Emergency minimally invasive versus open left-sided colonic resection for complicated diverticulitis: a systematic review and meta-analysis.

backgroundEmergency surgery for complicated diverticulitis carries substantial morbidity and mortality. Whether minimally invasive approaches offer advantages over open surgery in this urgent setting remains uncertain. We synthesized contemporary evidence comparing emergency minimally invasive versus open left-sided colonic resection for complicated diverticulitis.

methodsFollowing PRISMA 2020 guidelines and a prospectively registered protocol, we searched PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov through July 2025. We included comparative studies of emergency minimally invasive versus open colectomy for complicated diverticulitis (Hinchey II-IV). Random-effects meta-analysis with Hartung-Knapp-Sidik-Jonkman adjustment was performed. Risk of bias was assessed using ROBINS-I at the outcome level, and certainty of evidence was evaluated using GRADE.

resultsSix studies encompassing 9,637 patients (1,821 minimally invasive, 7,816 open) met inclusion criteria. Minimally invasive surgery was associated with lower 30-day mortality (4.5% vs. 8.7%; RR 0.48, 95% CI 0.40-0.59; P = 0.0002; I²=0%; low certainty); this estimate derived 86.9% of its weight from one database study and was no longer statistically significant when that study was excluded (RR 0.61, 95% CI 0.35-1.06). Major complications did not differ significantly (15.2% vs. 17.7%; RR 0.63, 95% CI 0.36-1.08; P = 0.10; very low certainty). Length of stay was shorter (MD - 2.55 days, 95% CI - 4.37 to - 0.74; P = 0.02) and incisional surgical site infection rates were lower (RR 0.30, 95% CI 0.12-0.75; P = 0.02), though operative time was longer (MD + 18.27 min, 95% CI 0.89-35.64; P = 0.04). Reoperation rates were similar (RR 0.98, 95% CI 0.78-1.22).

conclusionsEmergency minimally invasive resection was associated with lower 30-day mortality and shorter hospital stay, without conclusive evidence of fewer major complications. The mortality estimate derived most of its statistical weight from one large database study; after excluding that study, the point estimate remained favorable but imprecise. Overall certainty was low to very low, so these findings are hypothesis-generating rather than practice-changing. Minimally invasive resection may be considered in hemodynamically stable, selected patients operated on by surgeons with advanced laparoscopic colorectal expertise, pending prospective validation. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD420251142546.