Discussion

Elective laparoscopic colectomy for diverticular disease is at least as safe as conventional surgery because: 1) Morbidity seemed to be lower, and 2) mortality is at least the same. Whether there is a shorter period of postoperative ileus or whether patients experience less pain are also questionable because of a lack of quality of comparative data. The described shorter periods of ileus and postoperative pain in noncom-parative case series are not supportive data favoring laparoscopic over conventional surgery and may only suggest that early feeding accelerates postoperative recovery. Some surgeons may point to the results of RCTs on colorectal cancer (see Chapter 11.5) to support their belief about the superiority of the laparoscopic approach. However, surgery for diverticulitis differs in many aspects from oncologic surgery.

Regarding the role of the laparoscopic technique in emergent situations, i.e., in patients with acute diverticulitis with perforation or abscess, some surgeons advocate the laparoscopic approach.4 They described good results with a relative low proportion of conversions in experienced hands. We advocate caution in adoption of this approach, because proper treatment of perforated diverticular disease with peritonitis is a challenging task even in conventional surgery. Whether it is successfully treated laparoscopically or conventionally is less important than aspiring to achieve a low mortality and morbidity. The appeal of a laparoscopic approach lies in the avoidance of a large abdominal incision, which may become an incredibly morbid feature if infection, dehiscence, or herniation result. However, it should only be considered in highly selected patients without distended bowel and performed by a very experienced team.

Therefore, if enthusiasts of the laparoscopic approach aspire to convince other people that the laparoscopic approach is superior based on sound evidence-based surgical methodology, this must be achieved with convincing data not yet available. Our personal bias favors the laparoscopic colectomy for diverticular disease surgery, but our personal recommendation is based on grade D evidence which, by itself, cannot support that other surgeons must learn laparoscopic surgery.

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Managing Diverticular Disease

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