The research team, led by authors including Yudai Fukui, Koya Hida, Marie Hanaoka, and Yusuke Kinugasa, screened 438 records and ultimately synthesized 29 studies, comprising 20 observational investigations, four reports from randomized trials, and five systematic reviews or meta-analyses. Rather than pooling heterogeneous data into a single meta-analysis, which the authors argue would obscure clinically meaningful differences, they stratified the evidence by clinical setting, operative strategy, and patient risk profile. This framework allowed them to separate the true effects of the surgical approach itself from the powerful influence of patient selection, disease severity, and institutional expertise, factors that have long muddied comparisons between the two techniques.

The strongest evidence comes from the elective setting, where patients undergo planned sigmoid resection after recurrent episodes of diverticulitis. Randomized trials, including the landmark Dutch Sigma trial of 104 patients, demonstrated that laparoscopic sigmoidectomy reduced major morbidity, lessened early postoperative pain, shortened hospitalization, and sped recovery compared with open surgery. A Cochrane review of three randomized trials involving 392 patients confirmed that laparoscopy may reduce pain, though with low certainty and a notable trade-off: operative times ran nearly 50 minutes longer on average. Yet the review also highlights a sobering caveat. Mid- and long-term follow-up studies from these same trials found no clear differences in mortality, gastrointestinal function, or quality of life, and economic analyses from the Sigma trial showed that higher operative costs for laparoscopy were offset only to the point of comparable overall healthcare spending, not savings.

Large real-world database studies reinforce the short-term picture. Analyses of more than 124,000 elective colectomies in the Nationwide Inpatient Sample and nearly 7,700 cases in the American College of Surgeons NSQIP registry found lower postoperative morbidity, fewer wound complications, shorter hospital stays, and lower hospital charges with laparoscopy. For complicated diverticulitis specifically, a cohort of nearly 12,000 patients showed that the morbidity advantage was most pronounced among those receiving primary anastomosis. These observational findings are impressively consistent, but the authors caution that residual confounding by indication, the tendency to offer keyhole surgery to fitter patients with less severe disease, remains an unavoidable limitation of nonrandomized data.

The emergency setting is where the review delivers its most striking and clinically consequential findings. In one large NSQIP analysis of 9,194 emergent colectomies for diverticulitis, minimally invasive surgery was associated with significantly fewer major adverse events, 42.0 percent versus 56.4 percent, an adjusted odds ratio of 0.56, along with lower 30-day mortality of 4.1 percent versus 8.8 percent, dramatically lower ostomy formation at 35.8 percent versus 84.8 percent, fewer ileus cases, and shorter hospital stays of a median 7 versus 9 days. In selected cohorts, even operations that began laparoscopically and converted to open surgery were not associated with worse outcomes than planned open procedures, challenging the long-held assumption that conversion signals failure. Hospital volume emerged as a key modifier, with higher minimally invasive surgical volumes linked to lower conversion rates.

For perforated diverticulitis, the review’s most technically detailed domain, outcomes depended sharply on which operation was performed. In a propensity score-matched cohort of patients with purulent or fecal peritonitis, laparoscopic sigmoidectomy achieved lower overall morbidity of 44 percent versus 66 percent, shorter hospitalization of 7 versus 9 days, far fewer wound infections at 3 percent versus 29 percent, and a higher 12-month probability of being stoma-free among Hartmann procedure patients, 0.88 versus 0.64. By contrast, laparoscopic Hartmann procedures showed only limited advantages, chiefly reduced superficial surgical site infections, without consistent reductions in mortality or major complications. Most provocatively, the review concluded that laparoscopic lavage and drainage, a strategy of washing out the abdomen without removing the diseased segment, cannot be considered equivalent to laparoscopic resection, with comparative evidence suggesting lavage-based approaches may carry more frequent severe complications than open resection.

High-risk populations received special attention, and here the observational associations were among the most favorable. In cirrhotic patients undergoing colectomy for acute diverticulitis, laparoscopy was linked to lower mortality, shorter stays, and reduced costs. Among patients with respiratory comorbidities, hospital stays were dramatically shorter with laparoscopy, 5.3 versus 9.5 days in smokers, 6.8 versus 11.1 days in patients with dyspnea, and 7.4 versus 12.6 days in those with chronic obstructive pulmonary disease. In elderly patients, laparoscopic surgery reduced 30-day morbidity in both elective and non-elective settings, with odds ratios of 0.47 and 0.76 respectively, alongside fewer surgical site infections and shorter admissions. The authors repeatedly stress, however, that preferential selection of physiologically fitter patients for keyhole surgery may substantially inflate these apparent benefits.

Procedure-specific findings extended the favorable pattern to fistulizing disease and right-sided diverticulitis. A meta-analysis of diverticular colovesical fistulas, where the inflamed colon has eroded into the bladder, found fewer total postoperative complications with laparoscopy, an odds ratio of 0.55, and hospital stays nearly three days shorter, while mortality, anastomotic leak, and stoma rates remained comparable. A multicenter German study of fistulizing recurrent diverticulitis confirmed faster bowel recovery and shorter intensive care stays. For right-sided disease, a less common variant typically managed differently from sigmoid diverticulitis, NSQIP data showed comparable morbidity with shorter hospitalization after minimally invasive resection, and small comparative studies supported feasibility in selected complicated cases.

On the intraoperative front, the review found less to celebrate. Laparoscopic surgery consistently required longer operative time, with a matched perforated-disease cohort showing 127 versus 96.5 minutes, and while blood loss appeared numerically lower in several studies, evidence that laparoscopy reduces intraoperative complications remains insufficient. Questions about ureteral injury, a feared complication in inflamed diverticular fields, could not be answered definitively, though the authors note that fluorescence-guided ureter visualization techniques are attracting growing interest even as their protective value remains unproven.

The review’s ultimate contribution is a decision-making framework rather than a verdict. Laparoscopy offers its clearest and best-supported benefits in elective surgery, meaningful promise in selected emergency resections, perforated disease treated with resection rather than lavage, high-risk patients, fistulizing disease, and right-sided cases, while its role in Hartmann procedures and lavage-based strategies is far more uncertain. The authors emphasize that in emergency surgery, rapid and reliable source control of infection must take priority over completing a minimally invasive procedure, and that conversion to open surgery should be regarded as an appropriate safety decision rather than a technical failure. They also acknowledge their study’s limitations, including the absence of a formal risk-of-bias assessment, the exclusion of robotic surgery, and the reality that observational findings represent associations rather than causal proof. The choice of surgical approach, they conclude, should be driven not by technique alone but by the interplay of disease severity, patient condition, operative strategy, and institutional expertise, a conclusion that reframes the laparoscopic-versus-open debate as a question of matching the right operation to the right patient rather than crowning a single winner.

Subject of Research: Comparative outcomes of laparoscopic versus open surgery for colonic diverticular disease across elective, emergency, perforated, and high-risk clinical settings

Article Title: Laparoscopic Versus Open Surgery for Diverticular Disease: A Structured Review Across Clinical Settings and Operative Strategies

Article References: Hanaoka, M., Fukui, Y., Hida, K., Takeuchi, H., & Kinugasa, Y. (2026). Laparoscopic Versus Open Surgery for Diverticular Disease: A Structured Review Across Clinical Settings and Operative Strategies. Annals of Gastroenterological Surgery, Article ags3.70285. https://doi.org/10.1002/ags3.70285

Image Credits: AI Generated

DOI: 10.1002/ags3.70285

Keywords: diverticular disease, diverticulitis, laparoscopic surgery, open surgery, colectomy, sigmoidectomy, Hartmann procedure, laparoscopic lavage, emergency surgery, perforated diverticulitis, stoma creation, surgical outcomes