Laparoscopic management of Meckel's diverticulum in children

Background

Rectal bleeding, recurrent abdominal pain, nausea, and vomiting in children could present a diagnostic as well as therapeutic challenge. Meckel's diverticulum (MD) is one of the causes. The objective of the current study was to evaluate the feasibility and outcome of laparoscopic management of MD.

Methods

The clinical data of 33 children admitted with rectal bleeding and/or recurrent abdominal pain with no identifiable cause were reviewed over a period of 8 years. There were 23 boys and 10 girls with a mean age of 5.12 ± 2 years (range, 3-12 years). In 21 cases, MD was an incidental finding on laparoscopic appendectomy and symptomatic in 12 cases. Patients with rectal bleeding were subjected to upper gastrointestinal endoscopy; colonoscopy, and technetium Tc 99m-labeled pertechnetate scan (MS). All patients were subjected to routine laboratory investigations and diagnostic laparoscopy.

Results

Of the 1200 appendectomies, incidental MD was found in 21 (1.9%) patients and symptomatic in 12 cases. Upper gastrointestinal endoscopy and colonoscopy did not show a bleeding source in 7 patients presented with bleeding per rectum. Four cases showed a positive MS uptake. Of these, 3 were found on laparoscopy to have an MD. Three cases showed a negative scan. Of these, 2 had an MD. In 5 cases with recurrent abdominal pain nausea, vomiting, and abdominal distention, diagnostic laparoscopy revealed Meckel's diverticulitis in 3 cases and intussusception secondary to MD in 1 case. Laparoscopic Meckel's diverticulectomy and laparoscopic-assisted Meckel's diverticulectomy was done for 18 and 12 cases, respectively. Ectopic gastric mucosa was present in 13 cases (44%).

Conclusions

Laparoscopy is safe, cost-effective, and efficient for the diagnosis and definitive treatment of MD. Compared with conventional laparotomy, it has the advantage of precise operative diagnosis, less traumatic access, fewer intraoperative and postoperative complications, and shorter recovery period.     

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.     

Giant Meckel’s diverticulum: An exceptional cause of intestinal obstruction

Meckel's diverticulum(MD) results from incomplete involution of the proximal portion of the vitelline(also known as the omphalomesenteric) duct during weeks 5-7 of foetal development. Although MD is the most commonly diagnosed congenital gastrointestinal anom-aly, it is estimated to affect only 2% of the population worldwide. Most cases are asymptomatic, and diagno-sis is often made following investigation of unexplained gastrointestinal bleeding, perforation, inflammation or obstruction that prompt clinic presentation. While MD range in size from 1-10 cm, cases of giant MD(≥ 5 cm) are relatively rare and associated with more severe forms of the complications, especially for obstruction. Herein, we report a case of giant MD with secondary small bowel obstruction in an adult male that was suc-cessfully managed by surgical resection and anasto-mosis created with endoscopic stapler device(80 mm, endo-GIA stapler). Patient was discharged on post-operative day 6 without any complications. Histopatho-logic examination indicated Meckel's diverticulitis with-out gastric or pancreatic metaplasia.     

腹腔镜辅助Meckel憩室切除术

目的:探讨Meckel憩室的腹腔镜诊断及治疗方法。方法:总结分析2002年6月至2008年6月我们用腹腔镜诊断治疗Meckel憩室35例患者的临床资料。35例均于腹腔镜下找到憩室后结扎切除或延长脐部切口腹腔外切除吻合。结果:Meckel憩室并下消化道出血25例(71.4%),反复脐周或右下腹痛6例(17.1%),肠梗阻4例(11.5%)均治愈出院。术中腹腔镜探查确诊16例,占45.7%。手术时间45～90min,平均70min,平均住院时间5.6d。结论:腹腔镜辅助Meckel憩室切除术患者创伤小、疼痛轻、康复快,是诊断治疗Meckel憩室的良好方法。     

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.     

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.     

Intussusception associated with a Meckel's diverticulum and a duplication cyst

Intussusception is a frequent cause for bowel obstructions and pediatric surgical consults. First described by Barbette in 1674, the etiology and treatment of intussusception has undergone several revisions for the last 300 years. Currently, we understand most intussusceptions in young children to be of idiopathic in nature with the incidence of pathologic lead points increasing with the age of the child. Although both Meckel's diverticulum and duplication cysts have both been reported numerous times in the past as a source of a lead point, we report, to our knowledge, the only case of both found in a child requiring operative reduction.     

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.     

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.     

腹腔镜诊治儿童美克尔憩室出血

目的研究腹腔镜在儿童Meckel憩室出血诊断和治疗中的应用。方法分析近年来采用腹腔镜治疗的Meckel憩室出血病例31例,男19例,女12例。结果腹腔镜治疗31例Meckel憩室中1例因粘连广泛改行开腹手术,合并肠重复畸形1例,肠套叠2例。其中楔形切除吻合12例,肠切除端-端吻合18例。同时进行了3例阑尾及4例斜疝的联合手术。结论腹腔镜的应用为儿童Meckel憩室出血的诊断和治疗提供了一条极好的途径,具有诊断和治疗的双重作用。提高了疾病的诊断率,减少了并发症的发生率,降低了医疗费用。     

Laparoscopic Resection of Meckel's Diverticulum: Report of Two Cases

Symptoms of Meckel's diverticulum (MD) are present in only 4% of all cases and are often aspecific. The diagnostic modalities for the distal ileum are also often ineffective. We report herein two cases of MD's complications, intestinal obstruction and diverticulitis, which were managed laparoscopically. In both cases laparoscopy allowed the physician not only to make an accurate diagnosis but, at the same time, to perform a tangential resection of the MD. Received: August 14, 2000 / Accepted: March 6, 2001     

National trends in the surgical management of Meckel's diverticulum

Background

Treatment recommendations for Meckel's diverticulum (MD) come mostly from single-institution case series. The objective of this study was to review the surgical management and outcomes of children undergoing Meckel's diverticulectomy using contemporary data from a national database.

Methods

We queried 2007 to 2008 data from the Pediatric Health Information System database and analyzed demographic and outcome variables for patients undergoing surgical resection of MD. Cases were classified as primary (symptomatic MD) or secondary (incidental MD). Outcomes in primary cases were compared between open and laparoscopic approaches. Statistical analyses were performed using SPSS (Chicago, IL).

Results

Eight hundred fifteen children underwent Meckel's diverticulectomy. Meckel's diverticulectomy was more common in boys (boy-girl, 2.3:1), and half (53%) of the children required surgery before their fourth birthday. More cases (n = 485; 60%) were classified as primary, and most children were approached by laparotomy (75%). The most common presentations for primary cases were obstruction (30%), bleeding (27%), and intussusception (19%). In the primary group, patients treated with the laparoscopic approach had a shorter length of stay (open approach, 5.7 ± 5.2 days; laparoscopic approach, 4.3 ± 2.7 days; P < .02).

Conclusion

These data describe current trends in the surgical treatment of MD in the United States. Laparoscopic Meckel's diverticulectomy appears to shorten length of stay but is used much less frequently than the traditional open approach.     

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.     

Pancreas transplant and incidental Meckel's diverticulum: not always a straightforward decision

Abstract: Introduction: Unexpected intraoperative findings are not rare in surgical practice. Meckel’s diverticulum with a mass is one such example. There are only two previously reported cases of Meckel’s in transplantation, and neither involved pancreas transplant. Results and discussion: We present a case report of novel surgical technique using a Meckel’s diverticulectomy site for the duodeno‐enterostomy to managing the exocrine secretions of the transplanted pancreas. We also discuss management of Meckel’s diverticulum. The patient tolerated the procedure without complication, and continues to have normal renal and pancreatic function without any gastrointestinal (GI) complaints. The excised Meckel’s diverticulum contained both gastric and pancreatic tissue. Conclusion: Although uncertainty about the best management practices exists in the general surgery patient population, given the potential complications that may arise from Meckel’s diverticulum, in transplant patients the Meckel’s should be removed when encountered. The point of excision can safely be incorporated into other intestinal anastomoses.     

Incarcerated ventral (epigastric) hernia containing a strangulated Meckel's diverticulum

Summary A Meckel's diverticulum is the result of an incomplete obliteration of the omphalomesenteric, or vitelline, duct. The duct connects the midgut to the yolk sac of the developing intestinal tract and normally atrophies by the eighth to ninth week of gestation. This event fails to occur in approximately two percent of the population, resulting in the congenital anomaly named after Johann Friedrich Meckel, who first characterized this diverticulum in 1809. Our patient presented with signs and symptoms consistent with a small bowel obstruction secondary to an incarcerated hernia, and underwent emergent laparotomy. An ischemie small bowel segment with a Meckel's diverticulum was resected. Pathology revealed ectopic pancreatic tissue within the diverticulum. Meckel's diverticula have been observed among the contents of hernia sacs in various locations including the inguinal, femoral, and umbilical regions. We report a case of a Meckel's diverticulum presenting in a spontaneous ventral (epigastric) hernia.     

成人美克耳憩室49例诊治分析

目的探讨成人美克耳憩室的临床表现、诊断及治疗方法,以提高成人美克耳憩室的诊治水平。方法对我院1995年4月~2005年4月收治的成人美克耳憩室49例的临床资料进行回顾性分析。本组病人均经手术治疗。其中,行憩室切除加小肠部分切除32例,憩室切除加小肠楔形切除11例,腹腔镜辅助憩室切除加小肠部分切除6例。结果本组病例病理检查结果显示,美克耳憩室内有异位胃组织者21例,有异位胰腺组织者2例。本组病例均治愈出院。随访6月~10年,疗效满意。结论成人美克耳憩室主要表现为下消化道出血、急性憩室炎或小肠梗阻,无论有无临床症状,一经确诊,均以手术治疗为宜。腹腔镜可作为诊断和治疗成人美克耳憩室引起消化道出血的常规方法。     

The role of laparoscopy in symptomatic Meckel's diverticulum

We report two cases of symptomatic Meckel's diverticulum in adults with recurrent abdominal pain and episodes of minor lower gastrointestinal bleeding. In case 1, the diagnosis was suggested by ^99mTc pertechnetate scan and confirmed by laparoscopy; whereas in case 2, only diagnostic laparoscopy was performed because of suspected appendicitis. A segmental small bowel resection with attached diverticulum was performed extracorporeally after exteriorization through the umbilical port site in both cases. Received: 15 May 1998/Accepted: 7 April 1999     

Hirschsprung's disease, a rare precipitating factor in neonatal perforated Meckel's diverticulum

Perforation of Meckel's diverticulum (MD) during the neonatal period may occur in the presence of distal colon obstruction. Herein, we describe a unique case of a 2-day-old infant that presented with pneumoperitoneum, in which a perforated MD was induced by distal intestinal obstruction secondary to total colonic aganglionosis. In the setting of neonatal perforated MD found intraoperatively, the determination of the possible precipitating etiology is necessary. The clinical history of delayed passage of meconium is emphasized, and either a rectal or colon biopsy is recommended intraoperatively to avoid overlooking the associated presence of Hirschsprung's disease.     

腹腔镜诊治小儿美克尔憩室的临床价值

目的 :探讨腹腔镜对小儿美克尔憩室 (MD)并出血的诊断及治疗价值。方法 :1997年 6月至2 0 0 2年 4月对美克尔憩室 13例行腹腔镜憩室切除术。 13例患儿均有间歇性便血史 ,术前99mTc扫描 ,8例在右下腹显示放射物聚集 ,5例阴性。结果 :全组术后恢复顺利 ,随访 6月～ 2年 ,未再便血 ,生长发育正常。结论 :与传统的开腹手术相比 ,腹腔镜手术具有切口小 ,患者康复快 ,能直接进行诊断及治疗 ,术后并发症少等优点。有条件的医院可将其作为有症状的MD患儿的常规治疗方法。     

Leiomyosarcoma originating in Meckel's diverticulum: Report of a case and a review of 59 cases in the English literature

A 49-year-old woman was referred to our hospital with complaints of epigastric colicky pain and high fever. Abdominal computed tomography and ultrasonography showed a solid tumor in the lower abdomen. Laparotomy revealed a neoplastic mass arising in Meckel's diverticulum; therefore, a segment of the ileum, including the tumor-possessing diverticulum, was resected with a lymph node dissection. A histologic examination confirmed the lesion to be leiomyosarcoma. In the English literature, 59 cases of leiomyosarcoma in Meckel's diverticulum were reported from 1941 to 1994. The majority of patients were in their 4th decade of life, with both sexes equally affected. The most frequent symptoms associated with this disease were abdominal pain with nausea, vomiting, and melena. The majority were larger than egg-size. Although Meckel's diverticulum is difficult to diagnose preoperatively, mesenteric arteriography may at times prove useful. The standard management of this particular tumor is wide segmental resection, including the tumor and diverticulum with lymph node dissection.