W. Donald Buie, M.S., Editor
Acute Complicated Diverticulitis Managed by
Mahdi Alamili, M.S. • Ismail Go ¨genur, M.D. • Jacob Rosenberg, M.D., D.Sc.
Department of Surgery D, Herlev Hospital, Herlev, Denmark
PURPOSE: The classic surgical treatment of acute
complicated sigmoid diverticulitis with peritonitis is
often a two-stage operation with colon resection and a
temporary stoma. This approach is associated with high
mortality and morbidity and the reversal of the stoma is
in many cases not performed because of concurrent
diseases and age. Recently, several studies have
experimented with laparoscopic lavage as a treatment of
acute complicated diverticulitis. The aim of this review
was to give an overview of the literature for this new
approach and to determine the safety compared with
Hartmann’s procedure for patients with acute
complicated sigmoid diverticulitis.
METHODS: A PubMed search was performed for
publications between 1990 and May 2008. The terms
acute, perforated, diverticulitis, lavage, drainage, and
laparoscopy were used in combination. The EMBASE
and Cochrane databases were also searched.
RESULTS: Eight studies met the inclusion criteria and
reported 213 patients with acute complicated
diverticulitis managed by laparoscopic lavage. None of
these studies were randomized. The patients’ mean age
was 59 years and most patients had Hinchey Grade 3
disease. All patients were treated with antibiotics and
laparoscopic lavage. Conversion to laparotomy was made
in six (3%) patients and the mean hospital stay was nine
days. Ten percent of the patients had complications.
During the mean follow-up of 38 months, 38% of the
patients underwent elective sigmoid resection with
CONCLUSION: Primary laparoscopic lavage for
complicated diverticulitis may be a promising alternative
to more radical surgery in selected patients. Larger
studies have to be made before clinical recommendations
can be given.
KEY WORDS: Acute/perforateddiverticulitis;
and more than 60% of the population older than 70 years
ulosis develop diverticulitis.3
The management of diverticulitis depends on the ex-
tent of the disease (Table 1).4For patients with compli-
cated diverticulitis with localized abscess (Hinchey Grade
2) percutaneous drainage seems to be an effective initial
therapeutic approach.5–8The emergency surgical man-
agement has changed in the past 20 years for patients with
generalized peritonitis (Hinchey Grades 3 and 4), but the
ideal treatment remains controversial. The standard for
Hartmann’s procedure (HP) where the diseased sigmoid
or permanent stoma. However, this procedure involves a
major laparotomy with significant morbidity and mortal-
ity and, most of the patients never undergo colostomy re-
versal. The controversial management, primary resection
and anastomosis, emerged as an alternative to HP, but the
outcomes remain suboptimal with an overall morbidity
rate of 29%9and mortality rates of 10 to 20%.10
he prevalence of diverticular disease of the sigmoid
colon has increased over the past century.1One-
third of the Western population older than 50 years
Address of correspondence: Mahdi Alamili, M.S., Department of Sur-
gery D, Herlev Hospital, 2730 Herlev, Denmark. E-mail: mahdi_
Dis Colon Rectum 2009; 52: 1345–1349
©The ASCRS 2009
DISEASES OF THE COLON & RECTUM VOLUME 52: 7 (2009)
In recent years published studies have shown that pa-
may be successfully managed by laparoscopic lavage with-
out sigmoid resection in the acute setting. In this system-
atic review we present the current literature where laparo-
scopic treatment for acute complicated diverticulitis with
peritonitis has been used.
English-language publications where laparoscopic treat-
ment for acute complicated diverticulitis with peritonitis
had been reported. The search was made in the following
databases: MEDLINE, EMBASE, and The Cochrane Li-
consisted of the following key word combinations: acute/
perforated diverticulitis AND lavage/drainage AND lapa-
roscopy. Studies where laparoscopic lavage as treatment
for complicated diverticulitis, including purulent or fecal
peritonitis, were used. Studies with less than five patients
were not included in the review. Reference lists from the
included articles were manually checked and additional
studies were included when appropriate.
lavage had been used in the treatment for complicated di-
verticulitis.11–17An additional study was found in the
review relevant to this subject was found. Thus, the total
number of studies found was eight. None of the studies
were controlled or randomized. Only one study was pro-
spective16and the other seven were retrospective.11–15,18
Data concerning the number of patients in the studies, the
mean age of the patients, the Hinchey classification based
on the operative findings, the preoperative American So-
omy (during the primary operation and in the immediate
postoperative period caused by failure of laparoscopic la-
vage), the rates and the number of patients treated with
resection after the primary laparoscopic lavage, the mor-
bidity, and the mortality can be seen in Tables 2 and 3.
study,184 years in two studies,11,145 years in two stud-
ies,12,177 years in two studies,13,16and 15 years in one
age of 59 years; most of the patients were in ASA Class 3.
complicated diverticulitis with localized or generalized
peritonitis. The diagnosis was based on clinical signs indi-
cating perforated diverticulitis with supplementary com-
puted tomography (CT) or ultrasound (US). Patients
without peritonitis were excluded. Patients with acute di-
excluded patients with fecal peritonitis,13,16one study ex-
patients with extensive generalized peritonitis13, and one
study excluded a patient with rheumatoid arthritis, who
was taking corticosteroids.18
All patients in the eight studies were classified accord-
ing to the Hinchey classification based on the opera-
tive findings. The majority of the patients were Hinchey
The surgical treatment in the emergency surgical setting
consisted of laparoscopic peritoneal lavage, and drains
TABLE 1. The Hinchey classification4
Diverticulitis with a phlegmonous or a pericolic abscess
Diverticulitis with a pelvic abscess or a retroperitoneal
Diverticulitis with diffuse/generalized purulent peritonitis
Diverticulitis with fecal peritonitis
TABLE 2. Patient demographics
Faranda et al. .11
Da Rold et al.12
ASA ? American Society of Anesthesiologists’ risk classification.
aUnspecified classification of the 10 patients in this study.
ALAMILI ET AL: COMPLICATED DIVERTICULITIS MANAGED BY LAPAROSCOPIC LAVAGE
were placed near the affected colon. No resection of the
colon was made in the acute setting and colostomy was
never performed (Table 3). Intravenous antibiotics and
liquids were administered in the perioperative period and
the choice of antibiotics differed between the studies.
an overall conversion rate of 3%. Intestinal obstruction
making insufflation impossible was the reason for conver-
sion in one patient.12Reoperations with laparotomy were
performed in five patients. One patient had peritonitis
done open.13One patient with Hinchey Grade 2 disease
after percutaneous drainage.16In one study three patients
had a laparotomy: an 86-year-old and a 78-year-old pa-
postoperative day, respectively, and a 39-year-old patient
with obesity who had Hinchey Grade 3 disease required
open resection with primary anastomosis because of fever
and tenderness.14Thus, overall, the operation was con-
verted to laparotomy during the initial laparoscopic inter-
vention in one patient, and five patients underwent lapa-
rotomy days to weeks after the initial laparoscopy because
of treatment failure.
Morbidity after laparoscopic drainage consisted of
cardiopulmonary complications (myocardial infarction,
respiratory infection, pulmonary embolus, and atelecta-
tibiotic-related diarrhea), and other (lymphangitis). In
one study two patients developed pelvic abscess and were
managed by radiologic drainage.17The total number of
patients with postoperative complications was 22 corre-
sponding to an overall complication rate of 10%. In the
(3.3%) died after laparoscopic drainage.16No deaths oc-
curred in the other studies. The overall mortality is 1.4%
The patients were monitored after the laparoscopic drain-
age with a mean follow-up period of 38 (range, 2–96)
months. The interventions in this period consisted of ab-
copy to rule out colorectal carcinomas and to plan elective
1) Surgery to all patients: four institutions performed sec-
ondary elective surgery in 53 of 62 patients (the rest of the
patients refused, were rejected by the anesthetist, or be-
cause of other reasons).11,13,14,172) Surgery to the compli-
the longest mean follow-up period.15Inclusion criteria
mild diverticulitis.15In this study 24 of 40 patients under-
went elective laparoscopic resection. 3) Conservative ap-
proach: In the three remaining studies (a total of 105 who
underwent a successful laparoscopic lavage), resection
were only performed if a readmission required a resection
result, in two of these three studies, no patients had resec-
tions, whereas in the third study one patient had a colonic
resection because of a carcinoma of the descending colon
during the follow-up period.12,16,18During the follow-up
period four patients from two of these three studies were
servative management.16,18No readmissions occurred in
had an elective colon resection was 78 (38%).
TABLE 3. The outcomes of laparoscopic lavage management in the published studies
Da Rold et al.12
LOS ? length of hospital stay.
aFive of the patients had reoperations within weeks after the primary treatment because of failure of the original procedure, and the treatment of one patient was converted
to laparotomy during the original procedure.
bResection rate ? secondary elective sigmoideum resection rate.
DISEASES OF THE COLON & RECTUM VOLUME 52: 7 (2009)
rulent peritonitis) can effectively be managed by laparo-
mean length of stay was 9 days, 10% of the patients devel-
oped complications, and the overall mortality was 1.4%.
The standard procedure for patients with acute com-
plicated diverticulitis with peritonitis in many hospitals
is an acute HP. The advantages and disadvantages of HP
have been thoroughly investigated.19–24HP has decreased
mortality and morbidity compared with the previous
three-stage surgical intervention that dominated until the
1980s and consisted of a first stage with establishment
of a colostomy and drainage, a second stage with colonic
resection, and a third stage with the reversal of the sto-
ma.9,19The disadvantages of HP are high mortality (10–
28%), high risk of surgical site infection (25%), reanasto-
(7–16%), and a high risk for cardiovascular complications
(25%) because of comorbidities the result of the typically
high age for patients with diverticulitis.13,21,23–25Patients
of 20 to 38 days,21but the patients who undergo laparo-
scopic lavage have an average LOS of 9 days during their
The laparoscopic approach with lavage, drainage, and
no resection seems to have a low mortality and morbidity
rate despite patient comorbidity and disease severity. Co-
lostomy and the occurrence of wound infection are
is not seen. Subsequent elective resection, laparoscopic or
open, may be unnecessary in many patients, and readmis-
sion is unusual. The studies included in this article, how-
ever, may reflect the experience from specialist centers
with a high level of expertise in this field, and inclusion
criteria for laparoscopic lavage was not always clear. The
the lower range. The present data may therefore be biased,
and future studies should clarify which patient groups can
benefit from this minimally invasive approach for treat-
ment of peritonitis caused by complicated diverticulitis.
ble with respect to the reported outcome parameters.
However, the number of included patients has generally
been low and no randomized controlled trials have yet
been performed. The inclusion criteria were not the same
were included in all studies, but patients with Hinchey
Grade 4 disease were only included in four stud-
ticulitis who underwent a laparoscopic lavage were con-
verted to HP (conversion rate, 25%). This is very low
considering that these patients have a higher ASA grade
and higher mortality than all other patients with acute di-
verticulitis and that the intervention is very simple, con-
sisting of laparoscopic lavage and intravenous antibiotics.
this group of patients. Larger studies have to be made be-
fore clinical recommendations can be given regarding this
The follow-up period lasted for a mean period of 38
months where 38% of the patients underwent an elective
resection of the sigmoid colon. Elective resection is meant
to prevent complications and readmission of diverticular
disease and is based on the assumption that, without sur-
gical management, complications and readmission are
more likely to occur. The criteria for resection were differ-
ent in the studies. In four studies (n ? 62), where all pa-
tients were offered laparoscopic resection, 85% of the pa-
tients underwent resection. In the study with the longest
mean follow-up period, where elective resection was per-
formed in patients with complicated disease, 60% of the
patients underwent elective resection. In three other stud-
ies (n ? 105) where laparoscopic resection was performed
selectively only, 1% of the patients underwent resection.
Readmission was only seen in four patients, all from stud-
ies that performed laparoscopic resection if needed, which
corresponds to 4%. An important issue is whether the pa-
tients without resections will be readmitted if they are
that there is no evidence to support the idea that elective
surgery should follow two attacks of diverticulitis.26Fur-
thermore, there is no association between recurrent epi-
sodes of diverticulitis and increased risk of complicated
diverticulitis, and there is no association between multiple
attacks of diverticulitis and a less favorable outcome or an
increased mortality risk if complications develop.27–30
The outcomes from the eight studies show that the
new intervention with laparoscopic lavage combined with
intravenous antibiotics apparently had a low morbidity
without placing a colostomy. Other advantages compared
with acute HP are shorter operation time and lower eco-
nomic costs. Thus, laparoscopic lavage without sigmoid
resection in the acute setting for patients with purulent
peritonitis caused by complicated diverticulitis could be
considered a valid alternative to more radical procedures,
to be investigated more thoroughly: preoperative and in-
traoperative indications should be specified, whether elec-
tive colonic resection should be performed for all patients
or for a selected group in the follow-up period, and finally
randomized clinical trials are needed before clinical refer-
ences can be given precisely.
1. Bahadursingh AM, Virgo KS, Kaminski DL, Longo WE. Spec-
trum of disease and outcome of complicated diverticular dis-
ease. Am J Surg 2003;186:696–701.
ALAMILI ET AL: COMPLICATED DIVERTICULITIS MANAGED BY LAPAROSCOPIC LAVAGE
2. Parra-Blanco A. Colonic diverticular disease: pathophysiology Download full-text
and clinical picture. Digestion 2006;73(Suppl 1):47–57.
3. Stollman N, Raskin J. Diverticular disease of the colon. Lancet
4. Hinchey EJ, Schaal PG, Richards GK. Treatment of perforated
diverticular disease of the colon. Adv Surg 1978;12:85–109.
5. The Standards Task Force and The American Society of Colon
and Rectal Surgeons. Practice parameters for the treatment of
sigmoid diverticulitis. Dis Colon Rectum 2000;43:289–97.
6. Ko ¨hlerL,SauerlandS,NeuebauerE.Diagnosisandtreatmentof
diverticular disease: results of a consensus development confer-
Endoscopic Surgery. Surg Endosc 1999;13:430–6.
7. Stollman NH, Raskin JB. Ad Hoc Practice Parameters Commit-
tee of the American College of Gastroenterology: diagnosis and
management of diverticular disease of the colon in adults. Am J
8. Durmishi Y, Gervaz P, Brandt D, et al. Results from percutane-
ous drainage of Hinchey II diverticulitis guided by computed
tomography scan. Surg Endosc 2006;20:1129–33.
9. Abbas S. Resection and primary anastomosis in acute compli-
cated diverticulitis, a systematic review of the literature. Int J
Colorectal Dis 2007;22:351–7.
10. Salem L, Flum DR. Primary anastomosis or Hartmann’s proce-
dure for patients with diverticular peritonitis? A systemic re-
view. Dis Colon Rectum 2004;47:1953–64.
11. Faranda C, Barrat C, Catheline JM, Champault GG. Two-stage
laparoscopic management of generalized peritonitis due to per-
forated sigmoid diverticula: eighteen cases. Surg Laparosc En-
dosc Percutan Tech 2000;10:135–8.
rhaphy, irrigation and drainage in the treatment of complicated
acute diverticulitis: initial experience. Chir Ital 2004;56,1:95–8.
13. Mutter D, Bouras G, Forgione A, Vix M, Leroy J, Marescaux J.
Two-stage totally minimally invasive approach for acute com-
plicated diverticulitis. Colorectal Dis 2006;8:501–5.
14. Taylor CJ, Layani L, Ghusn MA, White SI. Perforated divertic-
ulitis managed by laparoscopic lavage. ANZ J Surg 2006;76:
15. Franklin ME Jr., Portillo G, Trevin ˜o JM, Gonzalez JJ, Glass JL.
Long-term experience with the laparoscopic approach to perfo-
rated diverticulitis plus generalized peritonitis. World J Surg
tis due to perforated diverticulitis. Br J Surg 2008;95:97–101.
17. Bretagnol F, Pautrat K, Mor C, Benchellal Z, Huten N, de Calan
L. Emergency laparoscopic management of perforated sigmoid
J Am Coll Surg 2008;206:654–7.
18. O’Sullivan GC, Murphy D, O’Brien MG, Ireland A. Laparo-
scopic management of generalized peritonitis due to perforated
colonic diverticula. Am J Surg 1996;171:432–4.
19. Krukowski ZH, Matheson NA. Emergency surgery for divertic-
ular disease complicated by generalized and faecal peritonitis: a
review. Br J Surg 1984;71:921–7.
20. Kronborg O. Treatment of perforated sigmoid diverticulitis: a
prospective randomized trial. Br J Surg 1993;80:505–7.
21. Seah DW, Ibrahim S, Tay KH. Hartmann procedure: is it still
relevant today? ANZ J Surg 2005;75:436–40.
22. Seetharam S, Paige J, Horgan PG. Impact of socioeconomic de-
privation and primary pathology on rate of reversal of Hart-
mann’s procedure. Am J Surg 2003;186:154–7.
23. Desai DC, Brennan EJ Jr., Reilly JF, Smink RD Jr. The utility of
the Hartmann procedure. Am J Surg 1998;175:152–4.
cation of diverticular disease. Br J Surg 1997;84:535–9.
25. Lorimer JW, Doumit G. Comorbidity is a major determinant of
severity in acute diverticulitis. Am J Surg 2007;193:681–5.
26. Janes S, Meagher A, Frizelle FA. Elective surgery after acute di-
verticulitis. Br J Surg 2005;92:133–42.
27. Issa N, Dreznik Z, Dueck DS, et al. Emergency surgery for com-
plicated acute diverticulitis. Colorectal Dis 2008 May 3 [epub
ahead of print].
ing complications. Ann Chir Gynaecol 1990;79:139–42.
29. Chautems RC, Ambrosetti P, Ludwig A, Mermillod B, Morel P,
Soravia C. Long-term follow-up after first acute episode of sig-
118 patients. Dis Colon Rectum 2002;45:962–6.
30. Anaya DA, Flum DR. Risk of emergency colectomy and colos-
tomy in patients with diverticular disease. Arch Surg 2005;140:
DISEASES OF THE COLON & RECTUM VOLUME 52: 7 (2009)