c l i n i c a l
f o l i o s :
d i s c u s s i o n
Diverticular Abscess
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Diverticular Abscess | ||
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Related narratives: Hartmann's Closure after Diverticular Abscess Diverticulitis can be complicated by abscess formation, either intramesenteric or peridiverticular walled off by adjacent structures (see colovesical fistula). Such an abscess can secondarily rupture into the free peritoneal cavity (see perforated diverticulum). In the case of a contained abscess, the cavity can often be successfully drained and treated by percutaneous CT-guided catheter placement, allowing the inflammatory process to resolve. After a six week interval, the patient can return to be bowel prepped and undergo a one stage sigmoid resection and anastomosis. If the primary inflammatory process cannot be controlled, as in this case, it is necessary to proceed to diversion with or without resection. It has been shown to be better for the patient to resect the inflamed colon when this is possible, rather than leaving a smoldering inflamed sigmoid in the abdomen. Only if there is a large phlegmonous mass whose resection would endanger adjacent structures (bowel, ureter, bladder) would the mass be left and a diverting colostomy be performed as a first stage. A left ureteral stent, with or without a light, helps protect the ureter during such a resection. Identifying and dissecting the rectal stump after pelvic diverticular inflammation can be a challenge. One method of identification is to attach a long blue monofilament suture to the stump, and tack the suture to the left lateral abdominal wall near the stoma site. A alternative method demonstrated in this case is to advance a sigmoidoscope from below. The anastomosis is made to the 4cm of rectum above the peritoneal reflection, so there are no diverticula on the distal side of the anastomosis, decreasing the chance of recurrence and anastomotic leak. The anastomosis can be hand sewn in interrupted fashion as in this case, or with a 3-0 slow absorbing monofilament in a continuous fashion, taking all layers with each bite. It is essential to have healthy vascularized ends that come together without tension. Greenfield, LJ, (Ed), Surgery, Scientific Principles and Practice, 3rd ed, Lippincott, Williams & Wilkins, Phila, 2001, 824, 1141-2.
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