Background: Ileal perforation, predominantly caused by typhoid fever and tuberculosis in developing countries, remains a significant surgical emergency with substantial morbidity and mortality. The optimal surgical approach—primary repair versus diversion ileostomy—continues to be debated, with limited high-quality comparative data available to guide clinical decision-making. This study aimed to compare postoperative outcomes between primary repair and diversion loop ileostomy in patients presenting with non-traumatic ileal perforation. Methods: A prospective comparative study was conducted at a tertiary care teaching hospital. A total of 186 patients who underwent emergency laparotomy for non-traumatic ileal perforation were included: 94 patients underwent primary repair (closure of perforation in two layers) and 92 patients underwent diversion loop ileostomy (exteriorization of the perforated segment or proximal diversion). Postoperative outcomes including surgical site infection (SSI), anastomotic or repair site leak, intra-abdominal abscess, wound dehiscence, duration of hospital stay, time to resumption of oral feeding, reoperation rates, stoma-related complications, and 30-day mortality were compared between groups. Results: The primary repair group demonstrated significantly shorter mean hospital stay (9.4 ± 3.6 vs. 14.2 ± 5.1 days, p < 0.001), earlier resumption of oral feeding (3.8 ± 1.2 vs. 5.6 ± 1.8 days, p < 0.001), and lower overall complication rates (29.8% vs. 44.6%, p = 0.036). Surgical site infection rates were comparable (19.1% vs. 23.9%, p = 0.425). Repair site leak occurred in 7.4% of primary repair patients, while stomal complications affected 28.3% of ileostomy patients. Thirty-day mortality was 8.5% versus 10.9% (p = 0.581). In multivariate analysis, peritoneal contamination severity and delay in surgical intervention were stronger predictors of adverse outcomes than the choice of surgical procedure. Conclusion: Primary repair of ileal perforation yields favorable short-term outcomes compared to diversion ileostomy in selected patients with limited peritoneal contamination and early presentation. Diversion ileostomy remains a valuable option in patients with extensive contamination, multiple perforations, or hemodynamic instability. Individualized surgical decision-making based on intraoperative findings is essential.

: Ileal perforation; primary repair; diversion ileostomy; typhoid perforation; surgical outcomes; peritonitis; emergency laparotomy