Laparoscopic treatment of bowel obstruction due to a bezoar in a Meckel's diverticulum

Background and Objectives:

Meckel''s diverticulum is a common anomaly of the gastrointestinal tract that may result in gastrointestinal bleeding, diverticulitis, and small bowel obstruction. This report describes the use of laparoscopy to treat a rare complication of Meckel''s diverticulum–small bowel obstruction due to phytobezoar impaction. More generally, it provides an example of the feasibility and utility of a laparoscopic approach to small bowel obstructions of unknown causes.

Methods:

A 34-year-old male presented to the emergency department complaining of episodic abdominal pain and vomiting. He had no history of abdominal surgery. His vital signs were stable, and his abdomen was distended, but only mildly tender. He had no abdominal wall hernias on examination. Imaging was consistent with small bowel obstruction. He was brought to the operating room where laparoscopy revealed a Meckel''s diverticulum with an impacted phytobezoar as the source of obstruction. The diverticulum was resected and the phytobezoar removed laparoscopically.

Results:

The patient recovered well and was discharged home on the third postoperative day, tolerating a regular diet.

Conclusions:

Phytobezoar impaction in a Meckel''s diverticulum causing small bowel obstruction is a rare event. It can be effectively treated laparoscopically. This case provides an example of the potential utility of laparoscopy in treating small bowel obstructions of unclear etiology.     

Phytobezoar in Meckel's diverticulum: A rare cause of small bowel obstruction

IntroductionMeckel's diverticulum (MD) is the prevailing anomaly of the gastrointestinal tract, found in about 2% of the population; it rarely gives rise to symptoms and its discovery is usually accidental. Phytobezoar is a concretion of poorly digested fruit and vegetable fibres that is found in the alimentary tract and rarely can be the cause of small intestinal obstruction. Herein we report a rare case of intestinal obstruction due to phytobezoar formation into a MD.Presentation of caseA 50 year-old patient, was admitted to author's institution with an history of abdominal pain, nausea and multiples episodes of vomiting. Plain X-ray showed dilated small-bowel loops. Computed tomography (CT) revealed jejunal loops with air-fluid levels. The patient underwent explorative laparotomy where we found a giant Meckel's diverticulum, filled by a phytobezoar that caused small bowel compression. We performed a segmental ileal, resection, containing the MD. The histological exam confirmed Meckel's diverticulum.DiscussionBowel obstruction due to a phytobezoar in a Meckel's diverticulum is rare: only 7 cases have been reported in literature. MD complications are rare and phytobezoar is one of them with only few cases described in literature.ConclusionThe conventional x rays studies were inconclusive whereas abdominal contrast enhanced CT led to a definitive diagnosis. Explorative laparotomy or laparoscopy is mandatory in these cases.     

Meckel's diverticulum with small bowel obstruction presenting as appendicitis in a pediatric patient

Background:

Meckel''s diverticulum is a congenital anomaly resulting from incomplete obliteration of the omphalomesenteric duct. The incidence ranges from 0.3% to 2.5% with most patients being asymptomatic. In some cases, complications involving a Meckel''s diverticulum may mimic other disease processes and obscure the clinical picture.

Methods:

This case presents an 8-year-old male with abdominal pain, nausea, and vomiting and an examination resembling appendicitis.

Results:

A CT scan revealed findings consistent with appendicitis with dilated loops of small bowel. During laparoscopic appendectomy, the appendix appeared unimpressive, and an inflamed Meckel''s diverticulum was found with an adhesive band creating an internal hernia with small bowel obstruction. The diverticulum was resected after the appendix was removed.

Conclusion:

The incidence of an internal hernia with a Meckel''s diverticulum is rare. A diseased Meckel''s diverticulum can be overlooked in many cases, especially in those resembling appendicitis. It is recommended that the small bowel be assessed in all appendectomy cases for a pathological Meckel''s diverticulum.     

Laparoscopic-assisted resection of Meckel's diverticulum in children.

BACKGROUND AND OBJECTIVES: Meckel's diverticulum (MD) presents unique challenges for a pediatric surgeon, as it is prone to varied complications. This case series highlights the diverse presentations and laparoscopic management of MD in children. METHODS: We performed a retrospective analysis of consecutive cases of laparoscopic-assisted transumbilical Meckel's diverticulectomy (LATUM) performed by the same surgeon for incidental as well as diverse Meckel's diverticular complications over 20 months. RESULTS: Eight patients (5 males and 3 females) aged 3 years to 13 years (median, 12) underwent LATUM. Three patients had painless per-rectal bleeding and 1 presented with intestinal obstruction due to a mesodiverticular band and intestinal ischemia. Two patients had features masquerading as appendicitis; one had perforated MD with secondary inflammation of the appendix, and the other had a torsed, gangrenous MD. In 2 patients, incidental MD with a narrow base was noted at appendicectomy for appendicitis. All patients underwent successful LATUM along with appendicectomy in 4 patients. The operative duration was 72 minutes to 165 minutes (mean, 112.1+/-30.6). There were no operative complications, and no conversion to open surgery was required. The hospital stay was 4 days to 7 days (mean, 4.7+/-1.2). The patient with mesodiverticular band intestinal obstruction presented with adhesive intestinal obstruction 2 weeks after the surgery. Laparoscopic-assisted minilaparotomy was done to release the pelvic adhesions. There were no other complications during the follow-up (median, 11 months). CONCLUSIONS: LATUM is a simple, safe, and effective procedure with a better cosmetic outcome that can be performed for diverse manifestations of MD. The technique also allows palpation of the MD and avoids use of expensive staplers.     

Laparoscopic reduction of incarcerated Meckel's diverticulum following abdominal hysterectomy.

BACKGROUND: Laparoscopic techniques are increasingly being utilized to diagnose and successfully manage intestinal obstruction. CASE REPORT: We describe a patient who presented with intestinal obstruction following a recent abdominal hysterectomy. The obstruction was caused by entrapment of a segment of small bowel containing a Meckel's diverticulum within a pouch formed by the peritoneal layer following mass closure of the abdominal wound. DISCUSSION: We discuss the literature on the abdominal wound closure technique. The role of laparoscopy in dealing with intestinal obstruction is reviewed briefly. We have also summarized the management of an incidental Meckel's diverticulum found at laparoscopy.     

A case report: Cecal volvulus caused by Meckel's diverticulum

INTRODUCTION

Meckel''s diverticulum is the most common congenital anomaly of the small intestine. Common complications related to Meckel''s diverticulum include hemorrhage, intestinal obstruction and inflammation. Acute large bowel obstruction is a rare complication of Meckel''s diverticulum and in the presented case it is caused by volvulus.

PRESENTATION OF CASE

We report a 39 year old female who presented with the diagnosis of a large bowel obstruction occurring as a result of cecal volvulus caused by adhesions of a perforated diverticulum.

DISCUSSION

The reported case presents one of the rare complications of MD, which is volvulus. The case described above presented with signs and symptoms suggestive of acute intestinal obstruction and radiological findings suggestive of cecal volvulus. The patient was taken to the operation room for exploration and we discovered the presence of a perforated MD. The main treatment of such case is to perform diverticulectomy in all symptomatic patients.

CONCLUSION

MD is mostly identified intraoperatively. Knowledge of the pathophysiologies by which MD can cause complications such as volvulus is important in order to plan management.     

A large incarcerated Meckel's diverticulum in an inguinal hernia

INTRODUCTION

Littre''s hernia is a rare finding consisting of a Meckel''s diverticulum inside of a hernia sac. Clinically, it is indistinguishable from a hernia involving small bowel and therefore may be difficult to diagnose pre-operatively.

PRESENTATION OF CASE

We report a case of an inguinal hernia involving an unusually large Meckel''s diverticulum measuring 15 cm in length. The diverticulum was resected using a linear GI stapler and the hernia was repaired without complication.

DISCUSSION

Meckel''s diverticulum is an embryologic remnant of the vitelline duct occurring in 1–3% of the adult population with an estimated 4% becoming complicated and presenting with intestinal obstruction, infection, bleeding or herniation. Surgical resection is the recommended treatment for any Meckel''s diverticulum causing symptoms. In the case of a Littre''s hernia, resection of the diverticulum should be followed by repair of the fascial defect in a standard fashion.

CONCLUSION

Littre''s hernia, although rare, should be a consideration at the time of repair for any abdominal hernia involving small bowel as resection of the Meckel''s diverticulum is critical in avoiding recurrent complications.     

Laparoscopy and Complicated Meckel Diverticulum in Children

Background and Objectives:

Meckel diverticulum can present with a variety of complications but is often found incidentally during other surgical procedures. The role of laparoscopy in the management of Meckel diverticulum is established. We reviewed our experience with complicated cases of Meckel diverticulum in children managed with laparoscopy.

Methods:

A 15-year retrospective chart review revealed 14 cases of complicated Meckel diverticulum managed with laparoscopy. Incidentally found Meckel diverticulum and cases done by laparotomy were excluded. Ages varied from 2 years to 16 years old. There were 10 males and four females. Eight cases had small bowel obstruction; of those, three had extensive intestinal gangrene. Four cases had significant rectal bleeding, three had acute diverticulitis, and two had intussusception caused by the diverticulum.

Results:

Eleven cases were treated with laparoscopic Meckel diverticulectomy and three with laparoscopic-assisted bowel resection because of extensive gangrene of the intestine. Two of the three cases with significant intestinal gangrene returned several weeks later with small bowel obstruction secondary to adhesions. They were successfully managed with laparoscopic lysis of adhesions. There were no other complications.

Conclusions:

Laparoscopy is safe and effective in the management of complicated Meckel diverticulum in children. Most cases can be managed with simple diverticulectomy. Laparoscopy is useful when the diagnosis is uncertain. When extensive gangrene is present, laparoscopy can help to mobilize the intestine and evaluate the degree of damage, irrigate and cleanse the peritoneal cavity, and minimize the incision necessary to accomplish the bowel resection.     

Diverticulectomy is inadequate treatment for short Meckel's diverticulum with heterotopic mucosa

BACKGROUND: Meckel's diverticulum is a vestigial remnant of the vitellointestinal duct that may occasionally contain heterotopic gastric mucosa thought to arise from residual yolk sac cells. This may cause significant rectal bleeding, the source of which may be difficult to identify. The present paper addresses the question of whether the choice of resection technique should depend on the macroscopic appearance of the Meckel's diverticulum. METHODS: A retrospective analysis of patients with resected Meckel's diverticulum at Prince of Wales and Sydney Children's Hospitals between 1992 and May 2003 was performed. The external appearance was expressed as a height-to-diameter ratio (HDR) and the presence or absence of macroscopic thickening was recorded. The morphology was then correlated with the presence and site of the heterotopic gastric mucosa (HGM). RESULTS: Seventy-seven patients were identified with an age range between 1 day and 92 years. Fifty-seven (74%) of the patients were men. Presenting symptoms were gastrointestinal bleeding (11.7%), diverticulitis (15.6%), volvulus (2.6%), intussusception (10%) and umbilical fistula (7.8%). Fifty-seven per cent of the resected Meckel's diverticulae were found incidentally. Eight patients underwent a technetium pertechnate nuclear Meckel's scan. The Meckel's scan detected only two of seven patients with HGM on pathological examination. Twenty-nine (38%) patients underwent diverticulectomy and 48 (62%) small bowel resection. Ectopic mucosa was found in 25 (32.5%) patients. Of the Meckel's diverticula that were defined as long (HDR >or=2.0) and containing HGM, five of five (100%) had the ectopic mucosa in the diverticular tip and body only. Of those that were short (HDR <2.0) there was a wide distribution of HGM sites with 12 (60%) involving the whole diverticulum including the base and eight (40%) involving the tip and body only. The presence or absence of macroscopic thickening was described in 18 resected Meckel's diverticula. Thirteen (72%) were described as thickened in the operation report and six of these 13 (46%) were found to have HGM. One of the seven (14%) Meckel's diverticulae with HGM was thought to be of normal appearance and was therefore undetected. CONCLUSION: Simple transverse resection is not recommended for the short Meckel's diverticulum. A HDR of 2.0 is recommended as the cut-off when deciding on the most appropriate operation. The external appearance of the Meckel's diverticulum does not predict the presence of HGM and is therefore an unreliable indicator to aid resection decisions when presented with an incidental Meckel's diverticulum.     

Laparoscopic management of symptomatic Meckel's diverticula: a simple tangential stapler excision.

BACKGROUND: Meckel's diverticulum was first described about 400 years ago and continues to be a rare congenital disorder. Laparoscopic surgery for Meckel's diverticulum has been described in mostly case reports. We present our series of patients with symptomatic Meckel's diverticulum. METHODS: We have treated 12 patients with symptomatic Meckel's diverticulum from 1994 through 2006 at our institution. All the patients presented with features of either appendicitis or peritonitis, some with a vague abdominal mass. Clinical diagnosis of Meckel's diverticulum was made in only 4 patients. Diagnostic laparoscopy confirmed Meckel's diverticulitis in all patients. Laparoscopic stapler resection of the lesions was performed for all patients, tangential excision in 10 and wedge excision in 2. RESULTS: The incidence of Meckel's diverticulum at our institution is 0.3%. The majority of patients were male children. There were no staple-line leaks in any case. All patients recovered well postoperatively, and the day of discharge was in the range of the fourth to the seventh POD. Heterotopic gastric mucosa was found in the majority of the diverticula. Eight patients were followed up for 24 months, and 4 patients reported for follow-up after 45 months and were found to be symptom-free. DISCUSSION: The diagnosis of Meckel's diverticulitis is rarely made preoperatively. Surgical resection is indicated only if the diverticulum is symptomatic or if the base is narrow. Traditionally, open wedge resection (including the anterior wall of the ileum) of the diverticulum is the treatment. We think that a simple tangential stapler resection can also be performed, with good outcome. CONCLUSION: Laparoscopy is useful in both diagnosis and treatment. Laparoscopic resection of Meckel's diverticulum is feasible and ideal, especially when performed in specialized centers.     

Laparoscopy in the diagnosis of bleeding Meckel's diverticulum

A rare case of bleeding Meckel's diverticulum in an adult, in which Tc-99m pertechnetate scan, mesenteric angiography, and barium examination failed to establish the diagnosis, is presented. The diagnosis was made by laparoscopy, and a laparoscopically assisted resection was carried out with a smooth postoperative course, early discharge from the hospital, and rapid return to work.     

Laparoscopic surgery for small-bowel obstruction caused by Meckel's diverticulum

A 26-year-old woman was referred to our hospital because of abdominal distention and vomiting. Contrastenhanced computed tomography showed a blind loop of the bowel extending to near the uterus and a fibrotic band connecting the mesentery to the top of the bowel,suggestive of Meckel's diverticulum(MD) and a mesodiverticular band(MDB). After intestinal decompression,elective laparoscopic surgery was carried out. Using three 5-mm ports,MD was dissected from the surrounding adhesion and MDB was divided intracorporeally. And subsequent Meckel's diverticulectomy was performed. The presence of heterotopic gastric mucosa was confirmed histologically. The patient had an uneventful postoperative course and was discharged 5 d after the operation. She has remained healthy and symptom-free during 4 years of follow-up. This was considered to be an unusual case of preoperatively diagnosed and laparoscopically treated small-bowel obstruction due to MD in a young adult woman.     

The Trouble with Investigating Anaemia in Young Adults: Bleeding from a Giant Meckel's Diverticulum Without Ectopic Gastric Mucosa

Giant Meckel''s diverticulum is rare and usually presents in childhood with haemorrhage or bowel obstruction. Bleeding results from the presence of ectopic gastric mucosa causing pepticulceration of adjacent mucosa. We discuss the case of a 21-year-old man with a giant Meckel''s diverticulum who presented with rectal bleeding. A Meckel''s scan was negative and histology following surgical excision ruled out the presence of ectopic gastric mucosa. There was however evidence of chronic inflammation and small bowel mucosal ulceration. We hypothesize that this arose from ischaemia and pressure necrosis because of the large size of the diverticulum and chronic distension by food debris. This case highlights the difficulties in investigating anaemia in young adults despite modern imaging techniques.     

Torsion of Meckel's diverticulum as a cause of small bowel obstruction: A case report

Axial torsion and necrosis of Meckel's diverticulum causing simultaneous mechanical small bowel obstruc-tion are the rarest complications of this congenital anomaly. This kind of pathology has been reported only eleven times. Our case report presents this very unusual case of Meckel's diverticulum. A 41-year-old man presented at the emergency department with complaints of crampy abdominal pain, nausea and re-tention of stool and gases. Clinical diagnosis was small bowel obstruction. Because the origin of obstruction was unknown, computer tomography was indicated. Computed tomography(CT)-scan revealed dilated small bowel loops with multiple air-fluid levels; the oral con-trast medium had reached the jejunum and proximal parts of the ileum but not the distal small bowel loops or the large bowel; in the right mid-abdomen there was a 11 cm × 6.4 cm × 7.8 cm fluid containing cavity with thickened wall, which was considered a dilated bowel-loop or cyst or diverticulum. Initially the patient was treated conservatively. Because of persistent abdominal pain emergency laparotomy was indicated. Abdominal exploration revealed distended small bowel loops proxi-mal to the obstruction, and a large(12 cm × 14 cm) Meckel's diverticulum at the site of obstruction. Meckel's diverticulum was axially rotated by 720°, which caused small bowel obstruction and diverticular necrosis. About 20 cm of the small bowel with Meckel's diverticulum was resected. The postoperative course was uneventful and the patient was discharged on the fifth postopera-tive day. We recommend CT-scan as the most useful diagnostic tool in bowel obstruction of unknown origin. In cases of Meckel's diverticulum causing small bowel obstruction, prompt surgical treatment is indicated; de-lay in diagnosis and in adequate treatment may lead to bowel necrosis and peritonitis.     

Multifaceted behavior of Meckel's diverticulum in children

Purpose/background

Meckel's diverticulum (MD) is one of the most common congenital malformations of gastrointestinal tract in children. However, the nonspecific clinical manifestations of MD often cause a diagnostic as well as therapeutic challenge to pediatric surgeon. This study aimed to review our experience in managing this disease while evaluating the management strategies.