Practice patterns in the surgical management of Hinchey III and IV diverticulitis: results of a national survey.

INTRODUCTION: Hinchey grade III (H3) and IV (H4) diverticulitis represent the operative spectrum of complicated diverticular disease, yet consensus on optimal management remains limited. We aimed to define current practice patterns and factors influencing operative decision-making to inform on future trials. METHODS: We conducted a cross-sectional survey of surgeons regarding management of H3/H4 diverticulitis. Respondents were provided clinical scenarios and asked to identify preferred operative approaches and provide free-text rationale. Surgeon demographics, training, and institutional characteristics were collected. Descriptive statistics, thematic analysis, and multivariable regression were performed. RESULTS: A total of 104 attending surgeons responded. Most practiced at academic centers (71.2%) and large hospitals (78.8%) with 24-h coverage (72.5%). Median practice duration was 8 years (IQR 3.75-14); 66.3% had trauma/critical care training. In unstable patients, nearly all (99%) selected open surgery, most commonly Hartmann's (52%) or resection in discontinuity (46%). Among discontinuity cases, 55.3% selected Hartmann's, while 40.4% chose delayed anastomosis with diverting loop ileostomy (DLI) at takeback. In stable patients, practice patterns diverged. Minimally invasive approaches were selected in over half of H3 cases, while most H4 cases (74%) were managed open. Surgeons were more likely to perform anastomosis in H3 than H4 (primary: 23.5% vs 7.9%; DLI: 45.1% vs 35.5%; p < 0.05). Laparoscopic approaches showed similar DLI use across groups. Qualitative analysis identified safety and leak avoidance as drivers of Hartmann's, protection and reversibility for DLI, and stoma avoidance for primary anastomosis. Regression analysis demonstrated that fewer years in practice and higher case volume predicted minimally invasive use. CONCLUSIONS: Respondents almost universally selected open surgery to manage unstable patients, with damage control resection nearly as common as Hartmann's. Management choices of stable patients demonstrated substantial variability, influenced by disease severity. Minimally invasive adoption was driven by surgeon experience and volume. These findings provide a foundation for future prospective trials.