elective laparoscopic surgery of the colon has been widely reported . following the controversy surrounding laparoscopic surgery for colorectal cancers after anecdotal reports of port site recurrences , chronic diverticulitis remained a mainstream indication for laparoscopic surgery . as the acute gallbladder was initially considered a relative contraindication to laparoscopic surgery , so it has been with minimally invasive colon surgery , there being very few reports of applying a laparoscopic approach to the acute inflammatory complications of diverticulitis . in recent years , the standard surgical approach to acute sigmoid diverticulitis has changed . originally a three - stage procedure , a two - stage or even single - stage approach to the unprepped inflamed bowel for resection and reanastomosis is now much more commonly seen . since 1995 , we have managed patients requiring emergent or urgent surgical intervention for acute diverticulitis with a minimally invasive approach . this series reports the results of sixteen patients operated upon for the indications outlined ( table 2 ) excluding those who had surgery for hemorrhagic complications of diverticular disease . sixteen patients underwent seventeen procedures ( hinchey classification i:10 , ii:6 , iii:1 , iv:0 ) . the indications were acute nonhemorrhagic complications of sigmoid diverticulitis ( table 2 ) . on presentation , patients were assessed by computed tomography for any evidence of abscess or perforation . those with a free perforation were taken to surgery . if an abscess was identified , it was , when amenable , drained by radiologically - guided percutaneous techniques with the patient later undergoing interval laparoscopic one - stage resection . barring these findings , patients were treated with parenteral antibiotics while their clinical , laboratory , and radiologic signs were followed . if all these acute criteria resolved within 48 to 72 hours , the patient underwent water - soluble contrast enema examination prior to advancement of their diet and discharge to outpatient follow - up on oral antibiotics . those failing to improve within this time frame underwent similar studies to rule out an occult perforation and were considered for surgery . in this group , fourteen patients underwent fifteen procedures , all under general anesthesia and all procedures initiated laparoscopically . the approach to the peritoneal cavity was , in all , by the open , hasson , technique . three of the four were 5 mm in size with the fourth , in the right lower quadrant , being a 12-mm port . following tran - section at the peritoneal reflection with a linear cutting endoscopic stapler distal to the diseased segment , the sigmoid colon was exteriorized through a left lower quadrant mini - laparotomy incision at the trocar site . transection at the peritoneal reflection assured the complete removal of the distal - most portion of diverticular - bearing colon . the diseased segment was then transected from the proximal bowel and the stump either converted to an end colostomy ( hartmann ) at that location or replaced within the peritoneal cavity following measurement for and placement of the anvil of a circular stapling device . the fascia was then closed , pneumoperitoneum reestablished and , under direct vision a low anastomosis created with transrectal placement of the stapling device . all anastomoses were leak tested under sterile instilled saline and insufflation with air by a sterile rigid proctoscope . three of the fifteen cases were converted to an open approach , two with pfannenstiel incisions and one with a midline incision . the indication for conversion was , in all three , the inability to delineate a safe dissection plane between the colon , the abscess , and the urinary bladder . of the seventeen procedures ( table 3 ) , three involved colovesical fistulas , and patients had to be converted to the open approach . no deaths occurred , but one major case of morbidity did occur , a deep venous thrombosis that presented following the patient 's discharge . this was managed with a greenfield ( ivc ) filter to allow for the planned reanastomosis in this two - stage procedure . the patient with the 45-day stay who was morbidly obese had been operated upon for the preoperative indication of perforated diverticulitis into the abdominal wall resulting in a necrotizing fasciitis requiring twice daily packing changes in the intensive care unit ( icu ) for over a month , the patient eventually making a full recovery . the average postoperative length of stay was 7.2 days , 4.6 days excluding the single outlier , with a median of 3.5 days . these approaches have ranged from laparoscopic peritoneal lavage in diffuse peritonitis with a sealed perforation6 in eight patients to a variety of surgical procedures including resection as well as lavage in 39 patients   ( selected from a larger series of 164 patients to match the presenting pathology described herein ) and standard resections , laparoscopically performed in eighteen . no evidence existed of septic complications secondary to a pneumoperitoneum and gross purulent infection ; indeed , no wound complications occurred in these patients and the majority of patients had a shorter postoperative length of stay than that of patients in reported series of open surgery . the two patients with colovesical fistulas converted to a pfannenstiel incision had a shorter recovery period ( 3 , 4 days ) than the single patient converted to a midline incision ( 11 days ) . in franklin 's series , colovesical fistula was successfully addressed laparoscopically and , with additional experience , and a certain degree of comfort with laparoscopic closure of potential vesicle enterotomies , it may be in our future cases as well . when doubt exists regarding tissue planes , however , conversion to a laparotomy remains a safe course of action and , with a low transverse incision , can preserve some of the benefits of the minimally invasive approach . although not used at our institution at the time of this series , the technique of hand - assisted laparoscopic surgery via a sleeve may be useful in performing the most difficult part of the dissection without sacrificing the demonstrated benefits of the minimally invasive approach . with adequate experience in minimally invasive colon surgery , surgeons can use minimally invasive techniques in the majority of patients with complex diverticulitis . either patients can be drained and downstaged for later interval resection , or , if necessary , approached directly by laparoscopic surgery with minimal morbidity . besides the benefit of a quicker recovery , the risks of later morbidity , such as incisional hernias in infected incisions , is minimized .
from march 1995 through march 2000 , we treated patients with the laparoscopic approach who had emergent and urgent indications for surgery . 
 we report a series of 17 procedures in 16 patients in the acute category excluding those with active bleeding . 
 one case of morbidity ( dvt ) but no moralities occurred , with 3 of 17 patients converted to an open approach . 
 the postoperative course and subsequent recoveries compare favorably with the open approach to this disease process . 
 three other series are discussed for comparison , all showing similar favorable results . we concluded that given sufficient experience in minimally invasive colon surgery , surgeons can manage acute inflammatory complications of sigmoid diverticulitis laparoscopically with potential benefit to the patient .