Less Is (Sometimes) More: Laparoscopic Peritoneal Lavage and Drainage for Diverticulitis.

Abstract

Introduction: Laparoscopic lavage and drainage (LLD) emerged as an alternative to Hartmann's procedure (HP) for patients with diverticulitis and uncontained perforation. Although initially popular as a less invasive approach, its use in modern practice is in question. This summary will review the available literature to show techniques, outcomes, and indications. Methods: The literature was reviewed for relevant case studies, randomized trials, prospective series, retrospective analyses, and meta-analyses to define peritoneal lavage and determine the clinical outcomes of peritoneal lavage. Results: LLD can be considered on an individual basis for Hinchey III diverticulitis (purulent peritonitis), but there are several contraindications. The extent of adhesionolysis (limited versus extensive) as well as the management of sites of perforation found during surgery are debated. Most surgeons continue lavage with warm saline until water runs clear and place drains in the operation. Three randomized controlled trials (RCTs), the LADIES, SCANDIV, and DILALA trials compared LLD with either resection and anastomosis or Hartmann's procedure. One other RCT (the LapLAND trial) is still with results pending. The LADIES trial studied LLD versus primary anastomosis and resection in Hinchey III diverticulitis and was terminated early secondary to higher 30-day morbidity in the LLD arm; however, 3-year data showed no significant difference in morbidity and mortality. The SCANDIV trial compared LLD with resection in acute diverticulitis (Hinchey I-III) and saw no difference in 90-day morbidity or mortality; however, it noted higher rates of reoperation in the LLD group. The DILALA trial compared Hinchey III diverticulitis patients undergoing LLD with open HP and found that the LLD group had a lower rate of reoperation at 2 years, but no difference in rates of readmission or mortality. Conclusions: Debate still remains over the technique of LLD and specific indications, as well as outcomes compared with resection and primary anastomosis or HP.