Diverticular disease - choice of surgical procedure

The clinical spectrum of diverticular disease varies from asymptomatic diverticulosis to symptomatic disease with potentially fatal complications, such as perforation or bleeding. Laparoscopic sigmoid resection with restoration of continuity is currently the prevailing modality for treating acute and recurrent sigmoid diverticulitis. The tenets of surgical treatment of diverticulitis are resection of the entire sigmoid and creation of a tension-free anastomosis in the upper rectum. With respect to the required extent of resection according to current data it is not necessary to remove the entire colonic segment bearing diverticula because such a strategy does not reduce the recurrence rate. In the emergency situation due to free perforation a primary anastomosis with defunctioning ileostomy should be favored because the stoma reversal rate after primary anastomosis is higher than after Hartmann's procedure. The Hartmann procedure should be reserved for perforated diverticulitis with severe septic complications; however, the final treatment decision for primary anastomosis or Hartmann's procedure should be dependent on the individual patient. There have been a number of recent publications on the use of laparoscopic peritoneal lavage for perforated sigmoid diverticulitis as an alternative to resection surgery. In cases of diverticular bleeding a subtotal colectomy should be performed if the diverticular bleeding site cannot be localized.