Surgical management of colocutaneous fistulae in diverticulitis.

Abstract

A 70-year-old female presented to the emergency department with a painful left inguinal mass along with intermittent nausea and vomiting but no constipation or obstipation. Her last bowel motion was on the morning of presentation. Her medical background was significant for gastro-oesophageal reflux disease, hysterectomy, a bowel containing reducible left inguinal hernia seen on ultrasound 3 months earlier for which the patient was awaiting surgical review and an episode of diverticulitis 4 years ago complicated by a 3.6 cm perisigmoid abscess. The previous episode of diverticulitis was treated successfully with intravenous (IV) antibiotics only as the abscess was not drainable. During this presentation, examination revealed a soft abdomen with the tender firm left inguinal mass with overlying erythema. Bowel sounds were present. The patient was afebrile, heart rate was 110 beats per minute and systolic blood pressure was 160 mmHg. Initial blood tests revealed a pH of 7.39, lactate of 1.1 mmol/L and a white cell count of 10.7 × 109/L. Attempts were made to reduce the left inguinal mass, but this was unsuccessful. After surgical review, a provisional diagnosis of an incarcerated left inguinal hernia was made. The patient proceeded to the operating theatre without imaging for an open groin exploration ± washout. Upon entering the inguinal canal, an abscess cavity was encountered unexpectedly (Fig. 1(a)). Laparoscopy was performed for concerns of bowel necrosis, revealing inflamed sigmoid bowel consistent with sigmoid diverticulitis as well as adherent bowel to the anterior abdominal wall and the bladder (Fig. 1(b)).