Abscess of the anterior abdominal wall as a consequence of perforated sigmoid colon diverticulitis, without peritonitis: a rare manifestation of complicated diverticulitis – a case report with a literature review.

Complicated diverticulitis remains a relatively commonly encountered surgical emergency in Croatia. Eventhough early stages of complicated diverticulitis can benefit from a conservative management, large abscesses, diffuse purulent or stercoral peritonitis usually require colonic resection. In Western countries, such scenarios commonly involve sigmoid colon resection with or without end colostomy formation. We report a rare presentation of complicated sigmoid diverticulitis manifesting as an abdominal wall abscess without signs of peritonitis in a 60-year-old female, with a significant medical history including type 2 diabetes, hypertension, dyslipidemia, extreme obesity, and prior laparotomy for complicated diverticulitis. The patient presented with localized lower abdominal pain, erythema, and tenderness consistent with cellulitis, alongside elevated CRP but normal white cell count. Imaging via CT scan revealed a large purulent collection in the lower abdominal wall, suggesting a contained perforation. Emergency surgical exploration confirmed a firm adhesion of the sigmoid colon to the abdominal wall and a large abscess cavity containing feculent material. There was no sign of free fluid or peritonitis in the abdominal cavity. Hartmann’s procedure was performed, including resection of the diseased colon and formation of a colostomy. Postoperative recovery was initially favorable but complicated by colostomy retraction due to the patient’s obesity. A revision surgery was successfully performed on day 11, restoring bowel continuity. We opted for the latter due to the absence of peritonitis. Further recovery was uneventful, with a complete resolution of the abdominal wall cellulitis and drainage. This case reports of an unusual route of perforation in diverticulitis leading to an abdominal wall abscess without intraabdominal contamination and highlights the importance of individualized surgical planning in complex recurrences.