Diverticulitis surgery

Surgery is not the first line treatment option for patients with diverticulitis. Emergency or urgent surgery is usually reserved for patients complicated with peritonitis, who are unresponsive to treatment, who have intestinal obstruction, or with abscess formation. Elective surgery may be performed and it depends on many factors like the age of the patient, the severity score, and persistence of symptoms.

Surgical intervention in patients with diverticulitis is not the first line of treatment, unlike medical therapy. However, surgery is required in complicated diverticulitis patients who are unresponsive to medical therapy or conservative measures against the disease.^[1] Hence, surgical intervention is the mainstay of therapy for complicated acute diverticulitis. Complicated cases are often associated with:

• Peritonitis
• Failed percutaneous drainage of an abscess
• Enterocutaneous fistula formation
• Bowel obstruction

Emergency surgery is performed in life threatening cases of diverticulitis when it is complicated by perforation. Urgent surgery is an operation that is required to be done immediately.^[2][3]

• Indications of the urgent surgery:
  • Diverticulitis complicated by peritonitis
  • Patient becomes unresponsive to the medical treatment
  • Diverticulitis complicated by intestinal obstruction
  • Abscess formation and not responsive to the percutaneous drainage
  • Enterocutaneous fistula formation
• Surgical procedures and techniques:^[4]
  • Based on the status of the patient and the severity of the disease (according to Hinchey classification of severity), the patient undergoes an emergent sigmoid resection with or without anastomosis.
  • The most common procedure in these cases is the Hartmann’s procedure.
  • The Hartmann’s technique includes sigmoid colectomy, end sigmoid or descending colostomy, and closure of the rectal stump. These colostomies may not be closed.
  • Besides the Hartmann technique, resection and anastomosis with ileostomy can be performed. The anastomosis may have a lower mortality rate than operations without anastomosis.^[5][6][7]

A video shows how Hartmann procedure is performed: {{#ev:youtube|v=rVgBZwY4Pt8&t=175s|}}

Unlike the emergent surgery, elective surgery can be performed after proper responsive treatment. The surgeon decides whether the patient requires colon resection or not. Elective surgery depends on many factors like the age of the patient, the severity score, and persistence of symptoms. Based on many studies, around one-third of the patients will have symptoms of the disease again after the first episode. Elective surgery may be indicated in some cases, but it is indicated on a case-by-case basis.^[8]

• Cases that may require elective surgery:^[9][10]
  • Diverticulitis complicated by fistula.
  • High-risk diverticulitis patients like immunocompromised patients.
  • Patients with past history of diverticulitis but who recovered.
  • Chronic diverticulitis patients who develop recurrent symptoms of the disease.
• Surgical procedures and techniques:
  • Patients with abscess should undergo CT-guided percutaneous drainage of the abscess. The procedure depends on the severity score of the disease and the size of the abscess. Abscess that is smaller than 3 cm and not associated with peritonitis can be treated conservatively with antibiotics. Large abscesses larger than 4 cm should be treated with percutaneous drainage.^[11]
  • After performing the percutaneous drainage, elective colectomy should be done to prevent recurrence of the symptoms.^[12]
  • Colectomy starts in the proximal bowel extending to the upper rectum.
  • In some cases, laparoscopic colectomy is preferred as it is less painful, creates a smaller scar, and fewer complications occur.^[13][14]

Video explaining the CT guided percutaneous abscess drainage: {{#ev:youtube|v=WQv26x3bnws|}}

Video showing laparoscopic colectomy: {{#ev:youtube|v=No4SzEmiPaM|}}

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