Will I need surgery?

Surgery is performed only in certain situations and may be done either as an emergency or as an elective procedure. The surgery may be open or done laparoscopically (keyhole), which requires a smaller cut, causes less postoperative pain and allows for a quicker recovery time. The surgeon looking after you will be able to give you more information a bout the surgery planned for you and its risks.

Indications for surgery

Emergency

• Severe bleeding of a diverticulum that cannot be controlled by other treatments
• Drainage of a large abscess not settling conservatively with a percutaneous drain
• Complete bowel obstruction to remove the affected colon
• Perforation of the colon with peritonitis.

Elective

• Patients with recurrent episodes of diverticulitis may be advised to have the affected colon removed because the risk of complications increases with each episode, and to improve quality of life. This is controversial because some advocate a sigmoid resection after two attacks, whereas others suggest that any decision to proceed should be on a case-by-case basis and not related to the number of presentations.
• Removal of a fistula and the affected colon.
• Partial bowel obstruction that fails to resolve.

Absolute indications for surgery

•     Perforation

•     Peritonitis

•     Stenosis causing bowel obstruction

•     Unsuccessful abscess drainage

•     Colovesical fistula

•     Persistent bleeding

•     Failure to respond to conservative management

•     Suspicion of colorectal cancer.

Relative indications for surgery

•     Recurrent diverticulitis

•     After a first attack if aged less than 40 years or immunosuppressed

•     After a first recurrence

•     Persistent symptoms despite treatment

•     Recurrent bleeding

•     Persistent urinary symptoms

•     Fistula.

Types of surgery in diverticulitis

Surgery is performed under a general anaesthetic. You will not be allowed to having anything to eat or drink before surgery and will be given fluids via an intravenous drip. You will probably have a urinary catheter to monitor your urine output and hydration status. Painkillers can still be given as an injection. You will be attached to a monitor to keep an eye on your heart rate, blood pressure and oxygen levels.

Once you are under anaesthetic, the surgeon will clean your skin and make an incision in the necessary area. The affected, inflamed bowel, which is often stuck to the lining of the abdomen, will need to be freed and the abdominal cavity may be washed out. After surgery you may be taken to a general surgical ward or, in certain cases, the high dependency or intensive care unit for close monitoring until your condition stabilises.

Complications of diverticulitis

• Open sigmoid resection: high postoperative complication rate and a mortality rate of two to five per cent
• Laparoscopic sigmoid resection: reduces pain and reduces hospital stay; improves quality of life; smaller scar. This is a highly skilled procedure and may compound what is already complex surgery. As a result it is has not been widely adopted as the standard technique for this condition.

Acutely in generalised peritonitis situation

•     Hartmann’s procedure or sigmoid resection and primary anastomosis plus or minus a temporary stoma

•     Laparoscopic resection (reduces morbidity and mortality).

Primary bowel resection

In this type of surgery the affected bowel is removed and the two healthy end pieces are either sewn or stapled together. This is called an anastomosis, and is ideal if the patient’s overall condition allows it and the surgeon is confident that there is no residual inflammation or infection that might compromise the anastomosis. A defunctioning transverse colostomy may be necessary at the same time to protect the anastomosis, and this can be closed in a two-stage procedure six to eight weeks later.

Bowel resection with colostomy

In this type of surgery the affected bowel is removed. Rather than joining the two healthy ends back together, one end opening is brought to the skin surface. This is called a stoma. A bag (colostomy bag) is then attached to the end of the opening outside the body. Stool can then be collected and emptied on a regular basis. The other end (rectal stump) is closed off and left inside the abdomen. This procedure is known as a Hartmann’s procedure and allows time for healing of the inflamed bowel. The colostomy is often temporary and second stage surgery can be performed months later to reverse the colostomy, for example to rejoin the two ends of bowel and close the stoma site. However, in severe cases this may not possible and the colostomy will be permanent. A Hartmann’s resection is used less frequently these days because the reversal procedure is complex with a high morbidity and mortality.