Laparoscopic peritoneal lavage for generalized peritonitis due to perforated diverticulitis (Br J Surg 2008; 95: 97–101)

Sir It is not often that a publication has the potential to radically change practice, and Myers and colleagues are to be congratulated on this remarkable study. Previous reports on small case series of laparoscopic management of acute diverticulitis have with one exception1 lacked a denominator, i.e. the total number of patients admitted with diverticulitis, and in some cases have deliberately excluded patients with generalised and faecal peritonitis who are the only group likely to benefit from early surgery. This has bolstered the suspicion that these studies report patients who may have settled without any operative intervention. This paper seems to show that laparoscopic lavage will reduce even further the number patients subjected to laparotomy and sigmoid resection. There are, however, a few omissions which detract from this manuscript and which, if clarified, would significantly enhance its value. A conservative approach to acute diverticulitis with a low resection rate exposes patients to the risk of later recurrence or ongoing symptoms. Concerns that an unacceptably high proportion of patients would require subsequent emergency or elective resection have not been realised2, but even so it is striking how few patients have merited subsequent resection. One presumes that this reflects a lack of symptoms and stricture formation rather than a desire to prove a point.