Perforated sigmoid diverticulitis with peritonitis State of the art surgical treatment

Background: A perforated sigmoid diverticulitis with generalized peritonitis represents an acute and life-threatening situation, which requires emergency surgery. Resection with primary colorectal anastomosis (+/- loop ileostomy), Hartmann's procedure, damage control surgery and laparoscopic lavage and drainage are possible options. Objective: The presented analysis gives an overview of the available surgical strategies, the scientific background and current guideline recommendations. Material and methodsA systematic review of the literature was carried out, with a focus on prospective randomized studies and selected associated meta-analyses. Results and conclusion: The current evidence supports a resection with primary anastomosis both for stage 3 (purulent peritonitis) and stage 4 (fecal peritonitis) according to the Hinchey classification. Laparoscopic lavage was rated negatively in two of three randomized controlled trials (RCT) due to elevated rates of complications and unplanned reinterventions. The methods can be considered as potential options in selected cases and in the presence of purulent peritonitis compared to other procedures. The concept of damage control surgery extends the spectrum of operative possibilities with a two-phase approach, which is characterized by a technically very simple emergency operation, a high rate of colorectal anastomoses at the time of the second intervention and a low stoma rate. This approach is always meaningful when a primary anastomosis is not possible for patient-related or team-related reasons in order to avoid a Hartmann's procedure.