Diverticulitis, characterized by the inflammation of diverticula in the colon, has been a focal point in gastrointestinal research and surgical innovation. Recent advancements in surgical interventions reflect a paradigm shift towards less invasive techniques and individualized management strategies, which have significantly improved patient outcomes. The introduction of laparoscopic approaches for both diagnosis and treatment of complicated diverticulitis has demonstrated shorter hospital stays. Still, the choice of required surgery should not be influenced by the mode of access, whether laparoscopic or open [1]. Laparoscopic resection and anastomosis may be preferred in uncomplicated sigmoid diverticulitis requiring surgery [1]. For diverticulitis cases complicated by abscess, the emergence of percutaneous drainage of abscesses has allowed for a more conservative initial treatment, often facilitating a one-stage resection and anastomosis [2]. Research highlights the importance of customizing treatment plans for diverticulitis, indicating that many uncomplicated cases can be managed without hospitalization or antibiotics. As the medical field continues to examine the advantages of laparoscopic and robotic-assisted surgeries, the primary emphasis is placed on enhancing recovery times and reducing complications. This focus ultimately aims to improve patients’ quality of life.

Recent advances in the surgical management of diverticulitis have significantly improved patient outcomes and treatment strategies. One notable development is the laparoscopic approach, which has been introduced for the diagnosis and definitive treatment of uncomplicated diverticulitis [3]. Laparoscopic surgery offers several advantages over open surgery across various fields, including reduced blood loss during the procedure, shorter duration of the operation, a quicker recovery time in the hospital, and a decreased rate of postoperative complications [4]. Surgical outcomes remain the same between the laparoscopy and open groups [5]. The percutaneous drainage of the diverticulitis abscesses permits a less invasive therapeutic approach before definitive surgery and reduces the risk of a permanent stoma [2, 6]. After the successful drainage, a semi-elective resection is frequently conducted, while in some high-risk and limited disease cases, drainage alone may be therapeutic [6, 7]. Additionally, resection surgery has been identified as the optimal management for acutely complicated diverticular disease, demonstrating significant benefits such as reduced mortality, shorter hospital stays, and lower wound infection rates [8]. Overall, diverticulitis management now trends towards more effective, less invasive surgical options that improve recovery and reduce complications in patients suffering from diverticulitis.

Recent studies have indicated that many patients with uncomplicated diverticulitis can achieve favourable outcomes through conservative measures such as dietary modifications and symptom management without surgical intervention [9]. Advances in computed tomography (CT) reporting have facilitated better stratification of patients, allowing for tailored interventions based on individual risk profiles [10]. Colonic wall thickness > 15 mm and peridiverucular inflammation of grade 4 are significant predictive factors for recurrence and requirement of surgical interventions [11, 12]. Peridiverticular inflammation grade 4 has more chances of recurrence, while grades 1 and 2 have less, and colonic wall thickness of 18.5 mm is indicative of chances of recurrence within 90 days (Tables 1 and 2) [11, 12]. Along with imaging, C-reactive protein (CRP) is also advised to be included in laboratory evaluation, with CRP > 50 having prognostic value [13]. These findings, along with clinical parameters, help in identifying patients requiring surgical intervention.

Percutaneous drainage of diverticular abscess is a minimally invasive procedure that has become an essential component in managing complicated diverticulitis [14]. This technique involves the insertion of a catheter through the skin to drain the abscess. Ideal candidates typically present with a well-defined abscess that is accessible via imaging studies, such as ultrasound or CT scans. Hemodynamically stable patients, without signs of systemic infection or perforation, are preferred. Successful drainage can lead to significant symptom relief and may allow for conservative management of diverticulitis [13, 15]. Most guidelines suggest thresholds for percutaneous drainage of 3 cm [15].

Minimally invasive surgical (MIS) techniques for diverticulitis management have gained prominence due to their potential benefits over open surgery [16]. These techniques, including laparoscopic surgery, offer advantages such as reduced blood loss, less postoperative pain, and shorter hospital stays [16, 17]. While some studies reported improvement in mortality, others did not [16, 17]. Cochrane review concludes that evidence to support or refute laparoscopy over open is insufficient [18]. With advances in surgical techniques, MIS techniques are now well established in advanced colorectal surgery for malignant cases. Similarly, they are gaining evidence and acceptance in instances of complicated diverticulitis [19]. Robotic surgery has also shown fewer morbidity and shorter hospital stay with longer operative time and increased cost compared to laparoscopic and open approaches [20]. Patient selection for these procedures is crucial and depends on the severity of the disease, the patient’s overall health, and the presence of complications [21].

The management of complicated diverticulitis has evolved with advancements in surgical techniques, offering a range of options from traditional open surgeries to modern minimally invasive approaches. Traditional surgical approaches include mainly:

Open colectomy: Historically, open colectomy has been a standard treatment for complicated diverticulitis, especially in cases involving perforation and peritonitis. It is often recommended for critically ill patients with multiple comorbidities, where the Hartmann procedure is preferred due to its safety in unstable conditions [1, 31, 32].

Modern surgical options focus on early recovery, smaller incisions, and quicker healing while maintaining effective treatment outcomes.

Primary anastomosis vs. Hartmann procedure: Primary anastomosis is favoured in stable patients as it avoids the need for a permanent stoma, which is often associated with the Hartmann procedure (Figure 2). Studies have shown that primary anastomosis can be safely performed in selected patients with perforated diverticulitis, with low rates of anastomotic leaks [21].

While primary anastomosis with or without diversion stoma is increasingly preferred in suitable patients, the Hartmann procedure remains a viable option for those with severe comorbidities or hemodynamic instability [21].

Perforation and peritonitis: Surgery is often necessary for patients with perforation and generalized peritonitis. Options include resection with primary anastomosis or Hartmann’s procedure, depending on the patient’s stability and the extent of contamination [21, 27].

The future directions in diverticulitis surgery research are shaped by evolving understandings of the disease’s natural history and the effectiveness of less invasive management strategies.

The landscape of surgical interventions for diverticulitis is shifting towards more effective, less invasive techniques that enhance patient recovery and quality of life. Minimally invasive strategies, like percutaneous drainage for abscesses, allow for a conservative approach in complicated cases while ensuring timely surgeries when needed. Minimally invasive strategies, like percutaneous drainage for abscesses, allow for a conservative approach in complicated cases while ensuring timely surgeries when required. Advancements in laparoscopic and robotic-assisted surgeries have led to improved outcomes, including reduced morbidity and shorter hospital stays. The focus on individualized treatment plans, guided by advanced imaging and patient risk stratification, highlights the importance of tailoring management to each patient’s needs. Ongoing research is crucial for refining techniques, establishing protocols, and understanding the long-term effects of non-operative management and minimally invasive approaches, promising better patient outcomes and satisfaction in diverticulitis treatment.