or laparotomy and various treat-
ment options have been described in the literature.
Case history
A 71-year-old woman was admitted to our hospital complain-
ing of several days of acute onset abdominal pain. Her pain
started as a dull central ache that had migrated to the right
lower quadrant. She was known to have chronic obstructive
pulmonary disease (COPD) and her exercise tolerance was
signicantly restricted. Examination revealed tenderness
and guarding in the right iliac fossa, over McBurney’s point.
Her inammatory markers were raised, her total white cell
count was 11.8 x 10
9
/l (normal range: 4–11 x 10
9
/l) and her
C-reactive protein was 116mg/l (normal range: <6mg/l).
A clinical diagnosis of appendicitis was made and she was
taken to the operating theatre for a diagnostic laparoscopy.
A 10mm umbilical balloon port was inserted by open
cut-down technique. A left iliac fossa 12mm port and a su-
prapubic 5mm port were inserted under vision. The appen-
dix was normal and an inamed and gangrenous solitary
diverticulum was noted on the antimesenteric surface of the
caecum (Fig 1). In view of her co-morbidities, the patient
was not felt to be t for open surgery or an extensive resec-
tion. A stapled diverticulectomy was therefore performed
using an Endo GIA™ (Covidien, Dublin, Ireland) stapling
device (Figs 2 and 3).
Histology conrmed a 3.5cm x 3.0cm x 1.5cm diverticu-
lum with transmural suppurative inammation and loss of
the mucosal lining. The patient made a slow recovery from
Figure 1 Solitary caecal diverticulitis with normal appendix
Page 1
e236 Ann R Coll Surg Engl 2012; 94: e235–e236
UWECHUE RICHARDS KURER
STAPLED DIVERTICULECTOMY FOR SOLITARY CAECAL
DIVERTICULITIS
surgery. She developed a post-operative chest infection that
was treated successfully. She was discharged a week after
surgery. At the follow-up appointment two months later, she
had made a full recovery. She had developed a port site her-
nia at the left iliac fossa port but was asymptomatic from this.
Discussion
The diagnosis of caecal diverticulitis is difcult to establish
accurately pre-operatively. The clinical presentation often
mimics that of acute appendicitis as seen in this case. Con-
sequently, the diagnosis is frequently made at the time of
surgery for presumed appendicitis.
1
Treatment options for caecal diverticulitis vary widely
depending on the presentation and local expertise. There is
no consensus among surgeons as to the best option. For un-
complicated caecal diverticulitis diagnosed pre-operatively,
a conservative approach can be taken with bowel rest and
antibiotics.
2
However, others advocate aggressive surgical
resection in caecal diverticulitis as less than 40% of patients
are successfully managed conservatively without recurrent
symptoms.
3
The surgical approach to resection of a solitary cae-
cal diverticulum varies from a simple diverticulectomy to
a right hemicolectomy. These can be performed open or
laparoscopically. The rst report of a laparoscopic diverti-
culectomy was in 1994.
4
Since then, there have been several
other reports showing that laparoscopic resection is feasible
in experienced hands.
1
Our case posed several challenges. First, the patient had
COPD, a signicant medical co-morbidity. This increased
her risk of peri-operative and post-operative complications.
It was therefore felt that laparoscopic resection was the
most appropriate option in order to reduce these risks as
it involved smaller incisions and facilitated faster recovery.
Indeed, the patient did suffer from a post-operative chest
infection, which was treated successfully.
Second, the diagnosis was made intra-operatively and
a decision as to how to treat this needed to be made intra-
operatively. Resection was performed as the diverticulum
was gangrenous and perforation was thought to be immi-
nent, the risk of recurrence if left unresected is known to be
signicant
3
and the surgeon was happy to proceed based on
his experience.
5
Furthermore, the diagnosis of caecal cancer
must always be entertained in all acute abdomens with intra-
operative caecal pathology. If suspected, an oncologically
sound right colectomy is the treatment of choice. In reference
to our case and as is clear from the pictures, we felt cancer
was unlikely. This was because we encountered a discrete,
well dened, outpouching area of the caecal wall (the soli-
tary caecal diverticulum), which looked gangrenous, and felt
rather soft and as though it were about to perforate. We were
condent that no characteristics of malignancy were present.
Finally, the patient developed a port site hernia at the
12mm left iliac fossa incision. We feel that this is most likely
a result of the patient’s chronic cough that she experiences
as part of her COPD. This highlights the importance of care-
ful consideration of port placement and closure technique,
taking into account the general condition of the patient.
This port site was not sutured at the sheath. In hindsight, it
may have been prudent to have closed the sheath.
Conclusions
A laparoscopic stapled diverticulectomy for solitary caecal
diverticulitis for a safe and effective therapeutic option, espe-
cially in patients in whom more radical surgery would pose a
high risk. We believe this is the rst reported case in the UK.
References
1. Kumar S, Fitzmaurice GJ, O’Donnell ME, Brown R. Acute right iliac fossa pain:
not always appendicitis or a caecal tumour: two case reports. Cases J 2009;
2: 88.
2. Yang HR, Huang HH, Wang YC et al. Management of right colon diverticulitis: a
10-year experience. World J Surg 2006; 30: 1,929–1,934.
3. Fang JF, Chen RJ, Lin BC et al. Aggressive resection is indicated for cecal
diverticulitis. Am J Surg 2003; 185: 135–140.
4. Rubio PA. Laparoscopic resection of a solitary cecal diverticulum.
J Laparoendosc Surg 1994; 4: 281–285.
5. Kurer MA. Solitary caecal diverticulitis as an unusual cause of a right iliac fossa
mass: a case report. J Med Case Rep 2007; 1: 132.
Figure 2 Diverticulum partially excised
Figure 3 Staple line following resection
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