Management of Perforated Diverticulitis in Transgender Patients
Core Principle: Gender Identity Does Not Alter Surgical Management
Transgender patients with perforated diverticulitis should receive identical evidence-based surgical management as cisgender patients, with treatment decisions based solely on hemodynamic stability, extent of peritonitis, and comorbidities. 1
The anatomical considerations and pathophysiology of perforated diverticulitis remain unchanged regardless of gender identity. Standard surgical algorithms apply universally.
Immediate Assessment and Resuscitation
Critical Initial Steps
- Initiate aggressive fluid resuscitation, correct electrolyte abnormalities, and establish hemodynamic monitoring immediately upon presentation 1
- Obtain contrast-enhanced CT scan to confirm perforation, assess extent of contamination (purulent vs. feculent peritonitis), and identify abscess formation 1, 2
- Start broad-spectrum intravenous antibiotics immediately covering anaerobes and gram-negative organisms 1
Antibiotic Selection
- First-line options: Meropenem, Doripenem, Imipenem/cilastatin, Eravacycline, or Piperacillin-tazobactam 1, 2
- Alternative regimen: Ceftriaxone plus metronidazole 2
- Duration: 4 days if source control is adequate and patient is immunocompetent and non-critically ill; extend to 7 days if immunocompromised or critically ill 1, 3
Surgical Decision Algorithm
For Hemodynamically Stable Patients Without Major Comorbidities
- Hartmann's procedure remains the safest approach for most patients with pneumoperitoneum and abscess formation 1
- Primary resection with anastomosis may be considered only in highly selected stable patients without fecal peritonitis, significant comorbidities, immunosuppression, or severely edematous/ischemic bowel 4
- The presence of pneumoperitoneum and abscess mandates urgent surgical intervention in the vast majority of cases 1
For Critically Ill or Hemodynamically Unstable Patients
Implement damage control surgery strategy with the following sequence: 5, 1
- Initial limited resection or primary closure of perforation
- Peritoneal lavage and drainage
- Temporary abdominal closure
- ICU resuscitation for physiological optimization
- Second-look operation within 24-48 hours for bowel reconstruction
This approach allows 84% of patients to achieve bowel continuity restoration at the second operation 5
Mortality with damage control approach is approximately 9.8%, with 76% of survivors leaving hospital with restored colon continuity 5
Laparoscopic Approach Considerations
- Emergency laparoscopic sigmoidectomy is feasible only in physiologically stable patients with purulent (not fecal) peritonitis, performed by experienced surgeons in centers with appropriate technical skills and equipment 5
- Conversion to open surgery occurs in 0-19% of cases 5
- Critical caveat: Do not attempt laparoscopic lavage as definitive treatment—reoperation rates are unacceptably high 1
Specific Contraindications to Primary Anastomosis
Avoid primary anastomosis in the following scenarios, as mortality significantly increases: 1, 4
- Hemodynamic instability or shock
- Feculent (Hinchey IV) peritonitis
- Severely edematous or ischemic bowel
- Significant malnutrition
- Immunocompromised state (including patients on hormone therapy with immunosuppressive effects)
- Advanced age with multiple comorbidities
Critical Pitfalls to Avoid
- Do not attempt non-operative management when pneumoperitoneum with large amounts of distant free gas or clinical peritonitis is present—failure rates approach 57-60% 1, 3
- Do not perform primary anastomosis in unstable patients—this dramatically increases mortality 1
- Do not delay surgical intervention in patients with diffuse peritonitis or hemodynamic compromise 2
- Do not rely on laparoscopic lavage alone—it has unacceptably high reoperation rates and should not be considered definitive treatment 1
Special Considerations for Transgender Patients
Hormone Therapy Implications
- Assess current hormone regimen, as some transgender patients on estrogen therapy may have increased thromboembolic risk requiring perioperative prophylaxis
- Patients on testosterone may have altered immune responses; consider this when determining antibiotic duration
- Continue gender-affirming hormone therapy perioperatively unless specific contraindications exist
Anatomical Considerations
- For transgender women who have undergone vaginoplasty, be aware of altered pelvic anatomy during surgical dissection
- Document surgical history thoroughly to anticipate anatomical variations
- Consider ureteral stent placement if pelvic anatomy is significantly altered from prior gender-affirming surgeries 4
Psychosocial Support
- Ensure appropriate gender pronouns and name are used consistently throughout hospitalization
- Provide access to mental health support, as major abdominal surgery with potential ostomy creation carries significant psychological burden
- Address body image concerns proactively, particularly if ostomy creation is necessary
Postoperative Management
Hartmann's Reversal Considerations
- Only 50-80% of patients will undergo successful colostomy reversal 5, 4
- Optimal timing for reversal is typically 6 months post-initial surgery when adhesions are softest 4
- Reversal operations are technically challenging; ensure experienced surgeon and comprehensive preoperative planning 4