Operative management for acute diverticulitis poses particular challenges to the surgeon (Roig et al. Minerva Chir. 73:163–178, 2018). The inflamed colonic segment is difficult to manipulate, and normal planes are often obliterated, making the identification of the key structures difficult and thus prone to injury. Furthermore, there are increasing data to suggest that resection and primary anastomosis, with or without proximal diversion, are safe and feasible in select cases, adding additional complexity to the decision-making process. The surgeon must be aware of the important differences in the operative management between acute and elective cases. The objective of this chapter is to provide the reader with a standardized operative decision-making process and approach, as well as to provide insights into specific challenges that may be encountered in the emergency setting.