Diverticulitis occurs when small, bulging pouches, called diverticula, in the lining of the colon become inflamed or infected. When medical management fails or a complication develops, surgery is often necessary to remove the diseased section of the large intestine. The goal is to eliminate the source of infection and prevent its recurrence. Whether this surgery results in a colostomy—the creation of an opening in the abdomen to divert waste into an external bag—depends entirely on the circumstances and the type of operation performed. A colostomy is not the standard outcome for elective surgery, but it is necessary during emergency, life-threatening situations.
Surgical Procedures for Diverticulitis
The specific surgical procedure chosen dictates whether a colostomy will be required immediately following the operation. The approach is determined by the severity of the disease and whether the procedure is performed electively or as an emergency. The most common procedure for planned, elective surgery is a bowel resection with primary anastomosis. This operation involves removing the diseased segment of the colon and immediately reconnecting the two healthy ends of the bowel together.
Intestinal continuity is restored when the colon is reconnected, meaning the patient does not require a stoma or a colostomy bag. This procedure is typically reserved for stable patients undergoing surgery to prevent future flare-ups. It is generally performed in a clean surgical field, allowing the surgeon to safely sew or staple the two ends of the colon together.
In contrast, an emergency operation for an acute, complicated flare-up often requires a different approach, commonly known as a Hartmann’s procedure. This involves removing the infected colon but leaving the remaining lower portion of the rectum temporarily closed. The upper, healthy end of the colon is brought through an opening in the abdominal wall, forming a stoma. Waste empties into a colostomy bag attached to this stoma, diverting the fecal stream away from the surgical site because immediate reconnection is too risky under emergency conditions.
Conditions That Require a Colostomy
A colostomy is most frequently required when the emergency nature of the disease makes immediate reconnection of the bowel unsafe. The primary concern is the risk of an anastomotic leak, which occurs if the newly connected ends of the colon fail to heal and leak intestinal contents into the abdominal cavity. This complication can be life-threatening.
One serious condition necessitating a colostomy is a bowel perforation, where the infected diverticulum has ruptured and allowed stool to leak into the peritoneum. This causes a widespread infection known as generalized peritonitis, which can rapidly lead to septic shock. In these contaminated and inflammatory conditions, tissues are swollen and fragile, making a successful anastomosis nearly impossible. Diverting the fecal stream allows the abdominal cavity to be cleaned and the surgical site to heal without further contamination.
Severe abscess formation or a patient’s unstable health status are also factors leading to the decision for diversion. Patients who are immunocompromised, on high-dose steroids, or suffering from septic shock are less likely to heal well. A surgeon will choose the safer option of a temporary colostomy to stabilize the patient, control the infection, and allow the body time to recover. The colostomy acts as a protective mechanism, shielding the internal operative area from the pressure and passage of stool during the healing phase.
Temporary Versus Permanent Diversion
The colostomy created during emergency diverticulitis surgery is most often intended to be a temporary solution. Its purpose is to allow the patient to recover fully from the acute infection and for the remaining colon to heal completely. After the patient has recovered, a second operation is typically planned to reverse the colostomy and restore intestinal continuity.
The reversal surgery usually takes place several months after the initial operation, commonly within three to six months. Before the reversal, the surgeon confirms that the patient is medically stable and that all inflammation and infection have resolved. This second procedure involves reconnecting the colon and rectum and closing the stoma. The goal is to return the patient to a life without the need for an external appliance.
However, a colostomy may become permanent in certain situations, though this is less common than temporary diversion. If the patient has significant pre-existing health conditions, such as severe heart or lung disease, the risk of a second major surgery for reversal may be considered too high. Additionally, if the anatomy is complex due to extensive disease or scar tissue, reversal may not be surgically feasible. In these cases, the permanent colostomy offers the best long-term quality of life by avoiding the dangers associated with another complex procedure.