Which surgical procedures are performed for the emergency treatment of acute diverticulitis?

Updated: Aug 06, 2019
  • Author: Elie M Ghoulam, MD, MS; Chief Editor: BS Anand, MD  more...
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Answer

A two-stage surgical approach is generally the most common procedure performed for the emergency treatment of acute diverticulitis. Note the following:

  • The preferred surgical approach in patients with fecal peritonitis and in most cases of purulent peritonitis is the traditional Hartmann procedure. [45, 46] It involves resection of the diseased segment of bowel, an end-colostomy, and closure of the rectal stump. Typically, 3 months later, a second procedure may be performed in which the colostomy is reversed and the intestinal continuity is reestablished with the rectal stump; however, this second operation can be technically difficult and is not performed in many patients.

  • An alternative to the Hartmann procedure involves resection of the diseased colon, primary anastomosis (with or without intraoperative colonic lavage), and creation of a proximal diverting stoma, either via colostomy or ileostomy. The second procedure in this process would be to close the stoma. This approach is primarily used when there are relative contraindications to the primary anastomosis but no purulent or feculent peritonitis, and there is nonedematous bowel. Its advantage lies in avoiding the technically difficult second stage used in the Hartmann procedure.

  • There is no role for extensive and unnecessary dissections, which open up tissue planes to infection and increase blood loss.

  • In a study that examined data from patients who had undergone the Hartmann procedure for acute diverticulitis and then (after a median 7-month period) underwent reversal surgery, Fleming and Gillen investigated the rate of, and risk factors for, complications linked to the reversal procedure and found that of 18 of 76 patients (25%) who underwent reversal had postreversal complications. [46]  Risk factors for reversal complications included being a current smoker, having a low preoperative albumin level, and allowing a prolonged period to elapse between the Hartmann and reversal procedures. The authors concluded that despite the reversal surgery's significant complication rate, offering the operation to appropriately selected patients is acceptable. They also suggested that preoperative identification of modifiable risk factors may benefit patients. [46]


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