Evidence - Sigmoidectomy, laparoscopic

  1. Summary of the literature

    Diverticulitis is an acute primary inflammation of colonic pseudodiverticula and their surrounding soft tissue structures, which may result in severe abdominal and septic complications. 

    In case of suspected acute diverticulitis, diagnostic work-up aims to classify the disease in order to recommend the proper treatment protocol. This step is essential because the treatment options range from watchful waiting to emergent surgery.

    The indication for surgery depends on the clinical picture of the diverticulitis, the risk of recurrence, subjective impairment of the patient, comorbidities, and medication. The response of nonsurgical treatment should also be taken into account.

    Acute uncomplicated diverticulitis

    The characteristic clinical signs of diverticulitis including changed laboratory findings, but without complications (phlegmon, abscess, fistulation or perforation) on imaging, suggest the diagnosis of acute uncomplicated diverticulitis. Closely monitored nonsurgical treatment is the first-line option here because these patients become asymptomatic after a short time and have a low risk of recurrence [13, 14, 29, 45]. Thus, there is no indication for elective surgery after the symptoms have abated [13, 36, 43]

    In case of persistent complaints or worsening symptoms despite adequate treatment, the initial diagnostic work-up including imaging should be repeated in order to detect previously unrecognized or new complications and to adapt the treatment protocol to the recommendations in complicated diverticulitis.

    While an antibiotic regimen in acute uncomplicated diverticulitis is not mandatory, the current German guideline S2k on diverticular disease/diverticulitis [34] recommends it for patients at risk for recurrence and complications.

    • Arterial hypertension
    • Chronic kidney disease 
    • Immunosuppression
    • Allergic disposition
    • Collagenosis
    • Vasculitis

    Depending on the risk profile of these patients surgery may still be indicated despite successful conservative treatment [2, 9, 10, 19, 49]. This is because post-transplant at patients and those otherwise immunocompromised have a significantly higher mortality than the normal population by up to 25%. In addition the risk of perforation is increased 2.7-fold [8].

    The literature is divided regarding surgery in phlegmonous diverticulitis (type 1b). After successful nonsurgical treatment only few patients relapse despite the fact that the pathophysiology suggests a microperforation [17]. Therefore, no general recommendation for surgery may be made for this population. The current German, Anglo-American and Dutch guidelines reflect this course of action [5, 6, 34, 38].

    Afebrile acute uncomplicated diverticulitis without leukocytosis, guarding, and fecal obstruction, and without evidence of perforation or complicated diverticulitis, but only slightly elevated CRP, may be treated on an outpatient basis. Adequate compliance, sufficient fluid and food intake and close medical follow-up, however, are mandatory [20,40]. One critique of the above trials is that all patients underwent an antibiotic regimen.

    Acute complicated diverticulitis

    Paracolonic abscess formation and free perforation are signs of acute complicated diverticulitis. When manifesting with the clinical picture of acute abdomen free-air perforation is an emergency and must to be treated by emergency surgery [28, 29, 34, 47].

    Patients with complicated diverticulitis should be hospitalized, even if there is no free-air perforation with the clinical picture of acute abdomen. However, the initial treatment should be conservative [6, 11]. Unsuccessful clinical result within 72 hours suggests persistent inflammation, and therefore urgent (within 48 hours) sigmoidectomy should be considered [34]).

    Paracolonic abscesses, fistulas, stenoses

    Imaging demonstrates paracolonic abscess in about 15% of patients with acute complicated diverticulitis [20]. If the abscess is > 5cm, percutaneous interventional drainage, accompanied by antibiotics, may be attempted to avoid emergency surgery [12, 17, 44].

    The data is incomplete regarding the question of whether elective surgery after successful conservative therapy of acute complicated diverticulitis is justified. However, histopathologic studies demonstrate persistent structural changes after paracolonic abscesses [26]. Furthermore, approximately 50% of patients develop secondary complications and about 40% relapse [3, 4]. Risk factors of these sequelae of paracolonic abscesses include [24]:

    • Positive family history of diverticulitis 
    • Length of affected bowel segment > 5cm 
    • Presence of retroperitoneal abscess

    In such cases elective surgery after inflammation has abated should be considered.

    Elective surgery in bland conditions may also be considered if fistulas or clinically significant colonic stenoses develop after successful conservative therapy. Especially fistulas in the urogenital tract should be treated electively because they bear the danger and risk of urosepsis [21, 46].

    Chronic recurrent diverticulitis

    In recent decades, the recommendation for an elective sigmoidectomy depended on the number of experienced episodes: Resection after the second episode [33]. The recommendation by T. G. Parks goes back to 1969 [37]. He wrongly believed that the second episode increased the risk of complications and decreased the success of nonsurgical treatment. Parks based his studies on 40-year old data on the spontaneous course of diverticulitis, obtained under the clinical conditions at that time. 

    Current data show that an increase in the frequency of episodes does not necessarily correlate with an increase in septic complications [34]. Perforations, which require emergency surgery, also happen either as the primary event of diverticulitis or after the first episode. Therefore, prophylactic surgery after the second episode, as recommended until a few years ago, is no longer justified.

    The indication for surgery in chronic recurrent diverticulitis should be evaluated individually, taking into account

    • Complaints
    • Risk factors
    • Age
    • Severity of disease
    • Personal situation and comorbidities

    The operation primarily aims to eliminate the complaints caused by the disease. There must be a careful risk-benefit analysis and the goals defined clearly because surgery will not prevent septic complications, emergency surgery and colostomy. Morbidity and mortality will not decrease either. 

    Diverticular bleeding

    The management of gastrointestinal bleeding first relies on the entire range of diagnostic and therapeutic endoscopy [1, 16, 27, 30, 35]. Emergency endoscopy is the treatment choice [23].

    Angiography (possibly CT-angiography) should be performed, if endoscopy cannot identify the source of the bleeding active at the time of the examination. 

    Surgery is indicated for persistent bleeding not controllable by endoscopy or intervention. The urgency depends on the cardiovascular situation, the intensity of bleeding and the present risk profile.

    Localizing the bleeding is essential because this allows targeted surgery. If the source of the bleeding cannot be localized, it cannot be assumed to be in the sigmoid. In these rare cases of unsuccessful bleeding localization a subtotal colectomy with ileostomy must be considered. Since “blind” segmental resections of the colon bear a high risk of persistent recurrent bleeding, they should not be performed. If the location is uncertain, subtotal colectomy is the treatment of choice [15].

    Recurrent clinically significant diverticular bleeding (e.g., drop in Hb >2g/dL, shock) without any option to decrease the risk of renewed recurrent bleeding by an interventional procedure should undergo early elective surgery after individual risk-benefit assessment [34].

    Patients with self-limiting diverticular bleedings and those after successful interventional treatment should not undergo surgery [34]. 

    Time of operation

    The American Society of Colon and Rectal Surgeons recommends elective resection 6–8 weeks after the beginning of symptoms [38]. The Danish and Dutch guidelines do not specify the best time for surgery [5, 6]. Resections in the phase after 6 – 8 weeks when inflammation has abated demonstrate less anastomotic failures, impaired wound healing and conversion to open surgery (“early-elective” surgery) [39]. 

    Technical aspects of sigmoidectomy

    The goal of elective sigmoidectomy surgery is the removal of the complete sigmoid and construction of a tension-free anastomosis at the upper rectum. 

    There is no correlation between the number of residual diverticula in the remaining colon and the risk of recurrent diverticulitis. Therefore, there is no indication to extend the resection [48]. The level of the distal transection has a significant impact on recurrence: The risk of recurrence decreases significantly if the level of transection is at the distal rectum [7]. 

    The splenic flexure does not necessarily need to be mobilized if the descending colon is long enough. According to some authors the risk of anastomotic failure and sexual dysfunction is minimized by sparing the inferior mesenteric artery [25].

    Unless there are specific reasons for open surgery (e.g., patient demand, lack of surgical expertise), laparoscopic or laparoscopically-assisted resection is preferred [2]. The same also applies to complicated and recurrent sigmoid diverticulitis [25].

    The direct comparison of open surgery versus laparoscopic sigmoidectomy for the short-term postoperative course favors laparoscopy in terms of lower blood loss, faster recovery, shorter length of stay in hospital, faster onset of intestinal motility, overall lower morbidity, and lower overall costs [18, 22]. In terms of quality of life and complications 6 months after surgery, however, the laparoscopic procedure did not evidence any superiority over the open procedure [31]. 

  2. Ongoing trials on this topic

  3. References on this topic

    1: Adams JB, Margolin DA. Management of diverticular hemorrhage. Clin Colon Rectal Surg. 2009 Aug;22(3):181-5.

    2: Al-Khamis A, Abou Khalil J, Demian M, Morin N, Vasilevsky CA, Gordon PH,Boutros M. Sigmoid Colectomy for Acute Diverticulitis in Immunosuppressed vs Immunocompetent Patients: Outcomes From the ACS-NSQIP Database. Dis Colon Rectum. 2016 Feb;59(2):101-9.

    3: Ambrosetti P. Acute diverticulitis of the left colon: value of the initial CT and timing of elective colectomy. J Gastrointest Surg. 2008 Aug;12(8):1318-20.

    4: Ambrosetti P, Chautems R, Soravia C, Peiris-Waser N, Terrier F. Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Dis Colon Rectum. 2005 Apr;48(4):787-91.

    5: Andersen JC, Bundgaard L, Elbrond H, Laurberg S, Walker LR. Danish Surgical Society. Danish national guidelines for treatment of diverticular disease. Dan Med J. 2012 May;59(5):C4453.

    6: Andeweg CS, Mulder IM, Felt-Bersma RJ, Verbon A, van der Wilt GJ, van Goor H, Lange JF, Stoker J, Boermeester MA, Bleichrodt RP; Netherlands Society of Surgery.; Working group from Netherlands Societies of Internal Medicine, Gastroenterologists, Radiology, Health echnology Assessment and Dieticians. Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Dig Surg. 2013;30(4-6):278-92.

    7: Benn PL, Wolff BG, Ilstrup DM. Level of anastomosis and recurrent colonic diverticulitis. Am J Surg. 1986 Feb;151(2):269-71.

    8: Biondo S, Lopez Borao J, Millan M, Kreisler E, Jaurrieta E. Current status of the treatment of acute colonic diverticulitis: a systematic review. Colorectal Dis. 2012 Jan;14(1):e1-e11.

    9: Biondo S. Age and immunocompromised status in acute diverticulitis. Colorectal Dis. 2012 Dec;14(12):1553-4; author reply 1554-5.

    10: Biondo S, Borao JL, Kreisler E, Golda T, Millan M, Frago R, Fraccalvieri D, Guardiola J, Jaurrieta E. Recurrence and virulence of colonic diverticulitis in immunocompromised patients. Am J Surg. 2012 Aug;204(2):172-9.

    11: Boostrom SY, Wolff BG, Cima RR, Merchea A, Dozois EJ, Larson DW. Uncomplicated diverticulitis, more complicated than we thought. J Gastrointest Surg. 2012 Sep;16(9):1744-9.

    12: Brandt D, Gervaz P, Durmishi Y, Platon A, Morel P, Poletti PA. Percutaneous CT scan-guided drainage vs. antibiotherapy alone for Hinchey II diverticulitis: a case-control study. Dis Colon Rectum. 2006 Oct;49(10):1533-8.

    13: Chautems RC, Ambrosetti P, Ludwig A, Mermillod B, Morel P, Soravia C. Long-term follow-up after first acute episode of sigmoid diverticulitis: is surgery mandatory?: a prospective study of 118 patients. Dis Colon Rectum. 2002 Jul;45(7):962-6.

    14: Collins D, Winter DC. Elective resection for diverticular disease: an evidence-based review. World J Surg. 2008 Nov;32(11):2429-33.

    15: Czymek R, Kempf A, Roblick UJ, Bader FG, Habermann J, Kujath P, Bruch HP, Fischer F. Surgical treatment concepts for acute lower gastrointestinal bleeding. J Gastrointest Surg. 2008 Dec;12(12):2212-20.

    16: Davila RE, Rajan E, Adler DG, Egan J, Hirota WK, Leighton JA, Qureshi W, Zuckerman MJ, Fanelli R, Wheeler-Harbaugh J, Baron TH, Faigel DO; Standards of Practice Committee.. ASGE Guideline: the role of endoscopy in the patient with lower-GI bleeding. Gastrointest Endosc. 2005 Nov;62(5):656-60. 17: Durmishi Y, Gervaz P, Brandt D, Bucher P, Platon A, Morel P, Poletti PA. Results from percutaneous drainage of Hinchey stage II diverticulitis guided by computed tomography scan. Surg Endosc. 2006 Jul;20(7):1129-33.

    18: Dwivedi A, Chahin F, Agrawal S, Chau WY, Tootla A, Tootla F, Silva YJ. Laparoscopic colectomy vs. open colectomy for sigmoid diverticular disease. Dis Colon Rectum. 2002 Oct;45(10):1309-14; discussion 1314-5.

    19: Floch CL; NDSG.. Emergent and elective surgery for diverticulitis. J Clin Gastroenterol. 2008 Nov-Dec;42(10):1152-3.

    20: Friend K, Mills AM. Is outpatient oral antibiotic therapy safe and effective for the treatment of acute uncomplicated diverticulitis? Ann Emerg Med. 2011 Jun;57(6):600-2.

    21: Garcea G, Majid I, Sutton CD, Pattenden CJ, Thomas WM. Diagnosis and management of colovesical fistulae; six-year experience of 90 consecutive cases.  Colorectal Dis. 2006 May;8(4):347-52.

    22: Gonzalez R, Smith CD, Mattar SG, Venkatesh KR, Mason E, Duncan T, Wilson R, Miller J, Ramshaw BJ. Laparoscopic vs open resection for the treatment of diverticular disease. Surg Endosc. 2004 Feb;18(2):276-80.

    23: Green BT, Rockey DC, Portwood G, Tarnasky PR, Guarisco S, Branch MS, Leung J, Jowell P. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol. 2005 Nov;100(11):2395-402.

    24: Hall JF, Roberts PL, Ricciardi R, Read T, Scheirey C, Wald C, Marcello PW, Schoetz DJ. Long-term follow-up after an initial episode of diverticulitis: what are the predictors of recurrence? Dis Colon Rectum. 2011 Mar;54(3):283-8.

    25: Holmer C, Kreis ME. Diverticular disease – choice of surgical procedure. Chirurg. 2014 Apr;85(4):308-13.

    26: Holmer C, Lehmann KS, Engelmann S, Frericks B, Loddenkemper C, Buhr HJ, Ritz JP. Microscopic findings in sigmoid diverticulitis–changes after conservative therapy. J Gastrointest Surg. 2010 May;14(5):812-7.

    27: Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med. 2000 Jan 13;342(2):78-82.

    28: Jurowich CF, Jellouschek S, Adamus R, Loose R, Kaiser A, Isbert C, Germer CT, von Rahden BH. How complicated is complicated diverticulitis?–phlegmonous diverticulitis revisited. Int J Colorectal Dis. 2011 Dec;26(12):1609-17.

    29: Kaiser AM, Jiang JK, Lake JP, Ault G, Artinyan A, Gonzalez-Ruiz C, Essani R, Beart RW Jr. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol. 2005 Apr;100(4):910-7.

    30: Kaltenbach T, Watson R, Shah J, Friedland S, Sato T, Shergill A, McQuaid K, Soetikno R. Colonoscopy with clipping is useful in the diagnosis and treatment of diverticular bleeding. Clin Gastroenterol Hepatol. 2012 Feb;10(2):131-7.

    31: Klarenbeek BR, Bergamaschi R, Veenhof AA, van der Peet DL, van den Broek WT,  de Lange ES, Bemelman WA, Heres P, Lacy AM, Cuesta MA. Laparoscopic versus open sigmoid resection for diverticular disease: follow-up assessment of the randomized control Sigma trial. Surg Endosc. 2011 Apr;25(4):1121-6.

    32: Kruis W, Germer CT, Leifeld L; German Society for Gastroenterology, Digestive and Metabolic Diseases and The German Society for General and Visceral Surgery. Diverticular disease: guidelines of the german society for gastroenterology, digestive and metabolic diseases and the german society for general and visceral  surgery. Digestion. 2014;90(3):190-207.

    33: Köhler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc. 1999 Apr;13(4):430-6.

    34: Leifeld L, Germer CT, Böhm S, Dumoulin FL, Häuser W, Kreis M, Labenz J, Lembcke B, Post S, Reinshagen M, Ritz JP, Sauerbruch T, Wedel T, von Rahden B, Kruis W. S2k guidelines diverticular disease/diverticulitis. Z Gastroenterol. 2014 Jul;52(7):663-710.

    35: Lewis M; NDSG.. Bleeding colonic diverticula. J Clin Gastroenterol. 2008 Nov-Dec;42(10):1156-8.

    36: Mueller MH, Glatzle J, Kasparek MS, Becker HD, Jehle EC, Zittel TT, Kreis ME. Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon. Eur J Gastroenterol Hepatol. 2005 Jun;17(6):649-54.

    37: Parks TG. Natural history of diverticular disease of the colon. A review of 521 cases. Br Med J. 1969 Dec 13;4(5684):639-42.

    38: Rafferty J, Shellito P, Hyman NH, Buie WD; Standards Committee of American Society of Colon and Rectal Surgeons.. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum. 2006 Jul;49(7):939-44.

    39: Reissfelder C, Buhr HJ, Ritz JP. What is the optimal time of surgical intervention after an acute attack of sigmoid diverticulitis: early or late elective laparoscopic resection? Dis Colon Rectum. 2006 Dec;49(12):1842-8.

    40: Ridgway PF, Latif A, Shabbir J, Ofriokuma F, Hurley MJ, Evoy D, O’Mahony JB, Mealy K. Randomized controlled trial of oral vs intravenous therapy for the clinically diagnosed acute uncomplicated diverticulitis. Colorectal Dis. 2009 Nov;11(9):941-6.

    41: Ritz JP, Lehmann KS, Frericks B, Stroux A, Buhr HJ, Holmer C. Outcome of patients with acute sigmoid diverticulitis: multivariate analysis of risk factors for free perforation. Surgery. 2011 May;149(5):606-13.

    42: Schuetz A, Jauch KW. Lower gastrointestinal bleeding: therapeutic strategies, surgical techniques and results. Langenbecks Arch Surg. 2001 Feb;386(1):17-25.

    43: Shaikh S, Krukowski ZH. Outcome of a conservative policy for managing acute sigmoid diverticulitis. Br J Surg. 2007 Jul;94(7):876-9.

    44: Siewert B, Tye G, Kruskal J, Sosna J, Opelka F, Raptopoulos V, Goldberg SN. Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters. AJR Am J Roentgenol. 2006 Mar;186(3):680-6. Erratum in: AJR Am J Roentgenol. 2007 Sep;189(3):512. Raptopoulos, Vassilios [added]; Goldberg, S Nahum [added].

    45: Simianu VV, Strate LL, Billingham RP, Fichera A, Steele SR, Thirlby RC, Flum DR. The Impact of Elective Colon Resection on Rates of Emergency Surgery for Diverticulitis. Ann Surg. 2016 Jan;263(1):123-9.

    46: Solkar MH, Forshaw MJ, Sankararajah D, Stewart M, Parker MC. Colovesical fistula–is a surgical approach always justified? Colorectal Dis. 2005 Sep;7(5):467-71.

    47: von Rahden BH, Germer CT. Pathogenesis of colonic diverticular disease. Langenbecks Arch Surg. 2012 Oct;397(7):1025-33.

    48: Wolff BG, Ready RL, MacCarty RL, Dozois RR, Beart RW Jr. Influence of sigmoid resection on progression of diverticular disease of the colon. Dis Colon Rectum.  1984 Oct;27(10):645-7.

    49: Yoo PS, Garg R, Salamone LF, Floch MH, Rosenthal R, Longo WE. Medical comorbidities predict the need for colectomy for complicated and recurrent diverticulitis. Am J Surg. 2008 Nov;196(5):710-4.


Ahmed AM, Moahammed AT, Mattar OM, Mohamed EM, Faraag EA, AlSafadi AM, Hirayama K, Huy NT. Surgical

Activate now and continue learning straight away.

Single Access

Activation of this course for 3 days.

€4.99 inclusive VAT

Most popular offer

webop - Savings Flex

Combine our learning modules flexibly and save up to 50%.

from €3.29 / module

€39.50 / yearly payment

price overview

general and visceral surgery

Unlock all courses in this module.

€9.08 / month

€109.00 / yearly payment

  • literature search

    Literature search on the pages of pubmed.