Diverticulitis is a common digestive condition that affects the large intestine. It occurs when small, bulging pouches, known as diverticula, form in the colon wall and become inflamed or infected. While the presence of these pouches, called diverticulosis, is often harmless, their inflammation can cause abdominal pain and fever. Most cases of acute diverticulitis are managed medically with diet modifications and sometimes antibiotics, allowing the colon to rest and heal. However, for a small percentage of patients, disease progression or recurrence necessitates surgical intervention to resolve the infection and prevent future attacks.
Understanding When Surgery Is Necessary
The decision to proceed with surgery depends on the severity of the current attack and the long-term history of the disease. Surgery is broadly categorized into two types: emergency and elective. Emergency surgery is required when the infection has caused a life-threatening event, such as a perforation or rupture of the colon wall. This can leak stool and infected material into the abdominal cavity, leading to peritonitis.
Other urgent situations demanding surgery include uncontrolled bleeding from the inflamed diverticula or a large abscess that cannot be effectively drained using non-surgical techniques. If a patient’s condition continues to worsen despite aggressive intravenous antibiotic treatment, surgery is necessary to remove the source of the infection.
Elective surgery is typically recommended for patients who have recovered from an acute episode but suffer from chronic problems. A common indication is recurrent diverticulitis, especially after two or more severe attacks, which significantly impairs quality of life. The goal in these cases is to prevent further episodes and complications.
Chronic complications that warrant elective intervention include the formation of a fistula, an abnormal connection that develops between the colon and another organ, such as the bladder. A stricture, a significant narrowing of the colon caused by repeated inflammation and scarring, can also lead to bowel obstruction. Elective surgery is usually performed after the initial inflammation has completely subsided, often four to six weeks following the acute episode.
Primary Surgical Procedures for Diverticulitis
The most common surgical procedure for diverticulitis is a colon resection, where the diseased segment of the colon, most often the sigmoid colon, is removed. After the infected portion is taken out, the surgeon must decide how to manage the two remaining healthy ends of the bowel. The two primary outcomes are a resection with primary anastomosis or a resection with ostomy.
A resection with primary anastomosis involves removing the affected section and immediately rejoining the two healthy ends of the colon. This technique, sometimes called a one-stage operation, restores the normal path of digestion. This approach is generally preferred in elective surgeries where the patient is stable and the abdominal cavity is not heavily contaminated with infection.
The alternative is a resection with ostomy, most commonly known as a Hartmann’s procedure. In this two-stage operation, the diseased colon is removed, the lower end of the remaining bowel is temporarily sealed off, and the upper, healthy end is brought through an opening in the abdominal wall. This opening, called a stoma, diverts stool into an external collection pouch, allowing the colon to heal completely.
The Hartmann’s procedure is frequently used in emergency settings, particularly when the patient is unstable or when widespread peritonitis is present. The high level of contamination in the abdomen makes the connection site of a primary anastomosis risky for leakage. The Hartmann’s procedure remains the traditional choice when the surgical field is highly infected.
The Surgical Approach and Post-Operative Recovery
Surgical Approach
The colon resection is classified as either open or laparoscopic surgery. Open surgery involves a single, larger incision in the abdomen, typically six to eight inches long, which provides the surgeon with a direct view of the colon. The open approach is often necessary in emergency situations or when the abdomen is severely scarred from previous surgeries or extensive inflammation.
Laparoscopic surgery is a minimally invasive approach that uses several small incisions, usually less than half an inch each, through which the surgeon inserts a camera and specialized instruments. This approach is favored for elective resections because it is associated with less pain, smaller scars, and a quicker return to normal activity compared to open surgery. The choice between the two methods is determined by the patient’s overall health and the complexity of the disease.
Post-Operative Recovery
Post-operative recovery begins immediately in the hospital, where patients often have an initial stay of several days. Pain management is controlled with medication, and patients are encouraged to walk soon after the procedure to promote healing and reduce the risk of blood clots. Diet progression starts with clear liquids and gradually moves to a soft diet before the patient returns to a normal eating pattern.
Patients are advised to avoid heavy lifting or strenuous activities for six to eight weeks to allow the internal surgical site to heal fully. If a temporary ostomy was created, the patient receives instructions on how to manage the stoma and the external collection pouch. For many patients who undergo a Hartmann’s procedure, the ostomy can be surgically reversed in a second operation a few months later once the colon has fully recovered.