Laparoscopy and resection with primary anastomosis for perforated diverticulitis: challenging old dogmas

Diverticulitis is a common disease in western countries, and its incidence is likely expected to increase over years. The burden of diverticular disease on health systems and resources utilization cannot be underestimated, given the high prevalence of diverticulosis and the rate of patients requiring hospitalization and/or surgery. Minimally invasive colorectal surgery can guarantee several benefits over traditional open surgery, even more prominently in the emergency settings. However, there is moderate to low agreement regarding the use of a minimally invasive approach in patients with perforated diverticular disease (Hinchey III/IV), as well as primary anastomosis is still feared too risky versus end colostomy. Over the last years, evidence has been growing that laparoscopy can reduce the magnitude of surgical injury, and last but not least, cause less adhesions and/or incisional hernias, and lead to easier subsequent surgeries. The recently published results from the DIVA arm of the Ladies trial showed that 12-month stoma-free survival was significantly better for patients randomized to primary anastomosis compared with patients who received Hartmann's procedure, without differences in short-term morbidity and mortality after index resection. Moreover, several recent studies showed that laparoscopic sigmoidectomy in the treatment of Hinchey III-IV diverticulitis is feasible in haemodynamically stable patients. Taken together, these findings suggest that laparoscopic sigmoidectomy is at least feasible and safe in this challenging subgroup of patients. However, patient selection and additional factors, including surgeon expertise and hospital resources, are crucial and need careful consideration.