1. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 32 Procedures for Diverticular Disease — 1
32 PROCEDURES FOR
DIVERTICULAR DISEASE
Jeffrey L. Cohen, M.D., F.A.C.S., F.A.S.C.R.S., and John P Welch, M.D., F.A.C.S.
.
Preoperative Evaluation
stration of a diverticular fistula should not be considered a man-
The extent of the preoperative evaluation received by patients datory precondition for operative treatment. A strong history of
undergoing surgical treatment of diverticular disease is dictated either a colovaginal or a colovesical fistula with suggestive findings
predominantly by the urgency of the situation. Whereas patients on CT scans (e.g., air in the bladder or pericolonic inflammation
with recurrent symptoms will undergo repeated assessments with contiguous with either the bladder or the vagina) constitutes a suf-
myriad diagnostic tests before the decision is made to proceed ficient indication for surgical resection.12,13
with surgical intervention, patients with perforated diverticulitis
may have only a chest x-ray documenting free air before they are
taken to the operating room. Given the varied complications of Operative Planning
diverticular disease and the numerous options for surgical treat- In planning the operative approach to a patient with diverticular
ment, we believe it is most convenient to divide the relevant oper- disease, the major decision is whether to perform a one-stage or a
ations into emergency procedures and elective procedures. Such two-stage procedure.Traditionally, an emergency operation for per-
a division facilitates discussion of technical issues, preoperative foration, obstruction, or massive bleeding includes a temporary
evaluation, and management of complications. stoma procedure to eliminate the risk of anastomotic leakage.14,15
As noted, in the emergency setting, a demonstration of pneu- The operation most commonly performed in this setting is the
moperitoneum may be the only workup performed. In fact, in Hartmann procedure [see Emergency Procedures, Hartmann Pro-
most patients with perforated diverticulitis, pneumoperitoneum cedure, below], named after Henri Hartmann, who first described
is the initial presentation.1,2 In patients who present with massive the use of this operation to treat colon cancer in 1923.16 The obvi-
lower GI hemorrhage, angiographic demonstration of the bleed- ous advantage of the Hartmann procedure is that it removes the in-
ing site is known to reduce operative mortality, even if therapeu- flammatory focus without putting the compromised patient at risk
tic superselective embolization is unsuccessful in controlling the for anastomotic leakage. Unfortunately, to restore intestinal conti-
bleeding.3,4 The other complication of diverticular disease that nuity after this procedure, it is necessary to perform a potentially
may necessitate an emergency operation is colonic obstruction. A difficult second operation; as many as one third of patients never
careful history may reveal progressive obstructive symptoms, but undergo reversal of their colostomy.17,18
if the patient presents with complete obstruction and cecal dilata- Another therapeutic option is to perform a primary anastomo-
tion, urgent decompression is required. In this setting, retrograde sis with a diverting loop ileostomy instead of a colostomy. In this
administration of a water-soluble enema may be very helpful—at situation, the risk of anastomotic leakage with possible fecal peri-
least for delineating the level of the obstruction, if not the specif- tonitis is still avoided, but only a relatively minor second proce-
ic cause.1,5 Communication with the radiologist should be main- dure is necessary to reverse the ileostomy.19 Occasionally, it may
tained to prevent both overly forceful instillation of the contrast be appropriate to perform on-table colonic lavage with a primary
material and the use of barium, which may cause problems if the anastomosis.This approach is most useful in the setting of colon-
agent cannot be evacuated. ic obstruction secondary to a diverticular stricture in a patient
When surgical treatment of diverticular disease is to be per- who is otherwise hemodynamically stable but has a large fecal
formed in the elective setting, a detailed preoperative evaluation load proximal to the intended anastomosis.20,21
is imperative[see 5:12 Diverticulitis].The key point here is that objec- Laparoscopic intestinal surgery has shown tremendous devel-
tive evidence of diverticulitis must be obtained at some point opment of late, benefited both by significant technological im-
in the care of the patient. Too often, symptoms of irritable bow- provements and by growing surgical experience with advanced
el syndrome are confused with those of diverticulitis, with the laparoscopic procedures.22,23 Newer approaches (e.g., hand-as-
result that the patient carries an incorrect diagnosis.6-9 In the sisted techniques) have markedly reduced the learning curve and
most common scenario, computed tomographic scanning is per- shortened the operating time.24,25 Consequently, minimal access
formed when a patient is experiencing left-side pain, possibly as- surgery is rapidly becoming the approach of choice in the man-
sociated with fever, nausea, anorexia, or abdominal distention. A agement of uncomplicated diverticular disease.26-29
finding of pericolonic inflammation in an area of diverticulosis
is the definitive radiographic presentation.10,11 Preoperative en-
doscopic evaluation of the colon, whenever feasible, is extremely Emergency Procedures
valuable not only for confirming the presence of diverticulosis but Patient setup and positioning are similar for all emergency
also for ruling out inflammatory bowel disease or even a neoplastic operations.The patient is placed in a modified lithotomy position
lesion. to facilitate access to the rectum. Urinary drainage with a Foley
It is possible to expend a great deal of effort on trying to catheter and temporary gastric decompression with a nasogastric
demonstrate a diverticular fistula. In many circumstances, howev- tube are performed. When feasible, the stoma is marked by an
er, this task proves difficult to accomplish. In our view, demon- enterostomal therapist before operation.

2. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 32 Procedures for Diverticular Disease — 2
HARTMANN PROCEDURE
Step 1: Incision and Initial Exploration
A lower midline incision is made and extended above the
umbilicus as necessary. The abdomen is thoroughly explored to
confirm the diagnosis of diverticular disease and to wash out any
gross fecal spillage. A self-retaining retractor (e.g., a Bookwalter
retractor) is placed, with care taken to pad the abdominal wall.
Step 2: Mobilization and Division of Sigmoid Colon
The patient is placed in the Trendelenburg position, with the
small bowel carefully retracted into the upper abdomen.The sig-
moid colon is mobilized away from the lateral peritoneal attach-
ments. Mobilization is continued into the pelvis lateral to the
upper portion of the rectum.
Troubleshooting If a severe phlegmon is stuck to the pelvic
sidewall, it may be helpful at some point in the mobilization to
dissect cephalad from below the mass so as to isolate the area
from above and below.
Step 3: Identification of Ureter
As the sigmoid colon is retracted medially, the ureter can usu-
ally be identified where it crosses over the bifurcation of the iliac
vessels. The gonadal vessels are usually identified first; the ureter
lies slightly medial and deep to them [see Figure 1].
Step 4: Division of Sigmoid Colon
Figure 1 Hartmann procedure. Illustrated is the relation of
The proximal sigmoid colon is divided through noninflamed tis- the ureter to other structures in the left lower quadrant.
sue with a linear cutting stapler [see Figure 2a].The sigmoid vessels
are sequentially divided (with attention paid to their relation to the
left ureter) up to the rectosigmoid junction, which is identified by Step 5: Construction of Colostomy
the loss of the taeniae coli. The rectum is then transected through The proximal colon is delivered through the previously marked
noninflamed tissue with a linear cutting stapler [see Figure 2b]. stoma site in the left lower quadrant with a muscle-splitting inci-
sion in the rectus abdominis (with care taken not to twist it on
Troubleshooting The top of the rectal stump can be marked its mesentery), and a colostomy is created [see 5:30 Intestinal
with a nonabsorbable suture to facilitate subsequent identification. Stomas].
a b
Figure 2 Hartmann procedure. (a) The colon is divided above the level of the inflammatory mass.
(b) The rectum is divided below the inflammatory mass; division must be through normal tissue.

3. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 32 Procedures for Diverticular Disease — 3
Step 5—Alternative (Primary Anastomosis with Diverting
Ileostomy): Creation of Colorectal Anastomosis
As an alternative to a colostomy, the surgeon may elect to per-
form a primary colorectal anastomosis with a diverting ileostomy.
(Such an anastomosis is described in more detail elsewhere [see 5:35
Procedures for Rectal Cancer].) The anvil of a circular stapler is posi-
tioned in the proximal colon, and a purse-string suture is placed
around it. If there is any gaping of the tissue around the shaft of the
anvil, a second suture may be added for reinforcement.
The stapler is inserted through the anus, with the shaft being
brought out either through the anterior wall of the rectum or
through the top of the rectal stump, adjacent to the staple line.
The stapler is then engaged, with care taken to ensure that no
extraneous tissue is caught between the body of the stapler and
the anvil and that the proximal bowel is not twisted on its mesen-
tery.The stapler is fired to create the anastomosis, and the integri-
ty of the anastomosis is tested by occluding the proximal bowel
and placing the anastomotic area under water while air is insuf-
flated into the rectum via a rigid proctoscope. Figure 3 On-table colonic lavage. Shown is full mobilization of
the colon, with corrugated anesthesia tubing secured in the colon
Troubleshooting It is helpful to divide the mesentery where and connected to a collection system. A Foley catheter is inserted
it is draped over the anvil. This measure diminishes the risk of through an appendicostomy into the base of the cecum.
bleeding from the circular staple line while also providing a
greater length of colon for the anastomosis. If there is any ques-
tion regarding possible tension on the anastomosis, the splenic Step 9: Excision of Appendix and Creation of Colorectal
flexure should be fully mobilized. Anastomosis
Step 6—Alternative (Primary Anastomosis with Diverting A formal appendectomy is performed [see 5:31 Appendecto-
Ileostomy): Construction of Loop Ileostomy my]. The corrugated anesthesia tubing is removed from the
A loop ileostomy is created in the right lower quadrant, using colon, and a colorectal anastomosis is performed, usually with a
a muscle-splitting incision in the rectus abdominis [see 5:30 Intes- circular stapler.
tinal Stomas]. Loop ileostomies can usually be designed to be di-
verting; however, stapling the distal end and leaving it at skin level Elective Procedures
will ensure complete diversion.
OPEN RESECTION
Troubleshooting If there is a column of stool between the
ileostomy and the anastomosis, it should be washed out before Open resection in the elective setting consists of steps 1
the ileostomy is completed. through 4 of the Hartmann procedure, followed by creation of a
primary colorectal anastomosis and a diverting loop ileostomy
ON-TABLE COLONIC LAVAGE (alternative steps 5 and 6) [see Emergency Procedures, Hartmann
Steps 1 through 4 Procedure, above].
Steps 1, 2, 3, and 4 of on-table colonic lavage are the same as LAPAROSCOPIC RESECTION
the first four steps of the Hartmann procedure.
The patient is placed in a low lithotomy position with minimal
Step 5: Mobilization of Flexures hip flexion. The right arm is well padded and tucked at the side
After the sigmoid resection, the hepatic flexure and the splenic because both surgeons will be operating from the right side of the
flexure are carefully mobilized to facilitate the washout process. table. Video monitors are placed on both sides of the table. It is
beneficial to place the patient on a bean bag because a significant
Step 6: Placement of Tubing portion of the operation will be performed with the patient in
Corrugated anesthesia tubing is placed in the colon proximal extremes of positioning.
to the resected segment and secured in place with umbilical tape. Step 1: Placement of Trocars
The distal end of the tubing is passed off the operating table and
is connected to a device that collects the effluent [see Figure 3]. The first port is placed at a periumbilical location by means of
an open Hasson approach, and a 30˚ laparoscope is inserted.
Step 7: Construction of Appendicostomy After pneumoperitoneum is achieved, the other ports are placed
An appendicostomy is performed, a Foley catheter is placed, under direct vision: 5 and 12 mm ports are placed in the right
and a purse-string suture is tied around the tube with the balloon lower quadrant, and an optional 5 mm port may be placed in the
inflated. If the patient has previously undergone appendectomy, midepigastrium [see Figure 4]. The midepigastric port facilitates
the terminal ileum is used instead. mobilization of the left colon and is essential for mobilization of
the splenic flexure.
Step 8: Irrigation of Colon
The colon is washed with an irrigant until the effluent is rela- Step 2: Mobilization of Sigmoid Colon
tively clear. It may be necessary to manipulate the colon so as to After the abdomen has been explored, the patient is placed in a
initiate flushing of formed stool. steep Trendelenburg position, with the right side tilted down. This

4. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 32 Procedures for Diverticular Disease — 4
initial dissection proceeds from the right side of the colon, mobi-
lizing the superior rectal vessels from the sacral promontory. The
left ureter is then visualized through the window thus created
before the sigmoid mesentery is divided. Division of the sigmoid
mesentery is performed in a proximal-to-distal direction, with the
inferior mesenteric vessels generally divided first. Once the sig-
moid mesentery has been completely divided, the bowel is tran-
sected with staplers at the rectosigmoid junction.
The advantage of the traditional approach is that surgeons are
more familiar with it from corresponding open procedures. In our
5 mm
(optional)
view, given the difficulty of mastering laparoscopic colon surgery,
5 mm
the medial-to-lateral approach to colonic mobilization only in-
Camera creases the steepness of the learning curve without affording any
significant benefit.
12 mm Step 3: Division of Rectum and Sigmoid Mesentery
An incision is made in the peritoneum along the right side of
the rectosigmoid mesentery and extended inferiorly to the pelvic
cul-de-sac. A window is created between the upper rectum and its
Figure 4 Laparoscopic sigmoid resection. Shown is recom- mesentery and enlarged to allow insertion of an endoscopic gas-
mended port placement. The midepigastric 5 mm port is essen- trointestinal anastomosis (GIA) stapler [see Figure 5]. The stapler
tial for mobilization of the splenic flexure. is then fired once or twice to divide the rectosigmoid bowel. The
mesentery of the sigmoid colon is sequentially divided with sta-
plers, clips, an ultrasonic scalpel, or the LigaSure system (Valleylab,
position allows gravity to retract the small bowel into the upper Boulder, Colorado).
abdomen.The sigmoid colon is mobilized from its lateral peritoneal
attachments, and the colon is thereby converted to a midline struc- Step 4: Exteriorization of Sigmoid Colon
ture. Mobilization is extended superiorly along the descending Once the colon is mobilized and the blood supply divided,
colon and inferiorly to the pelvic cul-de-sac.The left ureter is then either a left lower quadrant muscle-splitting incision or a Pfan-
identified and swept laterally away from the base of the mesentery. nenstiel incision is made to exteriorize the bowel, which is then
divided proximally.The anvil of a circular stapler is inserted in the
Alternative approach to colonic mobilization and divi- proximal colon and secured with a purse-string suture.The bowel
sion In place of the conventional approach (see above), a medi- is then replaced into the abdomen, and the incision is closed.
al-to-lateral approach can be undertaken. In this approach, the
Step 5: Creation of Colorectal Anastomosis
After pneumoperitoneum is recreated, the circular stapler is
inserted transanally. The shaft is brought out either through the
top of the rectal stump or through the anterior wall of the rectum
[see Figure 6]; the former is preferred if bowel length is an issue.
After the stapler is engaged but before it is fired, the proximal
colon is inspected to confirm that it is not twisted. The stapler is
Figure 6 Laparoscopic sigmoid resection. The shaft of the circu-
Figure 5 Laparoscopic sigmoid resection. Shown is lar stapler is guided through the top of the rectal stump by apply-
division of the rectum with the endoscopic stapler. ing countertraction with a laparoscopic instrument.

5. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 32 Procedures for Diverticular Disease — 5
Steps 5 and 6
Steps 5 and 6 are identical to steps 4 and 5 of a full laparo-
scopic resection.
Troubleshooting Having the surgeon’s hand in the pelvis
greatly facilitates engagement of the circular stapler and makes its
closure safer by protecting the surrounding structures [see Figure
9]. Furthermore, the presence of the hand in the pelvis not only
assists in testing the anastomosis but also helps the surgeon bet-
ter assess the degree of tension (if any) on the anastomosis. Given
that the size of the hand port is similar to that of the extraction
site in a full laparoscopic resection, we prefer the hand-assisted
technique on the basis of its greater safety and its ability to restore
a measure of tactile sense and proprioception to the surgeon.
LAPAROSCOPIC HARTMANN CLOSURE
Step 1: Placement of Trocars
Figure 7 Hand-assisted laparoscopic resection. Shown is the A port is placed by means of the Hasson technique at an upper
placement of one of the hand devices through which the surgeon’s midline location, cephalad to the previous incision if possible. A 30˚
hand is advanced into the pelvis.
laparoscope is inserted through this port. After pneumoperitoneum
is achieved, two 5 mm ports are placed in the right lower quadrant
then fired, and the anastomosis is then tested under water to con- to facilitate dissection of pelvic and midline adhesions as necessary.
firm the absence of an air leak.
Step 2: Mobilization of Colostomy and Rectal Stump
HAND-ASSISTED LAPAROSCOPIC RESECTION All adhesions and attachments should be cleared away from
the intra-abdominal portions of the colostomy [see Figure 10]. In
Steps 1 and 2 addition, the top of the Hartmann pouch should be cleared of all
The first two steps of a hand-assisted laparoscopic resection adherent small bowel or adjacent structures. Occasionally, other
are identical to steps 1 and 2 of a full laparoscopic resection. ports may have to be placed to facilitate takedown of adhesions,
especially those from the original midline incision.The colostomy
Step 3: Placement of Hand Device is detached from the skin circumferentially. The anvil of a circu-
A 6 to 8 cm muscle-splitting incision is made in the left lower lar stapler is then placed in the proximal bowel after the exposed
quadrant, and the hand device is placed [see Figure 7]. The sur- portion of the colostomy has been resected.
geon’s left hand is placed through this device into the abdomen.
Step 3: Placement of Hand and Completion of Anastomosis
Step 4: Division of Rectum and Sigmoid Mesentery The colostomy site is enlarged slightly so that the surgeon’s left
The surgeon’s left hand is used to facilitate creation of a window hand can be placed in the abdomen. The stapler is engaged and
between the rectum and the underlying mesentery. An endoscopic fired while the surgeon’s hand keeps any extraneous tissue away
GIA stapler is safely guided through this window, and the bowel is from the anastomotic area. The anastomosis is then tested by
divided [see Figure 8a].The hand is then used to isolate segments of placing it under water and insufflating air via a proctoscope.
the mesentery for division [see Figure 8b], as well as to help control
vessels that continue to bleed despite having been divided. Troubleshooting It is often easier to bring out the shaft of
a b
Figure 8 Hand-assisted laparoscopic resection. (a) Placement of the surgeon’s hand intracorporeally facilitates
division of the rectum. (b) The surgeon’s hand isolates mesenteric vessels for subsequent division.

6. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 32 Procedures for Diverticular Disease — 6
a b
Figure 9 Hand-assisted laparoscopic resection. The surgeon’s hand guides engagement of the circular stapler,
protecting surrounding pelvic structures.
the stapler through the anterior wall of the rectum, especially if times higher risk for anastomotic leakage than those undergoing
there has been a significant inflammatory response around the elective procedures.30,31 Furthermore, mortality is 13% in patients
area of the Hartmann pouch. presenting with purulent peritonitis and 43% in those presenting
with feculent peritonitis; these figures suggest that performing an
anastomosis in these settings is unwise.14,15,32,33
Complications
As with any anastomosis, the long-established basic technical
Operative management of diverticular disease poses distinct principles—using healthy, uninflamed tissue; ensuring an adequate
challenges, the level of which is proportional to the degree of in- blood supply; and avoiding tension on the anastomosis—should be
flammation present and to the urgency of the procedure.Whereas strictly adhered to. If any of these principles cannot be followed,
many of the complications encountered are not specific to this then either the patient should undergo proximal diversion or (pre-
setting but are common to all abdominal procedures, there are ferably) the problem with the anastomosis should be corrected. For
several that warrant particular attention in the context of surgical instance, in a situation where the sigmoid inflammatory process ex-
treatment of diverticular disease. tends into the rectal mesentery, attempts should be made to resect
below the level of the inflammation, even if the process is reaching
ANASTOMOTIC LEAKAGE
well into the rectum itself. Another technical point worth mention-
The most serious and potentially life-threatening complication of ing involves preserving the superior rectal vessels, though no ran-
procedures for diverticular disease is the development of an anasto- domized, prospective study has yet been performed to determine
motic leak. Many factors contribute to the maintenance of anasto- whether this measure has any significant positive effect.
motic integrity, ranging from the surgeon’s technical ability to the
patient’s comorbidities. Of these factors, however, the single most RECURRENT DISEASE
important one is probably the setting in which the operation is car- It is unusual for a recurrent diverticular fistula to develop after
ried out. Patients undergoing emergency procedures are at four takedown with resection of the involved colon. Much more likely
than the persistence of a diverticular fistula is the development of
a recurrent colovesical or colovaginal fistula secondary to an anas-
tomotic leak with drainage through the point of least resistance
(i.e., the anastomosis).
There is some question as to whether a recurrence of divertic-
ulitis after sigmoid resection is actually a complication of the pro-
cedure. Although it has been shown that resection of all divertic-
ulum-bearing colon is not required for successful treatment of the
disease process, it does appear that the location of any remaining
diverticulosis influences the recurrence of the disease. Studies
have demonstrated that if a sigmoid resection with a colorectal
anastomosis is performed, the recurrence rate is 5%, whereas if
the anastomosis is performed to the distal sigmoid colon, the
recurrence rate rises to 12%.34,35 When recurrent diverticulitis
develops, it is important to reexamine the histologic findings from
the original operation to rule out the possibility that the patient
was misdiagnosed. Occasionally, diverticulosis and Crohn disease
Figure 10 Laparoscopic Hartmann closure. Shown is a laparo- coexist; recurrence of Crohn disease is much more common than
scopic view of the colostomy after intra-abdominal adhesions recurrence of diverticulosis and, given a long enough follow-up
have been divided. period, is actually to be expected.

7. © 2004 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
5 Gastrointestinal Tract and Abdomen 32 Procedures for Diverticular Disease — 7
URETERAL INJURY
follow it down to the inflamed area. If a difficult dissection is antici-
Ureteral injuries occur in as many as 1% of patients undergoing pated or if technical difficulties are encountered intraoperatively,
diverticular resection.36 Because of the inflammatory process asso- ureteral stents may be placed.These stents do not prevent injuries
ciated with severe diverticular disease, it may be difficult to identify from occurring, but they can facilitate early identification of devel-
the ureter as it crosses the bifurcation of the iliac vessels; however, it oping problems. Ureteral injuries should always be repaired at the
is always possible to identify the ureter more proximally and then time of operation, in consultation with the urologist.
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