Version July 2025
INTRODUCTION —
Diverticular disease of the colon is an important cause of hospital admissions and a significant contributor to health care costs in industrialized nations [1,2]. In Western countries, the majority of patients present with sigmoid diverticulitis [3,4].
Most patients with acute sigmoid diverticulitis are treated medically; surgery is only indicated to treat severe complications, persistent symptoms despite best medical therapy, or recurrent attacks (algorithm 1) [5-7]. Approximately 15 percent of patients will require surgery for diverticular disease [5]; up to 32 percent of patients hospitalized for diverticulitis will require emergency surgery [8,9].
In the United States, diverticular disease is the leading indication for elective colon surgery [10]. For patients who require surgery for diverticulitis, the choice of techniques depends upon the patient's hemodynamic stability, extent of peritoneal contamination, and surgeon experience/preference [7].
Surgical treatment of acute colonic diverticulitis and its acute complications (perforation, abscess formation, or intractability) are described here. Diverticular fistulas, bleeding, and stricture/obstruction, which are typically subacute or chronic sequelae of diverticulitis, are discussed in other topics:
●(See "Diverticular fistulas".)
●(See "Colonic diverticular bleeding".)
●(See "Large bowel obstruction".)
The diagnosis and medical management of acute diverticulitis are discussed separately. (See "Clinical manifestations and diagnosis of acute colonic diverticulitis in adults" and "Acute colonic diverticulitis: Triage and inpatient management" and "Acute colonic diverticulitis: Outpatient management and follow-up".)
SURGERY FOR COMPLICATIONS
Perforation — The Hinchey classification is the most widely recognized system for categorizing the severity of perforated diverticulitis [11]:
●Stage I – Pericolic or mesenteric abscess
●Stage II – Walled-off pelvic abscess
●Stage III – Generalized purulent peritonitis
●Stage IV – Generalized feculent peritonitis
In general, the majority of microperforations (not included in the Hinchey classification), Hinchey I perforations, and Hinchey II perforations can be managed nonoperatively, while most Hinchey III and IV perforations require emergency surgical intervention.
Perforation with generalized peritonitis — Perforated diverticulitis with generalized peritonitis (Hinchey III or IV) is a life-threatening condition that mandates emergency surgery [5,6,12-14]. The primary goal of surgery is to achieve source control by removing the perforated segment of the colon. A secondary objective is to restore intestinal continuity, which depends on the patient's hemodynamic stability and the extent of peritoneal contamination [15-19].
Unstable patients with generalized peritonitis — Patients who are hemodynamically unstable due to perforated diverticulitis may not have the physiologic reserve to tolerate a colon resection and reconstruction. As such, damage control surgery should be expedited to obtain source control of their sepsis, while delaying less critical portions of the operation until after appropriate resuscitation [20-23]. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury".)
In this setting, damage control surgery is performed in two stages [20]:
●In the first stage, the perforated portion of the colon is resected and left in discontinuity, the peritoneum is lavaged, and the abdomen is temporarily closed.
●After the patient is further resuscitated, they are brought back for the second stage during which they are either definitely reconstructed (typically with a loop ileostomy) or with an end colostomy (ie, Hartmann procedure).
Employing a staged approach permits the reconstruction to be performed with less time pressure and the patient to have more physiologic reserve to avoid potential complications (eg, anastomotic leak). In a meta-analysis of 256 patients, an anastomosis was possible in 73 percent of second-look surgeries, and over half of surviving patients were stoma free at discharge [22,24].
Stable patients with generalized peritonitis — Stable patients with generalized peritonitis can generally tolerate a formal colon resection with either reconstruction or diversion. There is no widely accepted standard procedure here due to the extreme heterogeneity in patient presentations [14]. Options of surgical therapy include [7]:
●The Hartmann procedure involves resecting the diseased colonic segment, creating an end colostomy and a rectal stump, and then reversing the colostomy in the future (figure 1) [16]. It is the most commonly performed surgery for colonic perforation because it eliminates the risk of an anastomotic leak when the patient is least able to tolerate it [25]. However, subsequent closure of the colostomy is a technically difficult operation associated with high morbidity and mortality rates [26,27]. As a result, colostomy closure is only performed in approximately 50 to 60 percent of all patients after a Hartmann procedure [28-30].
●Primary colorectal anastomosis can be performed with or without proximal diversion with a loop ileostomy (figure 2).
●Laparoscopic lavage has been proposed as a less invasive alternative to colon resection in patients with Hinchey III perforated diverticulitis.
For stable patients with generalized peritonitis, we suggest performing a primary anastomosis with or without proximal diversion rather than a Hartmann procedure. A 2018 systematic review and meta-analysis of randomized trials [31-33] found that primary resection and anastomosis had a similar major complication rate (relative risk [RR] 0.88, 95% CI 0.49-1.55) and mortality rate (RR 0.58, 95% CI 0.20-1.70) compared with the Hartmann procedure. However, patients were more likely to be stoma free (RR 1.4, 95% CI 1.18-1.67) and avoid major complications related to the stoma reversal procedure (RR 0.26, 95% CI 0.07-0.89) [34].
A 2023 meta-analysis of two trials with long-term follow-up associated primary anastomosis with lower odds of long-term ostomy (odds ratio [OR] 0.02, 95% CI 0.003-0.195), long-term complications (OR 0.195, 95% CI 0.113-0.335), reoperations (OR 0.2, 95% CI 0.108-0.384), and incisional hernias (OR 0.184, 95% CI 0.102-0.333) compared with the Hartmann procedure [35].
The Hartmann procedure may be necessary for patients with a large burden of intra-abdominal contamination with stool, serious underlying comorbidities (eg, immunosuppression) that would render an anastomotic leak unsalvageable, or severely inflamed or edematous rectum that precludes a safe anastomosis.
Whether to protect a primary anastomosis with a diverting loop ileostomy depends on patient and intraoperative factors and surgeon experience. In a systematic review and meta-analysis of 17 nonrandomized studies comparing primary anastomosis with or without a diverting stoma, the 30-day mortality, major morbidity, anastomotic leak, reoperation rates, and length of stay were similar between the two groups [36]. Fewer patients had a permanent stoma after primary anastomosis without a diverting stoma than with a diverting stoma. The ongoing DIVERTI-2 trial is attempting to address this issue with higher-level evidence [37].
Laparoscopic lavage should only be contemplated in the absence of fecal contamination (ie, Hinchey III), and patients should be advised that a reoperation (usually Hartmann procedure) may be necessary if lavage alone fails to control the sepsis or if a sigmoid carcinoma is later found. Despite earlier enthusiasm for this procedure in the 1990s [38], later randomized trials (SCANDIV [39,40], LOLA [41], DILALA [42-44]) found that major complications were more frequent after laparoscopic lavage than sigmoidectomy, whereas postoperative mortality rates (RR 1.03, CI 0.45-2.34) were not different between the two procedures [34,45,46]. Lavage is also associated with a higher recurrence rate of diverticulitis than colonic resection (OR 5.8, 95% CI 2.33-14.42) [35].
Selecting an operative approach for perforated diverticulitis involves balancing two key objectives: reducing surgical morbidity (such as risks of anastomotic leaks and reoperations) and minimizing the need for stoma creation, particularly permanent stomas. The Hartmann procedure is frequently performed as it eliminates the risk of an anastomotic leak when the patient is acutely ill, yet it also carries the highest rate of permanent stomas. By contrast, laparoscopic lavage can avoid stoma formation if successful; however, it often requires subsequent rescue reoperations due to limited efficacy. Primary anastomosis may offer a lower stoma rate than the Hartmann procedure while also reducing the risk of septic complications and reoperations associated with laparoscopic lavage. The choice of surgical strategy must be individualized to best meet each patient's needs. For example, the Hartmann procedure may be preferable in an older patient with multiple comorbidities who is at high risk of dying if an anastomotic leak occurs, while laparoscopic lavage could benefit a fit patient with no signs of sepsis at presentation.
Perforation with localized peritonitis — Localized perforations present acutely either as microperforation or as a mesocolic or pelvic abscess (Hinchey I or II). Microperforation can be managed like uncomplicated diverticulitis using antibiotics. For diverticular abscesses, treatment usually involves percutaneous image-guided drainage, or intravenous antibiotics if the abscess is small (<4 cm) or difficult to reach with a drainage catheter. Surgery may be required to salvage patients whose condition does not improve or worsens after antibiotic therapy and percutaneous drainage. (See "Acute colonic diverticulitis: Triage and inpatient management", section on 'Microperforation' and "Acute colonic diverticulitis: Triage and inpatient management", section on 'Abscess'.)
Patients with a localized perforation can usually tolerate a preoperative bowel preparation. Thus, if the phlegmon or abscess can be resected with the colonic segment, a primary anastomosis is usually performed in these patients.
If there are concerns about either contamination or inflammation involving the surrounding tissue (eg, with a large pelvic abscess) but the bowel is not edematous, a primary anastomosis with proximal diversion can be performed. This is preferred to a Hartmann procedure as a protective loop ileostomy is easier to reverse than an end colostomy with a rectal stump [47,48].
Obstruction or stricture — It is rare for acute diverticulitis to be severe enough to cause a complete colonic obstruction. In patients who present with symptomatic large bowel obstruction, it is more likely that they already have an underlying sigmoid stricture from either a malignant or benign (chronic or recurrent diverticulitis) process.
Regardless of the underlying etiology, patients who present with a symptomatic large bowel obstruction should be evaluated and treated accordingly (see "Large bowel obstruction"). There are two methods of relieving the colonic obstruction: endoscopic stenting and surgical resection/diversion.
●Historically, endoscopic stenting is less effective for benign than for malignant colonic strictures [49]. In a 2014 systematic review, treating benign colorectal obstructions (most due to diverticulitis) with self-expanding stents resulted in more cases of perforation (12 versus 4 percent), stent migration (20 versus 10 percent), and recurrent obstruction (14 versus 7 percent) than stenting malignant colorectal obstructions [50]. When stenting was used as a bridging therapy to surgery, only 43 percent of patients with diverticulitis avoided a stoma. However, the success rates were higher in more recent series [51,52].
●In patients who present with large bowel obstruction, colonic resection for diverticular stricture usually requires a Hartmann procedure due to a significant size mismatch between a dilated colon and decompressed rectum.
Furthermore, a competent ileocecal valve in the context of a sigmoid stricture can set up a closed-loop obstruction, leading to significant colonic, especially cecal, distension. In some cases, this can progress to cecal ischemia or perforation, which adds complexity to the surgical treatment for the stricture.
Depending on the location and extent of the ischemia or perforation, an attempt should be made to save the intervening transverse and left colon by constructing separate ileocolonic and colorectal anastomosis with or without protective ostomy. Some patients may require a subtotal colectomy, after which the terminal ileum can be anastomosed to the upper rectum if the patient is otherwise stable. There is a paucity of evidence guiding the treatment of this patient population as most large bowel obstructions are due to malignant disease. Surgical treatment of large bowel obstruction is discussed in another topic [53]. (See "Large bowel obstruction".)
Fistulization — As a result of diverticulitis, a fistula can develop between the colon and another pelvic organ, such as the bladder (65 percent), vagina (25 percent), small bowel (7 percent), uterus (3 percent), or other sites. Diverticular fistulas rarely close spontaneously and therefore require surgical correction. The management of diverticular fistulas is discussed separately. (See "Diverticular fistulas".)
Bleeding — Colonic diverticular bleeding is the most common cause of overt lower gastrointestinal bleeding in adults, and it often resolves spontaneously. However, if bleeding persists, stable patients may require endoscopic intervention, while hemodynamically unstable patients may need angiographic procedures to locate and control the source of bleeding. (See "Colonic diverticular bleeding", section on 'Management'.)
Surgery for diverticular bleeding should be considered a last resort, only after all other efforts to identify and manage the bleeding source have been exhausted and the patient remains unstable despite resuscitation [54]. Studies of hospitalized patients with diverticular bleeding show that fewer than 1 percent ultimately require surgical intervention [55].
Segmental colectomy is performed when the source of bleeding can be localized with colonoscopy or angiography; subtotal colectomy is reserved for patients who continue to bleed without a documented site of bleeding; blind segmental resection should not be performed, due to a high rebleeding rate (approximately 40 percent) [56].
SURGERY FOR PERSISTENT SYMPTOMS —
Patients may require colon surgery for diverticulitis because of persistent or chronic symptoms that interfere with quality of life. Such patients generally fall into one of two categories:
●Failure of medical treatment – Patients who deteriorate or fail to improve despite three to five days of inpatient medical treatment with intravenous antibiotics may require surgery during the same hospitalization as further medical therapy is unlikely to resolve their diverticulitis. (See "Acute colonic diverticulitis: Triage and inpatient management", section on 'Failure of inpatient medical treatment'.)
●Chronic smoldering diverticulitis – Patients with acute diverticulitis who initially improve with medical treatment but later experience recurring symptoms, such as left lower quadrant abdominal pain, changes in bowel habits, or rectal bleeding, are considered to have chronic smoldering diverticulitis. If these symptoms persist for more than six weeks, patients should be referred for surgical evaluation. However, conditions like irritable bowel syndrome or other functional gastrointestinal disorders can present with similar symptoms, which should be excluded before any surgical intervention. (See "Acute colonic diverticulitis: Outpatient management and follow-up", section on 'Persistent or recurrent symptoms'.)
In the right patients, there is high-quality evidence that surgical resection may improve short-term functional outcomes and quality of life for those who remain symptomatic despite optimal medical therapy.
●In a multicenter trial (DIRECT) of 109 patients who either had three or more prior episodes of diverticulitis in the past two years or had chronic smoldering symptoms after a single episode, elective laparoscopic colon surgery resulted in superior quality-of-life scores at six months and five years compared with conservative management despite inherent surgical complications (11 percent anastomotic leak; 15 percent reintervention) [57,58] and was found to be cost effective at five years [59]. About half of the patients managed nonoperatively ultimately required surgery due to severe ongoing complaints [58].
●The LASER trial enrolled 85 patients with either three or more episodes of recurrent diverticulitis, complicated diverticulitis, or chronic pain following diverticulitis. At six months, the Gastrointestinal Quality of Life Index (GIQLI) score improved by 11.8 points in patients who underwent sigmoid resection, compared with just 0.2 points in those receiving conservative treatment. This was despite the fact that 10 percent of patients who had surgery experienced severe complications, such as abscesses and anastomotic leaks. At two years, the mean GIQLI score was similar between both groups; fewer patients in the surgery group had recurrent diverticulitis (11 versus 61 percent).
A one-stage colon resection with primary anastomosis is typically performed for patients with persistent or chronic symptoms from diverticulitis. However, intraoperative findings of complications may alter the operative plan to either a Hartmann procedure or the addition of a proximal diversion. In addition, surgeons may choose to protect the anastomosis in patients with poor nutritional status, immunosuppression, or other factors that could lead to anastomotic complications [60].
SURGERY FOR RECURRENT DIVERTICULITIS —
Surgical treatment for nonacute colonic diverticulitis has been de-escalating. The 2020 American Society of Colorectal Surgeons (ASCRS) guidelines advised against surgical resection for a prior history of uncomplicated diverticulitis that is successfully treated medically, regardless of the number of episodes [7]. Age is not a factor in deciding whether to operate as young patients are no longer thought to have more frequent or complicated recurrences [7].
However, these guidelines recommend elective surgery for patients who have had a previous episode of complicated diverticulitis or are immunosuppressed, even if they are currently asymptomatic, due to the elevated risk of severe complications or mortality from recurrent diverticulitis [7].
Elective surgery should be performed after all infection and inflammation have resolved, typically 10 to 12 weeks after an episode of acute diverticulitis; earlier surgery has been associated with a higher conversion rate and a longer hospital stay [61]. In a retrospective study of 332 patients, those who underwent laparoscopic surgery prior to three months after the latest acute episode were more likely to have residual inflammation (31 versus 11 percent), abdominal morbidities (21 versus 5 percent), and longer hospital stay (7.7 versus 5 days) compared with those who underwent surgery after three months [62]. A primary anastomosis without protective ostomy (ie, a one-stage procedure) is the standard procedure for diverticulitis.
Patients with prior complicated attack(s) — The 2020 ASCRS guidelines [7] recommend elective surgery for patients with one prior episode of complicated diverticulitis because some studies show that such patients are at a greater risk of developing complications or dying from a recurrent attack and therefore would benefit from early elective surgery [63,64].
As an example, in a retrospective study of over 200,000 patients admitted for diverticulitis, 85 percent were managed medically, of whom 16 percent suffered a recurrent attack [63]. The following complications of the initial episode of diverticulitis were independent predictors of mortality during the recurrent episode: bowel obstruction (hazard ratio [HR] 1.33, 95% CI 1.06-1.65), abscess (HR 2.18, 95% CI 1.60-2.97), peritonitis (HR 3.14, 95% CI 1.99-4.97), sepsis (HR 1.88, 95% CI 1.29-2.73), and fistula (HR 3.50, 95% CI 2.17-5.66). The mortality rate with elective surgery after the initial episode was substantially lower than the mortality rate with emergency surgery during the recurrent episode (0.3 versus 4.6 percent).
Healed diverticular abscess — Whereas surgery is almost always indicated for complications such as fistula, obstruction, stricture, and free perforation, the optimal management of a healed diverticular abscess is less certain [65], as some evidence suggests that it is not as significant a risk factor for future complicated recurrence [66-72]. For patients who have recovered from a diverticular abscess, surgery may be performed to alleviate any persistent symptoms and their impact on the patient's quality of life rather than solely to prevent future episodes. This is especially true if the patient is medically complicated. The 2018 European Association of Endoscopic Surgery (EAES) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) consensus guidelines also suggested against routine surgery solely to prevent future attacks following a single episode of Hinchey I/II acute diverticulitis successfully treated nonoperatively [14].
Patients who are immunocompromised — Immunocompromised patients with acute diverticulitis often present late or with atypical symptoms. Although those who do not perforate can be managed nonoperatively, emergency surgery in this patient cohort is associated with very high morbidity and mortality rates [73].
For these patients, elective surgery is associated with lower morbidity and mortality rates compared with emergency surgery. However, elective surgery in immunosuppressed patients still carries a higher rate of surgical complications compared with elective surgery in immunocompetent patients [74]. Thus, the decision of whether to pursue elective colon surgery after one or more episodes of diverticulitis should be tailored to the individual patient through shared decision making [6]. (See "Acute colonic diverticulitis: Outpatient management and follow-up", section on 'Immunosuppression'.)
PERIOPERATIVE CONSIDERATIONS
●Colonoscopy – Whenever possible, colonoscopy should be performed prior to colon resection. This applies to all patients undergoing elective colon resection to prevent recurrent diverticulitis and most patients undergoing semielective colon resection for chronic smoldering diverticulitis. The purpose of the colonoscopy is not to diagnose diverticulitis but to exclude malignancy, which requires a more radical (oncologic) resection [75]. (See "Acute colonic diverticulitis: Outpatient management and follow-up", section on 'Colonoscopy for all patients following diverticulitis'.)
●Antibiotics – Patients undergoing emergency or urgent surgery for acute diverticulitis should already be on antibiotics (table 1 and table 2 and table 3), the duration of which after surgery is discussed separately. (See "Antimicrobial approach to intra-abdominal infections in adults", section on 'Duration of therapy' and "Acute colonic diverticulitis: Triage and inpatient management", section on 'Intravenous antibiotics'.)
Most patients undergoing elective surgery for diverticular disease receive a single dose of prophylactic antibiotics within one hour before incision, with administration not exceeding 24 hours. Antibiotic selection is discussed separately (table 4). (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
●Bowel preparation – In general, we recommend mechanical bowel preparation and oral antibiotics before all resectional colorectal procedures when feasible, including those for diverticular disease. Preoperative bowel preparation is possible for all patients undergoing elective surgery and selected patients undergoing urgent surgery for Hinchey I or II diverticulitis. The indications for bowel preparation and the choice of agents are further discussed elsewhere. (See "Overview of colon resection", section on 'Bowel preparation'.)
●Stoma marking – Before surgery, patients should be advised of the possibility of a stoma, and the potential stoma site should be marked by a stoma therapist when available.
●Ureteral stent – There is no evidence for or against prophylactic ureteral stent placement. Surgeons may use it selectively based on imaging and patient characteristics (eg, for complex, chronic, or fistulous diverticular disease where anatomic distortion by the diverticular phlegmon is expected) [14]. (See "Overview of colon resection", section on 'Prophylactic ureteral stenting'.)
●Patient positioning – We prefer a modified lithotomy or a split leg position, which permits intraoperative proctoscopy and the use of a circular stapler in case an anastomosis is performed.
●Enhanced recovery – Fast-track recovery protocols have been shown to incrementally improve outcomes of gastrointestinal surgeries, including elective colon surgery for diverticular disease (table 5). As an example, a retrospective study showed that managing patients according to a fast-track recovery protocol shortened the time from surgery to the first solid meal (2.3 versus 3.6 days), first bowel movement (2.6 versus 3.5 days), and hospital discharge (3 versus 5 days) compared with traditional postcolectomy care [76]. In addition, patients on a fast-track recovery protocol also suffered fewer complications (15 versus 26 percent). Fast-track protocols in colorectal surgery are discussed elsewhere. (See "Overview of enhanced recovery after major noncardiac surgery (ERAS)".)
OPERATIVE CONSIDERATIONS
●We prefer anatomic resection of the sigmoid colon. An anatomic resection ensures proper mobilization of the colon, hence the formation of a tension-free anastomosis.
●The descending colon should be fully mobilized to provide sufficient colonic length to ensure a tension-free anastomosis. Although routine splenic flexure mobilization has not been shown to decrease either perioperative morbidities [77] or recurrences [78], it may be required to further increase colonic length in selected patients. In several studies, splenic flexure mobilization was performed in about half of the patients [77,78].
●The proximal margin is placed where the colon becomes soft and nonedematous. It is not necessary to resect all diverticula-bearing colon proximal to the intended anastomosis to prevent recurrence since diverticula in the transverse or descending colon rarely cause further symptoms [79].
●Distal transection should occur at or below the rectosigmoid junction in the upper third of the rectum where the teniae coli coalesce, at the level of the sacral promontory. A colorectal anastomosis has a four times lower risk of recurrent diverticular disease compared with a colosigmoid anastomosis [78].
●To qualify for a one-stage resection, the bowel must be well vascularized and nonedematous, and the anastomosis should be tension free and well prepared.
●Either a hand-sewn or stapled anastomosis can be performed based on surgeon preference, as there is no difference in outcomes [78]. For stapled anastomoses, the stapler not reaching and effacing the staple line of the rectal stump is indicative of a residual sigmoid colon. In this situation, the residual sigmoid colon should be resected to prevent recurrences, as opposed to advancing the stapler out the anterior wall of the rectum [14]. An intraoperative leak test should be performed to evaluate the integrity of the anastomosis.
●As there is no evidence to support routine peritoneal drainage [80], whether to leave such a drain is left to the surgeon's discretion.
OPEN VERSUS MINIMALLY INVASIVE APPROACH —
Colonic resection for diverticulitis can be performed open or minimally invasively (laparoscopic or robotic). The minimally invasive approach is preferred when feasible because it affords superior short-term outcomes and comparable long-term outcomes to open resection [14,81-91].
Whereas minimally invasive surgery has become the norm for elective colon resection for diverticular disease [92], its advantage in emergency surgery (ie, for complicated diverticulitis) is less certain [93-96].
●In a meta-analysis of 19 nonrandomized studies comparing 1014 patients undergoing elective laparoscopic surgery with 1369 patients undergoing open surgery, open surgery was associated with significantly higher rates of wound infection (relative risk [RR] 1.85, 95% CI 1.25-2.78), blood transfusion (RR 4, 95% CI 1.67-10), postoperative ileus (RR 2.7, 95% CI 1.52-5), and incisional hernia (RR 3.7, 95% CI 1.56-8.33) [97]. The rates of serious complications (eg, anastomotic leak or stricture, inadvertent enterotomy, small bowel obstruction, intra-abdominal bleeding, or abscess formation) were comparable between the groups.
●A 2017 Cochrane review of three randomized trials (two for complicated diverticulitis, one for elective resection) found insufficient evidence to either support or refute the superiority of laparoscopic surgery over open surgery for diverticular disease [98]. Similarly, a 2018 meta-analysis of five trials comparing laparoscopic sigmoid resection versus open sigmoid resection for the treatment of acute complicated diverticulitis found no significant difference in short-term postoperative overall morbidity (RR 0.89, 95% CI 0.61-1.31) and long-term postoperative major morbidity (RR 0.78, 95% CI 0.46-1.31) [99].
While minimally invasive surgery is now commonly used for elective sigmoid resection for diverticular disease, the optimal approach for complicated cases or acute indications remains unclear. In these situations, outcomes are likely influenced more by the patient's condition and the severity of the disease than by the choice of surgical technique itself.
OUTCOMES —
The mortality rates after colon surgery for diverticular disease range from 1.3 to 5 percent depending on the severity of illness and the presence of comorbidities [15,100].
●Emergency surgery for acute perforated diverticulitis is associated with the highest mortality rate of 15 to 25 percent and a morbidity rate of up to 50 percent [15-18,101,102].
●The incidence of postoperative complications following elective surgery for diverticular disease varies widely from 5 to 38 percent [93]. Laparoscopic surgery conveys a lower risk of postoperative complications compared with open resection [97].
Patients are typically cured of their diverticular disease after surgery. However, 15 percent will develop new diverticula in the remaining colon, and 2 to 11 percent will require repeat surgery [79,103,104]. Recurrences are more likely if the distal resection margin is not extended onto the rectum. (See 'Operative considerations' above.)
However, after elective surgery, up to 40 percent of patients may complain of persistent abdominal pain in the same location as their prior diverticular disease [105]. Such patients require further evaluation by gastroenterologists as these symptoms are more attributable to coexisting functional intestinal disorders (eg, irritable bowel syndrome) rather than recurrent diverticulitis. (See "Clinical manifestations and diagnosis of irritable bowel syndrome in adults" and "Treatment of irritable bowel syndrome in adults".)
In a retrospective study of 17,368 patients from the National Surgical Quality Improvement Program data (2012 to 2018) who underwent colectomy for acute diverticulitis, cancer was found in 164 (0.94 percent) [106]. Eighty-four percent of patients had locally advanced tumors (T3-4), and 37 percent had positive lymph nodes. In multivariate analysis, cancer was associated with sepsis, weight loss, and low albumin. For this reason, colonoscopy should be performed prior to colon resection whenever possible. (See 'Perioperative considerations' above.)
Specific complications of colon surgery are discussed elsewhere. (See "Management of anastomotic complications of colorectal surgery" and "Management of intra-abdominal, pelvic, and genitourinary complications of colorectal surgery".)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Colonic diverticular disease".)
SUMMARY AND RECOMMENDATIONS
●Risk and indications of surgery for diverticulitis – Although most patients with acute diverticulitis can be treated medically, approximately 15 percent will require surgery for various indications (up to 32 percent among hospitalized patients). Surgery is required to treat severe complications, persistent symptoms, or recurrences of diverticulitis. (See 'Introduction' above.)
●Surgery for complications
•Perforation – The majority of microperforations and localized perforations (abscesses) can be managed nonoperatively, while most generalized perforations require surgical intervention. (See 'Perforation' above.)
-For hemodynamically unstable patients with generalized perforation and septic shock, we suggest damage control surgery, rather than a conventional colonic resection (Grade 2C). Performed in two stages, damage control surgery permits rapid source control and time for resuscitation before reconstruction, which minimizes stoma rate. (See 'Unstable patients with generalized peritonitis' above.)
-For stable patients with generalized perforation, we suggest colon resection with primary anastomosis rather than a Hartmann procedure or a nonresectional drainage procedure such as laparoscopic lavage (Grade 2B). Compared with a Hartmann procedure, a primary anastomosis reduces the stoma rate without increasing the complication rate. It can be performed with or without proximal diversion. In fit patients with nonfeculent peritonitis, laparoscopic lavage is another option but may incur a higher reoperation or recurrence rate than resection. (See 'Stable patients with generalized peritonitis' above.)
-Patients with microperforation or localized perforation generally respond to antibiotic therapy or percutaneous drainage. For those who fail nonoperative management, we suggest a colonic resection with primary anastomosis rather than a Hartmann procedure or nonresection drainage (Grade 2C). Proximal diversion may be added for anatomic/patient factors. (See 'Perforation with localized peritonitis' above.)
•Other complications – Patients with obstruction/stricture or fistulization to another organ (eg, bladder, vagina) require surgical intervention. Diverticular bleeding rarely requires surgical treatment. (See "Large bowel obstruction" and "Diverticular fistulas" and "Colonic diverticular bleeding".)
●Surgery for persistent symptoms – Patients with persistent or chronic symptoms despite medical therapy warrant evaluation for either urgent or semielective surgery. Most can undergo colon resection with primary anastomosis. Surgery has been associated with a higher quality of life compared with continued medical therapy or observation. (See 'Surgery for persistent symptoms' above.)
●Surgery for recurrence prevention – When indicated, elective surgery is typically performed 10 to 12 weeks after an episode of acute diverticulitis when all infection and inflammation have resolved, and a primary anastomosis without protective ostomy (ie, a one-stage procedure) is standard. (See 'Surgery for recurrent diverticulitis' above.)
•For most asymptomatic patients with a prior episode of complicated diverticulitis, we suggest elective surgery to avoid the risk of future recurrence (Grade 2C). An exception is asymptomatic patients with a healed diverticular abscess, who are at lower risk for developing another complicated attack. (See 'Patients with prior complicated attack(s)' above.)
•For patients on chronic immunosuppressive therapy who develop diverticulitis, we suggest elective surgery after resolution of the acute inflammation (Grade 2C). For such patients, the mortality rate of an elective resection is much lower than that of an emergency resection. However, the complication rate of elective resection in immunosuppressed patients is higher than that of immunocompetent patients. Thus, the decision should be individualized. (See 'Patients who are immunocompromised' above.)
●Open versus minimally invasive surgery – While minimally invasive surgery is now commonly used for elective sigmoid resection for diverticular disease, the optimal approach for complicated cases or acute indications remains unclear. (See 'Open versus minimally invasive approach' above.)
ACKNOWLEDGMENT —
The editorial staff at UpToDate acknowledges Tonia Young-Fadok, MD, and John H Pemberton, MD, who contributed to earlier versions of this topic review.
