Acute colonic diverticulitis: Surgical management

Author:
John H Pemberton, MD
Section Editor:
Martin Weiser, MD
Deputy Editor:
Wenliang Chen, MD, PhD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: May 2017. | This topic last updated: Mar 27,
2017.

INTRODUCTION — Diverticular disease of the colon is an important cause of hospital

admissions and a significant contributor to healthcare costs in industrialized nations
[1,2]. In Western countries, the majority of patients present with sigmoid diverticulitis
[3,4]. Although most patients with acute diverticulitis can be treated medically,
approximately 15 percent will require surgery [5]. In the United States, diverticular
disease is the leading indication for elective colon surgery [6].

The indications for surgery, the choice of procedures in different clinical scenarios, the
surgical techniques, and the perioperative considerations are discussed here. The
diagnosis and medical management of acute diverticulitis are discussed separately.
(See "Clinical manifestations and diagnosis of acute diverticulitis in adults" and "Acute
colonic diverticulitis: Medical management".)

INDICATIONS FOR SURGERY — Since most patients with diverticulitis are treated
medically, surgery is only indicated when diverticular disease is either not amenable or
refractory to medical therapy (algorithm 1) [5,7-9].

Indication for emergency surgery — Acute diverticulitis with frank (free) perforation
is a life-threatening condition that mandates emergency surgery [5,9-11].
(See 'Resection' below.)

Indications for urgent surgery — Urgent surgery (in which an operation is generally
required during the same hospitalization) should be performed in patients with one of
the indications discussed below.

Failure of medical treatment — Patients who deteriorate or fail to improve after three
to five days of inpatient intravenous antibiotics may require urgent surgery, as further
medical therapy is unlikely to resolve their diverticulitis. (See "Acute colonic
diverticulitis: Medical management", section on 'Failure of inpatient medical treatment'.)

Obstruction — Patients who present with colonic obstruction attributable to acute

diverticulitis should undergo surgical resection of the involved colonic segment.
Because acute diverticulitis and colon cancer can both cause colonic obstruction and
are difficult to distinguish by abdominopelvic computed tomography (image 1), surgery
in this setting is required to rule out cancer and also to relieve symptoms of obstruction.
(See "Acute colonic diverticulitis: Medical management", section on
'Obstruction' and "Overview of mechanical colorectal obstruction", section on 'Surgical
management'.)

Colonic obstruction due to diverticular disease is rarely complete, which allows bowel
preparation to be attempted. Alternatively, on-table lavage can be used to clean out the
fecal load, which may also permit a primary anastomosis.

Endoluminal stenting may not be helpful for colonic obstruction caused by diverticulitis.
In a 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 [12]. When stenting
was used as a bridging therapy to surgery, only 43 percent of patients with diverticulitis
successfully avoided a stoma. (See "Enteral stents for the management of malignant
colorectal obstruction".)

Abscess failing nonoperative intervention — In contemporary practice, diverticular

abscesses are typically treated with percutaneous image-guided drainage or with
intravenous antibiotics if the abscess is too small or inaccessible to percutaneous
drainage. Surgery may be indicated for patients who deteriorate or fail to improve
within two to three days of percutaneous intervention or antibiotic therapy, as a
persistent intraabdominal abscess is unlikely to respond to further nonoperative
management. (See "Acute colonic diverticulitis: Medical management", section on
'Abscess'.)

Indications for elective surgery — Patients may require elective colon surgery
because of persistent symptoms from conditions such as diverticular fistula or chronic
smoldering diverticulitis. In addition, asymptomatic patients with a history of acute
diverticulitis may be offered elective surgery based upon their risk of developing
serious complications or dying from a recurrent diverticulitis attack.

Fistula — As a result of diverticulitis, a fistula can develop between the colon and
another pelvic organ, such as the bladder, vagina, uterus, small bowel, or the
abdominal wall. Diverticular fistulas rarely close spontaneously, and therefore require
surgical correction. The management of diverticular fistula is discussed separately.
(See "Acute diverticulitis complicated by fistula formation".)

Chronic smoldering diverticulitis — Patients with acute diverticulitis who initially

respond to medical treatment but subsequently develop recurrent symptoms, such as
left lower quadrant abdominal pain, alteration in bowel movements, and/or rectal
bleeding, are described as having chronic smoldering diverticulitis. If the symptoms
persist for longer than six weeks, patients should be referred for surgical evaluation.
However, since patients with irritable bowel syndrome or other functional
gastrointestinal disorders may present similarly, patients with chronic symptoms after
an acute diverticulitis attack must be evaluated carefully before being offered surgery.
(See "Acute colonic diverticulitis: Medical management", section on 'Symptomatic
patients after initial attack'.)

Asymptomatic but high-risk patients — We offer elective surgery to patients who

had a prior episode of complicated diverticulitis and those who are immunosuppressed
because such patients could develop serious complications or die from recurrent
attacks of diverticulitis.

Patients with prior complicated attack — Elective surgery is indicated for patients
with one prior episode of complicated diverticulitis, such as a microperforation that
was treated with antibiotics, or an abscess that was treated with percutaneous
drainage and/or antibiotics. 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 [13,14]. (See "Acute colonic diverticulitis: Medical
management", section on 'Complicated first attack'.)

Patients who are immunocompromised — Most surgeons would offer elective

surgery to immunocompromised patients after a single attack of diverticulitis because
they often require emergency surgery due to an atypical and delayed presentation.
Elective surgery is associated with lower morbidity and mortality rates compared with
emergency surgery in these and other patients. (See "Acute colonic diverticulitis:
Medical management", section on 'Immunosuppression'.)

CHOOSING A SURGICAL TECHNIQUE — For patients who require surgery for

diverticulitis, the choice of technique depends upon the patient's hemodynamic
stability, extent of peritoneal contamination, and surgeon experience [15].

Resection — The primary goal of surgery is to remove the diseased colonic segment,
the feasibility of which is predicated upon a patient's hemodynamic stability.

Hemodynamically unstable patients — Patients who require emergency surgery for

perforated diverticulitis may be too ill to tolerate a definitive colon resection and
reconstruction. For such patients, a damage control laparotomy with limited resection
of the diseased colonic segment with or without reconstruction should be performed
expeditiously [16]. (See "Overview of damage control surgery and resuscitation in
patients sustaining severe injury" and 'Drainage procedures' below.)

Hemodynamically stable patients — Patients undergoing emergency surgery who

are hemodynamically stable and all other patients undergoing urgent or elective
surgery should be able to tolerate a definitive resection of the involved colonic segment
[17-21] (figure 1). (See 'Colonic resection with end colostomy (ie, Hartmann's
procedure)' below.)

Reconstruction — The secondary goal of surgery is to restore intestinal continuity if

possible. The choice of reconstructive techniques largely depends upon the extent of
peritoneal contamination as assessed by the Hinchey classification system [22]:

●Stage I – Pericolic or mesenteric abscess

 ●Stage II – Walled-off pelvic abscess
●Stage III – Generalized purulent peritonitis
●Stage IV – Generalized fecal peritonitis

Diffuse contamination (Hinchey III or IV) — Hinchey III or IV diverticulitis is

characterized by generalized purulent or fecal peritonitis, for which a primary
anastomosis is contraindicated. The preferred surgical treatment is a Hartmann's
procedure with end colostomy. (See 'Colonic resection with end colostomy (ie,
Hartmann's procedure)' below.)

Localized contamination (Hinchey I or II) — Hinchey I or II diverticulitis is

characterized by one or more localized abscesses in the pericolonic, mesenteric, or
pelvic locations. Patients with Hinchey I or II diverticulitis can usually tolerate a
preoperative bowel preparation. Thus, if the abscess can be resected with the colonic
segment, a primary anastomosis can be performed in these patients. (See 'One-stage
procedures' below.)

If there are concerns about either contamination or inflammation involving the

surrounding tissue (eg, with a large pelvic abscess), a primary anastomosis can be
performed while protected by a diverting ostomy (eg, loop ileostomy or colostomy).
Compared with an end colostomy, a protective loop ostomy is easier to reverse at a
later time. (See 'Colonic resection with primary anastomosis and protective
ostomy' below.)

Minimal contamination (elective surgery) — Elective surgery is typically performed

six or more weeks after an episode of acute diverticulitis when all infection and
inflammation have resolved. Thus, a primary anastomosis without protective ostomy
(ie, a one-stage procedure) is standard. (See 'One-stage procedures' below.)

SURGICAL TECHNIQUES

One-stage procedures — A one-stage procedure (ie, colon resection with primary

anastomosis) is typically performed during elective surgery or during urgent surgery in
patients with Hinchey I or II diverticulitis who have an abscess that can be resected
along with the involved colonic segment. (See 'Localized contamination (Hinchey I or
II)' above and 'Minimal contamination (elective surgery)' above.)

A primary anastomosis is contraindicated for patients who have Hinchey III or IV

diverticulitis, and relatively contraindicated for patients with significant medical
comorbidities, poor nutritional status, immunosuppression, or other factors that could
lead to anastomotic complications [23].

To qualify for a one-stage resection, the bowel must be well-vascularized, non-

edematous, and the anastomosis should be tension-free and well-prepared. The distal
resection margin is typically placed in the upper third of the rectum, where the taenia
coli converge. The proximal margin is placed where the colon becomes soft and non-
edematous. 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 [24].

Open versus laparoscopic approach — A one-stage colon resection for diverticulitis

can be performed open or laparoscopically. The laparoscopic approach is preferred
when feasible. Growing evidence suggests that laparoscopic surgery in this setting can
be performed safely with superior short-term outcomes and comparable long-term
outcomes [25-35]. As examples:

●In a meta-analysis of 19 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 4.0, 95% CI 1.67-10.0),
postoperative ileus (RR 2.70, 95% CI 1.52-5.0), and incisional hernia (RR 3.70,
95% CI 1.56-8.33) [36]. The rates of serious complications (eg, anastomotic leak
or stricture, inadvertent enterotomy, small bowel obstruction, intraabdominal
bleeding, or abscess formation) were comparable between the groups.
●A randomized trial performed after the meta-analysis found that laparoscopic
surgery resulted in a significantly shorter duration of postoperative ileus (76 versus
106 hours) and length of hospital stay (5 versus 7 days), as well as a trend
towards less postoperative pain (4 versus 5 on a visual analog pain scale), when
compared with open surgery [37].
●Another randomized trial found that patients who underwent laparoscopic versus
open surgery had similar complication rates and reported similar quality of life
during the early postoperative period and at 12 months [38].

Laparoscopic surgery for diverticular disease can be performed with the standard
multiport technique or with a technique called single-incision laparoscopic colectomy
(SILC). Studies showed that SILC is feasible and safe when performed by experienced
surgeons [39,40]. In a prospective study of 330 patients with diverticular disease,
patients who underwent SILC had lower peak pain scores compared with patients who
underwent a standard laparoscopic procedure (4.9 versus 5.6) [39]. The techniques of
single-incision laparoscopic surgery are discussed elsewhere. (See "Abdominal access
techniques used in laparoscopic surgery", section on 'Single-incision ports and
placement'.)

Two-stage procedures — A two-stage procedure is primarily used for patients with

Hinchey III or IV diverticulitis, and for those with Hinchey I or II diverticulitis who have
excessive contamination or inflammation of the surrounding tissues or other risk factors
for anastomotic leakage. (See 'Diffuse contamination (Hinchey III or IV)' above
and 'Localized contamination (Hinchey I or II)' above.)

Colonic resection with end colostomy (ie, Hartmann's procedure) — Hartmann's

procedure is the most commonly performed two-stage procedure and the preferred
approach for patients with Hinchey III or IV diverticulitis. (See 'Diffuse contamination
(Hinchey III or IV)' above.)
A Hartmann's procedure involves resecting the diseased colonic segment, creating an
end colostomy and a rectal stump, followed by reversal of the colostomy three months
later [18] (figure 1).

Because creating a mucous fistula by bringing the distal end of the transected bowel
through the abdominal wall is often not possible after resecting the entire sigmoid
colon, many surgeons mark the rectal stump with a long nonabsorbable suture and
tack it to the anterior abdominal wall or sacral promontory to help identify the rectal
stump at the second-stage operation.

Subsequent closure of the colostomy is a technically difficult operation associated with

high morbidity and mortality rates [41,42]. As a result, colostomy closure is only
performed in approximately 50 to 60 percent of all patients after a Hartmann's
procedure [43,44].

Colonic resection with primary anastomosis and protective ostomy — Another

two-stage approach resects the colonic segment and creates a primary anastomosis
protected by a proximal diverting stoma (colostomy or ileostomy) at the first operation
(figure 2), and closes the stoma at the second operation.

This approach is most commonly used in Hinchey I or II diverticulitis when there are
relative contraindications to primary anastomosis (eg,
excessive contamination/inflammation of surrounding tissue) but the bowel is not
edematous. It is the preferred approach in this setting because a protective stoma is
easier to close than an end colostomy with a rectal stump [45,46]. (See 'Localized
contamination (Hinchey I or II)' above.)

Although a primary anastomosis is generally not performed for perforated (Hinchey III
or IV) diverticulitis, a primary anastomosis protected by a diverting ileostomy has been
attempted in such patients. In a randomized trial of 62 patients with left-sided colonic
perforation due to Hinchey III or IV diverticulitis, patients treated with a primary
anastomosis with diverting ileostomy, compared with patients treated with a
Hartmann's procedure, had similar mortality (9 versus 13 percent) and morbidity rates
(75 versus 67 percent) after the first operation [47]. However, a greater percentage of
patients treated with a primary anastomosis with diverting ileostomy underwent stoma
reversal (90 versus 57 percent); and reversal of the diverting ileostomy in those
patients required less operative time (73 versus 183 minutes), length of hospital stay (6
versus 9 days), and resulted in fewer serious complications (0 versus 20 percent),
compared with colostomy reversals in patients treated with a Hartmann's procedure.
Further studies are required before this approach can be recommended for general use
in all patients with Hinchey III or IV diverticulitis.

Drainage procedures — Drainage procedures include laparoscopic lavage and a

classic three-stage procedure. Drainage procedures are rarely performed because they
do not definitively address the underlying diverticular disease. However, they may be
useful in treating septic patients who are too ill to tolerate a resectional procedure.
(See 'Hemodynamically unstable patients' above.)
Laparoscopic lavage — Laparoscopic lavage and drainage were introduced as an
approach to avoid laparotomy and fecal diversion in patients with complicated
diverticulitis [48-51]. Based upon the best available data, we do not use laparoscopic
lavage in stable patients with Hinchey III or IV diverticulitis. Instead, we perform
sigmoidectomy with or without a colostomy depending upon each patient's clinical
condition. (See 'Diffuse contamination (Hinchey III or IV)' above.)

Although a 2010 systematic review of retrospective studies found a low mortality rate of
2 percent and avoidance of a permanent stoma in the majority of patients who
underwent laparoscopic lavage [52], subsequent randomized trials reported conflicting
results:

●In one trial (SCANDIV), 199 patients suspected of having perforated diverticulitis
based upon detection of free air by abdominal computed tomography scan were
randomly assigned to undergo emergency surgery with laparoscopic lavage or
sigmoidectomy [53]. Compared with sigmoidectomy, laparoscopic lavage
achieved similar mortality (13.9 versus 11.5 percent) and severe morbidity rates
(30.7 versus 26 percent) at 90 days. However, patients who were treated with
laparoscopic lavage were more likely to require reoperation (20.3 versus 5.7
percent) for complications such as secondary peritonitis (6 versus 0 patients) or
missed sigmoid cancer (4 versus 0 patients).
●Another randomized trial (LOLA) including 90 patients with purulent perforated
diverticulitis showed that laparoscopic lavage produced a higher combined major
morbidity and mortality rate within 30 days compared with sigmoidectomy (39
versus 19 percent) [54]. At 12 months, the rates were comparable between the
two groups (65 percent for lavage versus 63 percent for sigmoidectomy).
●Another trial (DILALA) randomly assigned 83 patients to laparoscopic lavage or
Hartmann's procedure after a laparoscopic diagnosis of purulent perforated
diverticulitis [55,56]. The mortality rates were similar at both 90 days (8 versus 11
percent) and one year (14 versus 15 percent); the major morbidity rates were
similar at 30 (13 versus 18 percent) and 90 days (21 versus 25 percent). The
reoperation rates were similar at 30 days (13 versus 17 percent). At one year,
however, fewer patients required reoperation after laparoscopic lavage (28 versus
63 percent). In addition, laparoscopic lavage resulted in shorter operative time (1
versus 2.5 hours) and hospital stay (6 versus 9 days for index admission; 8 versus
14 days at one year).

In all three trials, the major morbidity and mortality rates were similar between the two
groups. The trials, however, reported different reoperation rates, which affected their
conclusions (table 1). DILALA was the only trial that favored laparoscopic lavage,
largely due to lower reoperation rates.

However, reoperation rates can be affected by how they are calculated (table 1). All
patients in DILALA assigned to sigmoidectomy underwent colostomy, and colostomy
reversals were counted as reoperations. Thus, the reoperation rate in this trial of 63
percent at one year after sigmoidectomy was almost entirely accounted for by
colostomy reversals. In contrast, only approximately one-half of patients assigned to
sigmoidectomy in LOLA underwent initial colostomy, and colostomy reversals
were not counted as reoperations, resulting in a reoperation rate of just 19 percent.
SCANDIV only reported 90-day reoperation rates, which would not have been affected
by colostomy reversals, as reversals typically occur three to six months after the initial
surgery.

Short-term (30- or 90-day) reoperation rates, which by definition excluded colostomy

reversals, are more comparable among the three trials (table 1). After laparoscopic
lavage, the short-term reoperation rates were lower in DILALA (13 percent at 30 days)
than in SCANDIV (20 percent at 90 days) and LOLA (48 percent at 30 days). The lower
reoperation rate after laparoscopic lavage in DILALA may be attributed to better pre-
enrollment identification and exclusion of patients with fecal perforation and sigmoid
carcinoma, which were the major reasons for reoperations in all three trials. In
SCANDIV, patients did not undergo a diagnostic laparoscopy before randomization. In
LOLA, although patients did undergo a diagnostic laparoscopy, the authors argued that
patients with perforated diverticulitis often developed a phlegmon that obscured
visualization of the deep pelvis.

In common practice, it is unclear how conclusively fecal perforation and/or sigmoid

carcinoma can be excluded during the initial evaluation. Thus, sigmoidectomy remains
our standard treatment for perforated diverticulitis. We only use laparoscopic lavage in
select patients after excluding fecal perforation (Hinchey class IV) by diagnostic
laparoscopy, and after excluding either colon cancer or ongoing colonic air leak (from
perforation) by intraoperative sigmoidoscopy.

Patients who are candidates for laparoscopic lavage should be advised that a
reoperation (usually sigmoidectomy) may be necessary if laparoscopic lavage fails to
control the sepsis or a sigmoid carcinoma is later found. The reoperation rate is likely to
increase further with longer follow-up; LOLA reported that 20 percent of patients
treated with laparoscopic lavage developed recurrent diverticulitis within just the first
year [54].

Drainage and diversion — A classic procedure for colonic perforation includes three
stages: the first stage involves drainage but not resection of the diseased segment and
construction of a proximal diverting stoma; the second stage involves resection of the
diseased segment with a primary anastomosis under the protection of the proximal
stoma; the third stage closes the proximal stoma.

This classic procedure has been largely replaced by other procedures (eg, the
Hartmann's procedure) because of a higher postoperative mortality rate with the three-
stage procedure (26 versus 7 percent) [57,58]. In contemporary practice, the three-
stage procedure is only performed when inflammation precludes safe pelvic dissection
of the colon from critical sidewall structures (eg, iliac vessels and ureters), or when the
patient is unstable. Drainage and fecal diversion in these situations can serve as a
temporizing measure to allow treatment of infection and inflammation before further
surgery or transfer to a more experienced center. (See "Overview of mechanical
colorectal obstruction", section on 'Three-stage'.)
PERIOPERATIVE CONSIDERATIONS

Antibiotics — Patients undergoing emergency or urgent surgery for acute diverticulitis

should already be on antibiotics (table 2 and table 3 and table 4), the duration of which
is discussed separately. (See "Antimicrobial approach to intra-abdominal infections in
adults", section on 'Duration of therapy' and "Acute colonic diverticulitis: Medical
management", section on 'Intravenous antibiotics'.)

Patients undergoing elective surgery for diverticular disease should receive

prophylactic antibiotics within one hour of skin incision. The choice of antibiotics is
discussed elsewhere (table 5). (See "Antimicrobial prophylaxis for prevention of
surgical site infection in adults".)

Bowel preparation — 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 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.

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 protocol — Fast-track recovery protocols have been shown to

incrementally improve outcomes of gastrointestinal surgeries, including elective colon
surgery for diverticular disease. As an example, a retrospective study showed that
managing patients according to a fast-track recovery protocol shortened the time from
surgery to 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 [59]. 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 "Enhanced recovery after colorectal surgery".)

OUTCOMES

The mortality rates after colon surgery for diverticular disease range from 1.3 to 5
percent depending upon the severity of illness and the presence of comorbidities
[17,60]. Emergency surgery for acute perforated diverticulitis has been associated with
a mortality rate of 15 to 25 percent, and a morbidity rate of up to 50 percent [17-
20,58,61]. 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".)
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 [24,62,63]. After surgery, up to 27 percent of patients may
complain of persistent abdominal pain in the same location as their prior diverticular
disease. 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".)

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

●Although most patients with acute diverticulitis can be treated medically,

approximately 15 percent will require surgery for various indications.
(See 'Introduction' above and 'Indications for surgery' above.)
●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. (See 'Choosing a surgical
technique' above.)
•Patients who are hemodynamically stable should have a definitive resection
of the involved colonic segment; patients who are unstable may instead
require a limited resection or drainage procedure. (See 'Resection' above
and 'Drainage procedures' above.)
•Patients who have Hinchey III or IV diverticulitis should undergo a
Hartmann's procedure, rather than a procedure involving a primary
anastomosis. (See 'Diffuse contamination (Hinchey III or IV)' above
and 'Colonic resection with end colostomy (ie, Hartmann's procedure)' above
and 'Laparoscopic lavage' above.)
•Patients who have Hinchey I or II diverticulitis may undergo a colon
resection, followed by a primary anastomosis with or without a protective
ostomy, depending upon the condition of the local tissue. (See 'Localized
contamination (Hinchey I or II)' above and 'One-stage procedures' above
and 'Colonic resection with primary anastomosis and protective
ostomy' above.)
•Patients undergoing elective surgery for diverticular disease should undergo
a colon resection and primary anastomosis. The laparoscopic approach is
the preferred approach when feasible. (See 'Minimal contamination (elective
surgery)' above and 'One-stage procedures' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate, Inc. would like to

acknowledge Dr. Tonia Young-Fadok, who contributed to earlier versions of this topic
review.
 Use of UpToDate is subject to the Subscription and License Agreement.

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