The role of laparoscopy in symptomatic Meckel's diverticulum

Incidentally discovered Meckel's diverticulum: should I stay or should I go?

BACKGROUND

The aim of this study was to assess the indication for surgical treatment of incidentally discovered Meckel's diverticulum (MD) on the basis of clinical and histological features.

METHODS

The charts of patients undergoing surgery for MD were analysed. Two groups were identified: (1) patients who had incidentally discovered MD resected (incidental MD, IMD) and (2) patients who received first-line surgery for a complicated MD (CMD). Demographics and intraoperative and post-operative outcomes were compared. Histological findings were also analysed and compared.

RESULTS

Sixty-five patients were included in the study. IMD was observed in 39 patients (60%), while CMD was observed in 26 (40%). Male gender was significantly more frequent in CMD (P = 0.020), and mean age was significantly higher in IMD (P = 0.025). Body mass index and the American Society of Anesthesiologists score >2 were similar in both groups. Laparoscopy was carried out in 36% of IMD and in 50% of CMD patients (P = 0.309). A tangential resection was performed in 92% of IMD and 73% of CMD patients (P = 0.07). No complications related to diverticular resection were found in IMD, while they occurred in 8% of CMD patients (P = 0.931). Meanly, diverticula were longer when complicated (P = 0.001). CMD showed significant histological differences and more frequent gastric ectopic mucosa (P = 0.039). A malignant tumour was incidentally found in IMD.

CONCLUSION

As surgery is mandatory in CMD, the optimal management of IMD remains uncertain. Mucosal abnormalities may favour complications, but these cannot be identified before excision. Stapled diverticulectomy is safe and effective. A surgical approach to IMD may prevent complications at a very low cost.

Laparoscopic approach to symptomatic meckel diverticulum in adults

Background:

Meckel diverticulum (MD) is the most common congenital gastrointestinal malformation found in approximately 2% of the general population. MD manifests in adults as gastrointestinal bleeding, bowel obstruction, intussusception, or perforation in <5% of cases. There is no consensus on the ideal management strategy in symptomatic MD. Therefore, we searched the literature to highlight the role of laparoscopy in diagnosing and treating symptomatic MD.

Method:

We used PubMed, Medline, Google Scholar, Ovid, and Cochrane data search engines looking for articles containing terms such as Meckel diverticulum, ectopic gastric mucosa, laparoscopic, technetium 99m pertechnetate, and acute management. We included articles reporting on case series in the English language on adult patients only and reporting on laparoscopic approach in the management of symptomatic MD.

Results:

A total of 5 articles reporting on 35 cases were found. We report on the pooled data from these series with emphasis on number of patients, age, male to female ratio, length of stay, conversion to open procedure, method of resection, complications, first presentation, and confirmation of diagnosis preoperatively. We also compare the results of laparoscopic versus open approaches mentioned in the literature.

Conclusions:

The laparoscopic approach was found to be effective as a diagnostic and therapeutic modality in patients with symptomatic MD; however, its adoption as the gold standard still needs further studies with larger patient numbers.

Unusual Presentation of Meckel's Diverticulum: Gangrene due to Axial Torsion

Meckel's diverticulum is the most common congenital anomaly of the small bowel. The majority of cases are asymptomatic; however, life-threatening complications can also take place. We present a case of a 37-year-old male who was admitted with symptoms of acute, severe abdominal pain in the right iliac fossa. The patient was operated on with the preoperative diagnosis of acute appendicitis but the operative findings were consistent with torted Meckel's diverticulum due to presence of mesodiverticular band and he was treated successfully with surgical resection.

A Rare Internal Herniation in Adult: Meckel's Diverticulum

Intestinal obstruction due to Meckel's diverticulum is the most common presentation in adults. There are various mechanisms by which it can cause intestinal obstruction such as volvulus of small intestine around a fibrous band extending from Meckel's diverticulum to umbilicus, intussusception, and Littre's hernia. We report the case of a young adult operated on emergency for acute intestinal obstruction. The CT scan suggested a nonspecific internal herniation. Surgical exploration confirmed a rare type of obstruction due to Meckel's diverticulum.

Laparoscopic management of perforated Meckel's diverticulum in adults

OBJECTIVE

To determine the role of laparoscopy in diagnosis and surgical treatment of perforated Meckel's diverticulum (MD) in adults.

METHODS

Between July 2003 and July 2011, fifteen patients were seen with perforated MD. Eleven were male and four were female. The median age was 38 years (range, 21-68). All patients presented with a sudden onset of pain. Among them 9 had a past medical history of bloody stools and /or chronic recurrent abdominal pain. 2 were preoperatively diagnosed with perforated MD confirmly and 4 suspiciously, 9 with perforated acute appendicitis. All 15 patients underwent exploratory laparoscopy.

RESULTS

4 patients with broad-base(≧ 2 cm) and 2 patients with narrow-base(<2 cm) whose perforative site was near the base underwent laparoscopically assisted extracorporal bowel segment resection, the other 9 patients with narrow-base(<2 cm) underwent laparoscopically intraabdominal wedge resection of the MD. No intraoperative or postoperative complications occurred. The median hospital stay was 4 days (range, 2-7 days). The histopathologic studies showed heterotopic gastric mucosa (HGM) in 10 cases (66.7%). All patients recovered uneventfully.

CONCLUSION

To patients with sudden abdomen pain mimic acute appendicitis accompanied by a past medical history of bloody stools and/or chronic recurrent abdominal pain, proferated MD should be kept in mind as a differential diagnosis. Laparoscopy is a safe and effective surgical modality for diagnosis of proferated MD and has a therapeutic role that results in an excellent cosmetic result.

Complicated Meckel's diverticulum in pediatrics: role of laparoscopy-two rare cases

Meckel's diverticula are mostly asymptomatic. Even complicated disease is hardly diagnosed preoperatively and hence met with fatal outcomes, if not intervened on immediately. In this paper, we present 2 pediatric cases with complicated Meckel's diverticula that were diagnosed and successfully treated by the totally laparoscopic approach. To the best of our knowledge such cases have not been reported in the literature, so far. Nevertheless, we caution about keeping a high index of suspicion for diagnosing such pediatric cases and stress the need for an early laparoscopy in them.

Transumbilical approach for neonatal surgical diseases: woundless operation

PURPOSE

The transumbilical approach by means of a circumumbilical incision has up until recently been the main method for performing a pyloromyotomy. This study aims to assess the clinical usefulness of the transumbilical approach for neonates with a variety of surgical intraabdominal diseases in order to achieve minimally invasive surgery with excellent cosmetic results.

METHODS

In 14 neonates with surgical diseases (3 hypertrophic pyloric stenoses, 3 ileal atresias, 2 jejunal atresias, 1 duodenal stenosis, 1 duodenal atresia, 2 ovarian cysts, 1 malrotation, and 1 segmental dilatation of ileum), treatment using a transumbilical approach by means of a half circumumbilical incision was performed at our institution. The clinical features of 14 cases were evaluated.

RESULTS

Eight cases except for three patients with hypertrophic pyloric stenosis, two with ovarian cysts and one with intestinal malrotation underwent the operation within 4 days of birth. In 10 of 14 cases, the umbilicus was incised on its upper half circumference, while the umbilicus of 4 cases was incised on its lower half circumference. In one ileal atresia patient with a remarkable degree of oral intestinal dilatation, a slight additional transverse incision was added. In four cases (1 case with ileal atresia, 2 cases of an ovarian cyst, and 1 case with a segmental dilatation of the ileum), laparoscopy-assisted transumbilical surgery was performed. In all cases, no operative complications were encountered. Postoperatively, there was no wound in appearance and the umbilicus appeared to be normal.

CONCLUSION

The transumbilical approach with or without laparoscopic assistance is considered to be a feasible, safe, and cosmetically excellent surgical procedure in neonates with a wide variety of surgical intraabdominal diseases.

Meckel's diverticulum: comparison of incidental and symptomatic cases

Although Meckel's diverticulum is the commonest congenital gastrointestinal anomaly, there is still debate concerning the proper management of asymptomatic diverticula. Records of all patients whose Meckel's diverticulum was resected at our hospitals between 1990 and 2002 were reviewed. Clinical characteristics, mode of presentations, and management for all patients were analyzed. Meckel's diverticula were resected in 68 patients. Patients were divided into two groups: the incidental group included 40 patients (24 males) in whom the diagnosis of diverticula was incidental. The symptomatic group included 28 patients (20 males) who presented with diverticulum-related complications. Preoperative diagnosis was possible in only four cases. In four patients from the symptomatic group, Meckel's diverticula were found and left untouched during a previous laparotomy. There was no significant difference between the two groups with respect to gender (p = 0.48). Patients in the symptomatic group were significantly younger than patients in the incidental group (p = 0.002). The diverticula in the symptomatic group tended to be longer (p = 0.001) with a narrower base (p = 0.001) than the diverticula in the incidental group. A diameter of < or = 2 cm was significantly associated with more complications (p = 0.01). Heterotopic tissue was present more significantly in the symptomatic group than the incidental group (p = 0.01). There was no significant difference in the morbidity rate between the two groups (p = 0.71), and there was no mortality in either group. Preoperative diagnosis of Meckel's diverticulum is difficult and should be kept in mind in cases of acute abdomen. Resection of incidentally found diverticula is not associated with increased operative morbidity or mortality.

Laparoscopy-assisted surgery for prenatally diagnosed small bowel atresia: simple, safe, and virtually scar free

PURPOSE

The aim of this study was to describe a new technique for the surgical management of prenatally diagnosed small bowel atresia.

METHODS

Under general anesthesia, a 5-mm trocar was inserted using an open technique through an intraumbilical incision. The proximal atretic bowel end was identified using laparoscopy and mobilized toward the umbilicus using an additional 3-mm trocar inserted in the left lower quadrant. The umbilical trocar then was removed, and a ring retractor was inserted into the trocar site and used to expand the wound to deliver both atretic bowel ends. The bowel was repaired and returned to the abdomen through the umbilical wound. The umbilical fascia and skin were closed conventionally.

RESULTS

Three patients were reviewed. Two had minimal abdominal distension, and the atretic bowel ends could be identified easily; laparoscopy-assisted surgery was successful. The third case had significant dilatation, and laparotomy was required. Postoperatively, there was minimal abdominal scarring, and the umbilicus was normal in appearance.

CONCLUSIONS

Although this experience is limited to 3 patients, this technique is simple, safe, and virtually scar free and can be applied for the treatment of neonates with prenatally diagnosed small bowel atresia, especially if there is minimal abdominal distension at birth.

The role of laparoscopy in the management of lower gastro-intestinal bleeding

This report describes three cases of significant lower gastro-intestinal haemorrhage caused by a bleeding Meckel's diverticulum. In the first two cases a pre-operative technetium-pertechnetate or Meckel's scan was negative or inconclusive, and in the third case no Meckel's scan was carried out. The diagnosis was established at laparoscopy in all three cases and in each case the diverticulum was excised extracorporeally.

[Massive rectal bleeding after appendectomy: report of 2 further cases and review of the literature]

Massive rectal bleeding complicating appendectomy is extremely rare. This study describes two cases of severe gastrointestinal haemorrhage from an appendiceal stump, occurring one and seven days after appendectomy respectively. The two cases were successfully treated by emergency cecal resection. We reviewed the other previously reported etiologies of massive rectal bleeding after appendectomy for appendicitis.

Laparoscopy-assisted resection of complicated Meckel's diverticulum in adults

The era of videoendoscopic surgery in emergency surgery practice has facilitated a wide range of endoscopic operative procedures. In our unit the diagnosis of acute abdomen is made after sequential clinical and laboratory examination, and diagnostic laparoscopy is advocated. Laparoscopy-assisted resection of complicated Meckel's diverticulum in two adult patients was performed, and the results are discussed. Between December 1996 and June 2000, 98 patients underwent diagnostic laparoscopy at the Cerrahpasa Medical Faculty Emergency Surgery Unit of Istanbul University because of signs and symptoms of acute abdomen. Among these, we have diagnosed one case of intestinal obstruction due to a volvulus around Meckel's diverticulum and one of acute abdomen masquerading as acute appendicitis but actually involving omphalomesenteric duct cyst torsion. Both of these patients underwent diagnostic laparoscopy and laparoscopy-assisted Meckel's diverticulectomy. Diagnostic laparoscopies were performed on 46 male (47%) and 52 female (53%) patients. In all cases, laparoscopy successfully confirmed the diagnosis. Although in 27 patients the interventions were converted to open procedures, the operations were completed laparoscopically in 71 patients. Two of these patients underwent laparoscopy-assisted Meckel's diverticulectomy and their postoperative periods were uneventful. Both patients were discharged from the hospital on their fourth postoperative day. Diagnostic laparoscopy is a safe and effective method for diagnosis of acute abdomen. In emergency surgery practices in developing countries, advanced laparoscopy should be performed to reduce expenses. Laparoscopy-assisted Meckel's diverticulectomy is a safe and economic procedure and can be performed in adults for treatment of complicated cases without staplers.