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Acute colonic diverticulitis: Surgical management

John H Pemberton, MD
Section Editor
Martin Weiser, MD
Deputy Editor
Wenliang Chen, MD, PhD


Diverticular disease of the colon is an important cause of hospital admissions and a significant contributor to healthcare costs in industrialized nations [1,2]. In Western countries, the majority of patients present with sigmoid diverticulitis [3,4]. Although most patients with acute diverticulitis can be treated medically, approximately 15 percent will require surgery [5]. In the United States, diverticular disease is the leading indication for elective colon surgery [6].

The indications for surgery, the choice of procedures in different clinical scenarios, the surgical techniques, and the perioperative considerations are discussed here. The diagnosis and medical management of acute diverticulitis are discussed separately. (See "Clinical manifestations and diagnosis of acute diverticulitis in adults" and "Acute colonic diverticulitis: Medical management".)


Since most patients with diverticulitis are treated medically, surgery is only indicated when diverticular disease is either not amenable or refractory to medical therapy (algorithm 1) [5,7-9].

Indication for emergency surgery — Acute diverticulitis with frank (free) perforation is a life-threatening condition that mandates emergency surgery [5,9-11]. (See 'Resection' below.)

Indications for urgent surgery — Urgent surgery (in which an operation is generally required during the same hospitalization) should be performed in patients with one of the indications discussed below.

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Literature review current through: Nov 2017. | This topic last updated: Mar 27, 2017.
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  1. Everhart JE, Ruhl CE. Burden of digestive diseases in the United States part II: lower gastrointestinal diseases. Gastroenterology 2009; 136:741.
  2. Shaheen NJ, Hansen RA, Morgan DR, et al. The burden of gastrointestinal and liver diseases, 2006. Am J Gastroenterol 2006; 101:2128.
  3. Hughes LE. Postmortem survey of diverticular disease of the colon. I. Diverticulosis and diverticulitis. Gut 1969; 10:336.
  4. Fischer MG, Farkas AM. Diverticulitis of the cecum and ascending colon. Dis Colon Rectum 1984; 27:454.
  5. Morris AM, Regenbogen SE, Hardiman KM, Hendren S. Sigmoid diverticulitis: a systematic review. JAMA 2014; 311:287.
  6. Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg 2005; 140:681.
  7. Rafferty J, Shellito P, Hyman NH, et al. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006; 49:939.
  8. Dharmarajan S, Hunt SR, Birnbaum EH, et al. The efficacy of nonoperative management of acute complicated diverticulitis. Dis Colon Rectum 2011; 54:663.
  9. Regenbogen SE, Hardiman KM, Hendren S, Morris AM. Surgery for diverticulitis in the 21st century: a systematic review. JAMA Surg 2014; 149:292.
  10. Krobot K, Yin D, Zhang Q, et al. Effect of inappropriate initial empiric antibiotic therapy on outcome of patients with community-acquired intra-abdominal infections requiring surgery. Eur J Clin Microbiol Infect Dis 2004; 23:682.
  11. Stocchi L. Current indications and role of surgery in the management of sigmoid diverticulitis. World J Gastroenterol 2010; 16:804.
  12. Currie A, Christmas C, Aldean H, et al. Systematic review of self-expanding stents in the management of benign colorectal obstruction. Colorectal Dis 2014; 16:239.
  13. Rose J, Parina RP, Faiz O, et al. Long-term Outcomes After Initial Presentation of Diverticulitis. Ann Surg 2015; 262:1046.
  14. Devaraj B, Liu W, Tatum J, et al. Medically Treated Diverticular Abscess Associated With High Risk of Recurrence and Disease Complications. Dis Colon Rectum 2016; 59:208.
  15. Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum 2014; 57:284.
  16. Cirocchi R, Arezzo A, Vettoretto N, et al. Role of damage control surgery in the treatment of Hinchey III and IV sigmoid diverticulitis: a tailored strategy. Medicine (Baltimore) 2014; 93:e184.
  17. Constantinides VA, Tekkis PP, Senapati A, Association of Coloproctology of Great Britain Ireland. Prospective multicentre evaluation of adverse outcomes following treatment for complicated diverticular disease. Br J Surg 2006; 93:1503.
  18. Constantinides VA, Tekkis PP, Athanasiou T, et al. Primary resection with anastomosis vs. Hartmann's procedure in nonelective surgery for acute colonic diverticulitis: a systematic review. Dis Colon Rectum 2006; 49:966.
  19. Abbas S. Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis 2007; 22:351.
  20. Salem L, Flum DR. Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum 2004; 47:1953.
  21. Gooszen AW, Tollenaar RA, Geelkerken RH, et al. Prospective study of primary anastomosis following sigmoid resection for suspected acute complicated diverticular disease. Br J Surg 2001; 88:693.
  22. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated diverticular disease of the colon. Adv Surg 1978; 12:85.
  23. Rothenberger DA, Wiltz O. Surgery for complicated diverticulitis. Surg Clin North Am 1993; 73:975.
  24. Benn PL, Wolff BG, Ilstrup DM. Level of anastomosis and recurrent colonic diverticulitis. Am J Surg 1986; 151:269.
  25. Köhler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc 1999; 13:430.
  26. Köckerling F, Schneider C, Reymond MA, et al. Laparoscopic resection of sigmoid diverticulitis. Results of a multicenter study. Laparoscopic Colorectal Surgery Study Group. Surg Endosc 1999; 13:567.
  27. Franklin ME Jr, Dorman JP, Jacobs M, Plasencia G. Is laparoscopic surgery applicable to complicated colonic diverticular disease? Surg Endosc 1997; 11:1021.
  28. Stevenson AR, Stitz RW, Lumley JW, Fielding GA. Laparoscopically assisted anterior resection for diverticular disease: follow-up of 100 consecutive patients. Ann Surg 1998; 227:335.
  29. Eijsbouts QA, Cuesta MA, de Brauw LM, Sietses C. Elective laparoscopic-assisted sigmoid resection for diverticular disease. Surg Endosc 1997; 11:750.
  30. Dwivedi A, Chahin F, Agrawal S, et al. Laparoscopic colectomy vs. open colectomy for sigmoid diverticular disease. Dis Colon Rectum 2002; 45:1309.
  31. Scheidbach H, Schneider C, Rose J, et al. Laparoscopic approach to treatment of sigmoid diverticulitis: changes in the spectrum of indications and results of a prospective, multicenter study on 1,545 patients. Dis Colon Rectum 2004; 47:1883.
  32. Alves A, Panis Y, Slim K, et al. French multicentre prospective observational study of laparoscopic versus open colectomy for sigmoid diverticular disease. Br J Surg 2005; 92:1520.
  33. Purkayastha S, Constantinides VA, Tekkis PP, et al. Laparoscopic vs. open surgery for diverticular disease: a meta-analysis of nonrandomized studies. Dis Colon Rectum 2006; 49:446.
  34. Jones OM, Stevenson AR, Clark D, et al. Laparoscopic resection for diverticular disease: follow-up of 500 consecutive patients. Ann Surg 2008; 248:1092.
  35. Pendlimari R, Touzios JG, Azodo IA, et al. Short-term outcomes after elective minimally invasive colectomy for diverticulitis. Br J Surg 2011; 98:431.
  36. Siddiqui MR, Sajid MS, Qureshi S, et al. Elective laparoscopic sigmoid resection for diverticular disease has fewer complications than conventional surgery: a meta-analysis. Am J Surg 2010; 200:144.
  37. Gervaz P, Inan I, Perneger T, et al. A prospective, randomized, single-blind comparison of laparoscopic versus open sigmoid colectomy for diverticulitis. Ann Surg 2010; 252:3.
  38. Raue W, Paolucci V, Asperger W, et al. Laparoscopic sigmoid resection for diverticular disease has no advantages over open approach: midterm results of a randomized controlled trial. Langenbecks Arch Surg 2011; 396:973.
  39. Champagne BJ, Papaconstantinou HT, Parmar SS, et al. Single-incision versus standard multiport laparoscopic colectomy: a multicenter, case-controlled comparison. Ann Surg 2012; 255:66.
  40. Vestweber B, Galetin T, Lammerting K, et al. Single-incision laparoscopic surgery: outcomes from 224 colonic resections performed at a single center using SILS. Surg Endosc 2013; 27:434.
  41. Maggard MA, Zingmond D, O'Connell JB, Ko CY. What proportion of patients with an ostomy (for diverticulitis) get reversed? Am Surg 2004; 70:928.
  42. Vermeulen J, Coene PP, Van Hout NM, et al. Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann's procedure be considered a one-stage procedure? Colorectal Dis 2009; 11:619.
  43. Banerjee S, Leather AJ, Rennie JA, et al. Feasibility and morbidity of reversal of Hartmann's. Colorectal Dis 2005; 7:454.
  44. Vermeulen J, Gosselink MP, Busschbach JJ, Lange JF. Avoiding or reversing Hartmann's procedure provides improved quality of life after perforated diverticulitis. J Gastrointest Surg 2010; 14:651.
  45. Rege RV, Nahrwold DL. Diverticular disease. Curr Probl Surg 1989; 26:133.
  46. Rodkey GV, Welch CE. Changing patterns in the surgical treatment of diverticular disease. Ann Surg 1984; 200:466.
  47. Oberkofler CE, Rickenbacher A, Raptis DA, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann's procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 2012; 256:819.
  48. O'Sullivan GC, Murphy D, O'Brien MG, Ireland A. Laparoscopic management of generalized peritonitis due to perforated colonic diverticula. Am J Surg 1996; 171:432.
  49. Myers E, Hurley M, O'Sullivan GC, et al. Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis. Br J Surg 2008; 95:97.
  50. Franklin ME Jr, Portillo G, Treviño JM, et al. Long-term experience with the laparoscopic approach to perforated diverticulitis plus generalized peritonitis. World J Surg 2008; 32:1507.
  51. Biffl WL, Moore FA, Moore EE. What is the current role of laparoscopic lavage in perforated diverticulitis? J Trauma Acute Care Surg 2017; 82:810.
  52. Toorenvliet BR, Swank H, Schoones JW, et al. Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review. Colorectal Dis 2010; 12:862.
  53. Schultz JK, Yaqub S, Wallon C, et al. Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: The SCANDIV Randomized Clinical Trial. JAMA 2015; 314:1364.
  54. Vennix S, Musters GD, Mulder IM, et al. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet 2015; 386:1269.
  55. Angenete E, Thornell A, Burcharth J, et al. Laparoscopic Lavage Is Feasible and Safe for the Treatment of Perforated Diverticulitis With Purulent Peritonitis: The First Results From the Randomized Controlled Trial DILALA. Ann Surg 2016; 263:117.
  56. Thornell A, Angenete E, Bisgaard T, et al. Laparoscopic Lavage for Perforated Diverticulitis With Purulent Peritonitis: A Randomized Trial. Ann Intern Med 2016; 164:137.
  57. Roberts P, Abel M, Rosen L, et al. Practice parameters for sigmoid diverticulitis. The Standards Task Force American Society of Colon and Rectal Surgeons. Dis Colon Rectum 1995; 38:125.
  58. Nagorney DM, Adson MA, Pemberton JH. Sigmoid diverticulitis with perforation and generalized peritonitis. Dis Colon Rectum 1985; 28:71.
  59. Larson DW, Batdorf NJ, Touzios JG, et al. A fast-track recovery protocol improves outcomes in elective laparoscopic colectomy for diverticulitis. J Am Coll Surg 2010; 211:485.
  60. Sarin S, Boulos PB. Long-term outcome of patients presenting with acute complications of diverticular disease. Ann R Coll Surg Engl 1994; 76:117.
  61. Morris CR, Harvey IM, Stebbings WS, Hart AR. Incidence of perforated diverticulitis and risk factors for death in a UK population. Br J Surg 2008; 95:876.
  62. Wolff BG, Ready RL, MacCarty RL, et al. Influence of sigmoid resection on progression of diverticular disease of the colon. Dis Colon Rectum 1984; 27:645.
  63. Corman ML. Colon and Rectal Surgery, 3rd edition, JB Lippincott, Philadelphia 1993. p.817.
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