Surgical management of patients with acute colonic diverticulitis is evolving from multiple towards single operations. The patterns of presentation and treatment of 146 patients with acute perforated diverticulitis have been reviewed (1983-1988) using the Hinchey classification system (Stages I-IV). This paper focuses on the six patients who presented with fecal peritonitis (Stage IV disease), half of whom were treated by primary resection and anastomosis and the remainder by a Hartmann procedure. The mean length of stay was 18.7 +/- 7.9 days and 12.7 +/- 4.8 days with a mortality of zero and one, respectively. These data suggest that in selected patients who present with perforated diverticular disease, primary resection with anastomosis offers a possible alternative to other operative management. The presence of fecal peritonitis should no longer be considered an absolute contraindication to immediate bowel reconstruction. Furthermore, we suggest that this decision be based on the relative absence of concomitant disease, a satisfactory response to preoperative resuscitation, the availability of a surgeon experienced in colonic surgery, and attention to postoperative management.