Surgical Management of Right Colon
Diverticulitis
S. S. Ngoi, M.B.B.S., F.R.C.S., J. Chia, M.B.B.S., F.R.C.S.,
M. Y. Goh, M.B.B.S., F.R.C.S., E. Sim, M.B.B.S., F.R.C.S.,
A. Rauff, M.B.B.S., M.S., F.R.C.S.
From the Department of Surgery, National University Hospital, Singapore, Singapore
The infrequent occurrence of right colon diverticulitis in
the developed West has led to a controversy in the man-
agement of this disease. In Singapore, we continued to
avoid colectomy whenever possible because this disease
is usually nonprogressive. We reviewed 68 patients
treated by conservative surgery to evaluate the effective-
ness of this treatment policy. Almost 70 percent of our
patients were below 40 years of age, and the clinical
presentation was indistinguishable from acute appendi-
citis. Diverticulectomy was done only for inflamed and
perforated diverticula (25 cases), while the nonperfor-
ated diverticulum was left alone (40 cases). The inflam-
mation invariably responded to antibiotic therapy. Only
three patients had colonic resection since a malignant
neoplasm could not be excluded. There were no adverse
sequelae over a mean follow-up period of three and one-
half years, except for one patient who had recurrent
attacks of right colon diverticulitis necessitating colec-
tomy. With this policy of management we encountered
no mortality, and morbidity was acceptable. [Key words:
Right colon diverticulitis; Conservative surgery; diver-
ticulectomy]
Ngoi SS, ChiaJ, Goh MY, Sire E, RauffA. Surgical manage-
ment of right colon diverticulitis. Dis Colon Rectum
1992;35:799-802.
he incidence of diverticular disease in Singa-
T p o r e is increasing as a c o n s e q u e n c e of rapid
u r b a n d e v e l o p m e n t and c h a n g i n g dietary patterns.
A barium e n e m a study a m o n g Singaporean patients
r e c e n t l y r e v e a l e d the i n c i d e n c e of diverticulosis to
b e close to 20 percent, a figure c o m p a r a b l e to that
in the West. Interestingly, there is a u n i q u e predi-
lection for disease to occur in the right colon, a
situation peculiar to the Orient. >4 Consequently,
m o r e cases of right c o l o n diverticulitis are s e e n in
these communities.
The extent of local surgical t r e a t m e n t for right
c o l o n diverticulitis r e m a i n s controversial. Most
w o u l d agree that a mass lesion indistinguishable
f r o m a n e o p l a s m n e e d s resection. H o w e v e r , opin-
Poster presentation at the meeting of The American Society of
Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to
17, 1991.
Address reprint requests to Dr, Ngoi: Department of Surgery,
National University Hospital, 5 Lower Kent Ridge Road, Singa-
pore 0511, Singapore.
799
ions differ w h e n a positive p r e o p e r a t i v e or intra-
operative diagnosis is made. 5-s Based on an earlier
study, w e c o n t i n u e to avoid c o l e c t o m y w h e n e v e r
possible for this nonlethal condition. 9 O u r pre-
ferred m e t h o d of t r e a t m e n t for p e r f o r a t e d i n f l a m e d
diverticula is local excision, c h o o s i n g to leave the
n o n p e r f o r a t e d i n f l a m e d diverticulum alone. We
report our results a c h i e v e d with this conservative
management.
MATERIALS AND METHODS
The records of 68 patients with acute right c o l o n
diverticulitis w h o u n d e r w e n t surgery at the De-
p a r t m e n t of Surgery, National University of Singa-
pore, f r o m January 1981 to January 1990 w e r e
reviewed. From these records, we extracted data
on clinical presentation, physical findings, labora-
tory investigations, surgical p r o c e d u r e s , and even-
tual o u t c o m e .
Preoperative b r o a d - s p e c t r u m antibiotics against
Gram-negative o r g a n i s m s w e r e given to all patients
and c o n t i n u e d for three to s e v e n days after surgery.
All patients u n d e r w e n t surgery on a p r e o p e r a t i v e
diagnosis of acute appendicitis, and the a p p r o a c h
to the a p p e n d i x and cecal region was t h r o u g h a
gridiron incision.
The policy of m a n a g e m e n t in the d e p a r t m e n t
was to p e r f o r m an a p p e n d e c t o m y f o l l o w e d by di-
v e r t i c u l e c t o m y if a p e r f o r a t e d diverticulum was
e n c o u n t e r e d . If the i n f l a m e d diverticulum was not
perforated, it was not resected. In cases w h e r e a
mass was p r e s e n t and could b e dissected f r o m the
i n f l a m e d diverticulum, colonic resection was not
carried out.
RESULTS
T h e r e w e r e 36 m a l e s and 32 f e m a l e s in the study
group. Their ages r a n g e d f r o m 20 to 85 years, with
a m e a n of 37.9 years. The majority of the patients
w e r e u n d e r the age of 40 years (69 p e r c e n t ) .
800 NGOI E T AL Dis Colon Rectum, August 1992

Clinical Features was approached through a gridiron incision, and

this was extended laterally and/or medially when
All 68 patients had right iliac fossa pain or dis-
necessary to gain more access. In 25 patients who
comfort as the main presenting complaint. Tender-
had an inflamed and perforated diverticulum, di-
ness and guarding over the right iliac fossa was
verticulectomy was performed. The pus was aspi-
present on physical examination, and the site of
rated, and the healthy edges of the colon were
maximal tenderness was noted to be lateral to
closed primarily in two layers of interrupted su-
McBurney's point. Fever was present in over half
tures (Fig. 1). tn most cases, the inflamed divertic-
of these patients, but none exceeded 38.5~ A
ulum was surrounded by a mass of inflamed fatty
raised leukocyte count was seen in two-thirds. In
tissue, which could be dissected away. Three pa-
five patients (7.3 percent), a tender mass in the
tients with an inflammatory mass (noted preoper-
right iliac fossa was clearly present at preoperative
atively) needed a right hemicolectomy because the
examination. The duration of symptoms was short,
attending surgeon found it difficult to separate the
with a mean of 2.1 days (range, one to seven days).
inflamed fatty tissue covering from the diverticu-
Preoperative radiologic studies were not per-
lum to determine the nature of the underlying
formed routinely, and endoscopic examination was
lesion and was unable to exclude a malignant tu-
not done. No additional effort was made to distin-
mor (Figs. 2 and 3).
guish acute appendicitis from cecal diverticulitis
The mean duration of hospital stay for the latter
preoperatively (Table 1).
two groups of patients was similar (7.9 days). The
mean duration of hospital stay for patients who
Surgical Procedures
received only appendectomy and antibiotic therapy
The most common procedure was an appendec- was shorter (5.5 days), although not significantly.
tomy with or without drainage depending on the
presence of pus or purulent exudates in the right Morbidity and Mortality
paracolic gutter (40 patients) (Table 2). Surgery
There was no mortality in this study. The overall
Table 1. morbidity rate was 19.1 percent (eight cases), con-
Clinical Characteristics of Patients with Right Colon sisting mainly of wound infection (Table 3).
Diverticuiitis Wound infection was largely subcutaneous and was
Age treated by daily dressing and secondary suture.
Range 20-85 years One patient each developed a cecal fistula and a
Mean 37.9 years
liver abscess. This was from the group of patients
Percent > 40 years 31
Sex distribution who had appendectomy and drainage only. Both
Male/female ratio 36:32 of these complications resolved on conservative
Signs and symptoms treatment without serious sequelae. Complete
Right lilac fossa pain 68/68 (100%) wound dehiscence, anastomotic leakage, intraper-
Right lilac fossa tenderness/ 68/68 (100%)
guarding
Fever 40/68 (58.8%)
Diarrhea 12/68 (17.6%)
Right iliac fossa mass 5/68 (7,3%)
Nausea and vomiting 5/68 (7.3%)
Total white count > 12 x 103 43/68 (63.2%)

Table 2.
Hospital Stay
Mean
Procedures Number Hospital
Stay (days)
Simple appendectomy 40 5.5
_+drainage
Appendectomy 25 7.9
+ diverticulectomy Figure 1. Primary repair after diverticulectomy for an in-
Right hemicolectomy 3 7.9 flamed, perforated cecal diverticulum (arrow).
Vol. 35, No. 8 TREATMENT OF RIGHT COLON DIVERTICULITIS 801

Figure 2. Postoperative specimen showing an inflamma- Figure 3. Close-up view showing the perforated divertic-
tory mass as a result of a perforated diverticulum, which ulum with a track leading to the inflammatory mass. His-
was sealed off by the omentum. This was clinically difficult tology confirmed the presence of a perforated diverticulum
to separate because of dense adhesions. and no malignancy.

Table 3.
Complications
Follow-Up
Number of
Complications Patients The follow-up ranged from 12 months to 6 years,
with a mean of 389 years. During this period, only
Wound infection 8
Liver abscess 1 one patient needed an elective right hemicolec-
Cecal fistula 1 tomy for persistent symptoms of right colon diver-
Others* 3 ticulitis. These consisted mainly of persistent right
Total 13 (19.1%) iliac fossa pain, which interfered with his work.
* Includes one patient with gastric stress ulcers and two There was complete relief of symptoms after the
patients with incisional hernia. surgery. The remaining 64 patients (i. e., excluding
those who had an emergency right hemicolec-
itoneal abscess, enteric fistulations, prolonged par- tomy) were asymptomatic at the time of this report.
alytic ileus, and ileal obstruction were not encoun-
tered. In one patient, upper gastrointestinal bleed- DISCUSSION
ing from stress ulcers occurred. This responded to Experience with right colon diverticulitis in the
conservative treatment. Two patients developed developed West is scarce, and thus surgical man-
incisional hernia over the gridiron incision a few agement policies are still controversial. 5-8 The
years later and required surgical repair. complications of right colon diverticulosis such as
802 NGOI E T AL
b l e e d i n g and inflammation are infrequent occur-
rences, unlike those of left-sided disease. 1~ The
treatment for left-sided diverticular disease centers
a r o u n d surgical resection, while right-sided lesions
can be more conservatively managed. It has b e e n
our practice to perform diverticulectomy only for
perforated diverticula and to repair the defect pri-
marily. In these y o u n g patients we have tried to
avoid a major colectomy. A right c o l e c t o m y was
carried out w h e n the possibility of a n e o p l a s m
could not be excluded. Of five cases with a t e n d e r
mass n o t e d preoperatively, in only two patients
were we able to separate the inflamed fat to reveal
the perforated diverticulum. In the inflamed non-
perforated diverticulum (40 cases), no further ther-
apy b e y o n d simple drainage of purulent fluid was
done. The inflammation will invariably settle with
antibiotic treatment. Supplemental a p p e n d e c t o m y
is r e c o m m e n d e d to avoid confusion with appen-
dicitis if s u b s e q u e n t attacks occur.
It was very difficult in our series to make a correct
preoperative diagnosis of right c o l o n diverticulitis.
This is because the clinical presentation of this
disease is very similar to that of acute appendicitis.
In several r e p o r t e d series, the rate of correct diag-
nosis varies from 0 p e r c e n t to 24 percent. 5'8-12 Many
authors have suggested that, in patients with right
colon diverticulitis, the duration of symptoms was
longer, nausea and vomiting o c c u r r e d less fre-
quently, and the site of t e n d e r n e s s was lateral to
McBurney's point, s'1~ Furthermore, the infre-
quent o c c u r r e n c e of right colon diverticulitis com-
pared with acute appendicitis and the conse-
q u e n c e s of a higher morbidity from perforated
appendicitis have swayed surgical policy toward
intervention rather than conservative treatment.
With the advent of video laparoscopy, differentia-
tion of these two conditions is n o w facilitated. It
will certainly change the course of s u b s e q u e n t
surgical management. ~3
Our results s h o w that, in the vast majority of
patients with right c o l o n diverticulitis, simple
drainage and diverticulectomy for perforated di-
verticula have resulted in no mortality, minimal
postoperative morbidity, and a short hospital stay.
This disease is usually nonprogressive, unlike left
Dis Colon Rectum, August 1992
c o l o n diverticulitis. Differentiation from cancer of
the right colon is not difficult in the majority of
cases. Colonic resection may b e c o m e necessary in
a few selected patients w h o continue to suffer
r e p e a t e d attacks of right iliac fossa pain and in
those in w h o m malignancy cannot be ruled out
satisfactorily.
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