Surgical Intervention for Diverticulitis
Emergency Surgery: Immediate Indications
Patients with perforated diverticulitis and diffuse peritonitis (WSES stage 3-4) require prompt surgical source control and should not be managed non-operatively. 1
Absolute Indications for Emergency Surgery:
- Diffuse peritonitis with hemodynamic instability – Hartmann's procedure is the recommended approach, involving sigmoid resection with end colostomy and rectal stump closure 1, 2
- Pneumoperitoneum with abscess formation – Urgent surgical intervention is mandated in most cases, with Hartmann's procedure preferred given the ongoing septic source 2
- Distant intraperitoneal free air without free fluid (WSES stage 2b) – Non-operative management is not recommended as a viable option 1
Surgical Approach Selection in Emergency Settings:
- Hartmann's procedure is recommended for elderly patients or those with physiological derangement and generalized peritonitis 1
- Resection with primary anastomosis may be considered in hemodynamically stable patients without major comorbidities, though both approaches are reasonable options 1
- Damage control surgery (emergency laparotomy, source control, open abdomen with vacuum-assisted closure) is viable for patients with severe physiological derangement 1, 2
- Laparoscopic lavage alone is not recommended due to higher risk of failure to control sepsis and unacceptably high reoperation rates 1, 2
Critical Pitfall:
Do not attempt non-operative management in patients with large amounts of distant free gas or clinical peritonitis, as failure rates approach 57-60% 2
Elective Surgery: Indications After Initial Treatment
Elective sigmoid resection should be discussed with patients who have either persistent uncomplicated diverticulitis (>3 months), frequently recurring episodes (≥3 episodes within 2 years), or any episode of complicated diverticulitis. 1
Specific Indications for Elective Surgery:
- Complicated diverticulitis (abscess, fistula, obstruction, perforation) after initial treatment – surgery reduces 25% five-year recurrence risk 1, 3
- Persistent symptoms >3 months despite conservative management 1, 3
- ≥3 episodes of uncomplicated diverticulitis within 2 years – surgery is cost-effective at 5-year follow-up 1, 3
- Stenosis, fistulae, or recurrent diverticular bleeding in patients fit for surgery 1
- Significant quality of life impairment from recurrent symptoms 1
- Immunocompromised patients should be considered for surgery even after one episode if fit for surgery 1, 3
Important Considerations:
- Surgery reduces but does not eliminate recurrence (15% recurrence at 5 years post-resection) 3
- Perioperative complications occur in 1.4-5.5% of patients (anastomotic leak, sepsis, myocardial infarction) 1, 3
- 22-25% of patients continue experiencing abdominal pain after surgery – this must be discussed during shared decision-making 3
- Laparoscopic approach is preferred for elective cases when feasible 1
What NOT to Do: Outdated Recommendations
Do not routinely recommend elective surgery based solely on "two episodes" of uncomplicated diverticulitis – this outdated guideline has been abandoned 4
Modern Approach:
- Asymptomatic elderly patients after conservatively treated uncomplicated diverticulitis without stenosis, fistulae, or bleeding should not undergo routine elective resection 1
- Age <50 years alone is no longer an automatic indication for surgery after first episode 4
- Complicated recurrence after uncomplicated episodes is rare (<5%) 4
Adjunctive Management
Colonoscopy:
- Refer patients for colonoscopy 4-6 weeks after complicated diverticulitis episode if no recent colonoscopy performed 1, 5