Surgical Treatment of Hinchey III Diverculitis

Surgical treatment of Hinchey III diverticulitis is still controversial, with debate between the proponents of laparoscopic lavage and those proponents of sigmoid resection. In this latter group there is debate between the laparoscopic and open approaches and between anastomosis and colostomy. Laparoscopy may be challenging in the setting of acute inflammation but allows peritoneal lavage, drainage of abscesses and bowel resection, offering enhanced patient recovery and reduced morbidity.

A recent meta-analysis of 3 randomized controlled trials comparing laparoscopic lavage versus surgical resection concludes that laparoscopic lavage is associated with reduced operating time, shortened postoperative stay and a lower surgical reintervention rate at 12 months. By contrast, postoperative mortality rate at the index operation and 90 postoperative days, surgical reintervention during the index hospitalization and at 90 days, and Clavien-Dindo grade I-III complications favoured emergency sigmoid resection although they did not achieve statistical significance.

Laparoscopic lavage was associated with a significant increase in postoperative intra-abdominal abscess formation within 90 days, which may explain the higher unplanned reintervention rate in the laparoscopic lavage group. Laparoscopic lavage is non-inferior to sigmoid resection although in this group of patients may be necessary an increased number of late procedures related to ongoing sepsis, mainly due to intra-abdominal abscess. Patients undergoing these unplanned procedures may be exposed to increased morbidity.

The video presents the case of a patient with acute diverticulitis Hinchey III who was initially treated with laparoscopic lavage and had persistent sepsis. 3 days after the index surgery, a laparoscopic sigmoidectomy with colostomy was performed. After the unplanned procedure the patient had a normal postoperative course with discharge in the 5th postoperative day.

Surgical treatment of Hinchey III acute diverticulitis is still controversial. Laparoscopic lavage seems a useful tool in selected patients but it may be associated with an increased need for unplanned procedures that may increase morbidity.