- JEFFREY L. COHEN, MD, FACS, FASCRS
- JOHN P. WELCH, MD, FACS
Diverticula are small (0.5 to 1.0 cm in diameter) outpouchings of the colon that occur in rows at sites of vascular penetration between the single mesenteric taenia and one of the antimesenteric taeniae. The sigmoid colon is the most common site and is involved in 90% of patients with diverticulosis. If a diverticulum becomes inflamed as a result of obstruction by feces or hardened mucus or of mucosal erosion, a localized perforation (microperforation) may occur—a process known as diverticulitis Both diverticulosis and variants of diverticulitis may be subsumed under the more encompassing term diverticular disease. This review describes the increasing incidence of diverticula, citing age and diet with this increase; the symptoms of both uncomplicated (simple) and complicated diverticulitis; and the expected findings on physical examination. Computed tomographic (CT) scan with oral and rectal contrast is offered as the most useful diagnostic imaging tool. Management is discussed and can include both medical treatment and surgical resection (open or laparoscopic). Special types of diverticulitis are discussed, including cecal diverticulitis, diverticulitis in young patients, diverticulitis in immunocompromised patients, atypical presentations (involving multiple organ systems), giant diverticula, recurrent diverticulitis after resection, and subacute and atypical diverticulitis. Preoperative evaluation, operative planning, emergency procedures, and complications are detailed. Tables describe the differential diagnoses of uncomplicated diverticulitis, advantages of minimally invasive procedures, necessary conditions for diverticulectomy in patients with cecal diverticulitis, the unusual extra-abdominal presentations of diverticulitis, and differential diagnoses of recurrent diverticulitis. Figures show a colon segment containing diverticula, segmentation in the colon, napkin ring carcinoma, major complications of diverticular disease in the sigmoid colon, the Hinchey classification, various CT scans of diverticulitis, extravasation images, a colonoscopic view of sigmoid diverticula, treatment options for complicated diverticulitis, a high-grade retrograde obstruction, proposed classification of pathologic types of cecal diverticulitis, perforated diverticulitis, a giant sigmoid diverticulum, trends in operative techniques, the Hartmann procedure, on-table colonic lavage, laparoscopic sigmoid resection, hand-assisted laparoscopic resection, and laparoscopic Hartmann closure. Videos include lateral medial mobilization of the sigmoid colon, hand-assisted division of the superior rectum and division of the rectosigmoid mesentery, and creation of colorectal anastomosis.
This review contains 30 figures, 5 tables, 3 videos, and 232 references.