Meckel's diverticulum surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]
Overview
Surgery is the primary treatment modality in patients with Meckel's diverticula. Asymptomatic patients are treated in the presence of features such as narrow diverticular mouth, fibrous bands, ectopic gastric tissue, diverticular length >2cm, stasis, narrow neck, intramural pathology, thickening and inflammation of the diverticulum. On the other hand, absolute indications for resection of a symptomatic Meckel's diverticulum include complications such as hemorrhage, umbilico ileal fistulas, diverticulitis and bowel obstruction. Fibrous band division, diverticulectomy, segmental resection of the diverticulum with end-to-end intestinal anastomosis and wedge resection are the various surgical procedures performed, whenever indicated.
Surgery
- Surgery is the preferred modality of treatment in patients with Meckel's diverticula.
- General principles of abdominal surgery for preoperative (including antibiotic use), intraoperative and postoperative management of Meckel's diverticulum are followed by surgeons. [1][2][3][4]
Asymptomatic Meckel’s diverticulum
- An asymptomatic Meckel's diverticulum is discovered incidentally on abdominal imaging or exploration( laparoscopy or laparotomy) for an indication such as a presumptive diagnosis of acute cholecystitis.
- Generally, surgical resection is avoided in cases of asymptomatic diverticula as in order to benefit a single patient, 800 incidental diverticula need to be removed.[5]
- In elderly patients, resection of diverticulum may be preferred to prevent complications.
- Removal of an asymptomatic diverticulum is not advised in the presence of complications such as:
- The decision regarding resection is made by the surgeon based on appearance of the diverticulum.
- Indications for surgery include:[6][7][8]
- Absence of a wide mouth
- Diverticula with fibrous bands
- Presence of ectopic gastric tissue
- Length of diverticulum more than 2 cm
- Presence of stasis within the diverticulum
- Narrow neck of diverticulum may undergo twisting or obstruction
- Presence of intramural pathology
- Thickened, inflamed diverticulum
- Children
- Elderly patients
- Preferred technique in asymptomatic cases undergoing surgery: Tangential excision with suture closure of the base
Symptomatic Meckel diverticulum
- Absolute indications for resection of a symptomatic Meckel's diverticulum include complications such as:[9]
- Hemorrhage
- Umbilicoileal fistulas
- Inflammation of diverticulum: Diverticulitis
- Bowel obstruction
- Surgical procedures considered in patients with symptomatic Meckel's diverticulum are as follows:
- Fibrous band division
- Diverticulectomy, along with suture closure of the base
- Segmental resection of the diverticulum and the intestine, followed by end-to-end anastomosis
- Wedge resection of the diverticulum along with the adjacent intestinal wall, followed by suture closure
- Special surgical considerations are required in case of:
- Meckel's diverticulitis: In a case of suspected appendicitis where appendix is normal on surgical exploration, the distal ileum must be examined for signs of diverticulitis
- Umbilical fistula and sinus: In such cases, umbilical excision may be necessary
- Broad based diverticula in children: Segmental resection is preferred as the risk of ileal stenosis is high if wedge resection or diverticulectomy is performed
- Bowel obstruction: The extent of excision is determined by the viability of the intestinal wall
- Hemorrhage : Segmental or wedge resection may be used for excision of ulcerated bowel and gastric mucosa
- Care must be taken during surgical management of Meckel's diverticulum to ensure:
- Decreased incidence of intestinal stenosis due to narrowing
- Awareness of tension of suture-line
- Bowel viability
- Adequate blood supply to resectional margins
- Advantages of stapling over handsewn technique :
- Low rate of complications
- Easy fit into stapling device, facilitating easy removal
- Quicker resection of Meckel's diverticulum
- Decreased postoperative and septic complications as the intestinal lumen is not opened
- Laparoscopic treatment of Meckel's diverticulum is restricted to symptoms of bleeding and abdominal pain.[10][11][12][13]
- Postoperative complications of Meckel's diverticulum:
- Early post-operative complications:
- Ileus
- Intra-abdominal abscess
- Pulmonary embolism
- Anastomotic leakage
- Suture-line leakage
- Late post-operative complications:
- Intestinal stenosis
- Intestinal obstruction due to postoperative adhesions
- Early post-operative complications:
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References
- ↑ Zani A, Eaton S, Rees CM, Pierro A (2008). "Incidentally detected Meckel diverticulum: to resect or not to resect?". Ann. Surg. 247 (2): 276–81. doi:10.1097/SLA.0b013e31815aaaf8. PMID 18216533.
- ↑ Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR (2005). "Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002)". Ann. Surg. 241 (3): 529–33. PMC 1356994. PMID 15729078.
- ↑ Lohsiriwat V, Sirivech T, Laohapensang M, Pongpaibul A (2014). "Comparative study on the characteristics of Meckel's diverticulum removal from asymptomatic and symptomatic patients: 18-year experience from Thailand's largest university hospital". J Med Assoc Thai. 97 (5): 506–12. PMID 25065089.
- ↑ Robinson JR, Correa H, Brinkman AS, Lovvorn HN (2017). "Optimizing surgical resection of the bleeding Meckel diverticulum in children". J. Pediatr. Surg. 52 (10): 1610–1615. doi:10.1016/j.jpedsurg.2017.03.047. PMID 28359587.
- ↑ Soltero MJ, Bill AH (1976). "The natural history of Meckel's Diverticulum and its relation to incidental removal. A study of 202 cases of diseased Meckel's Diverticulum found in King County, Washington, over a fifteen year period". Am. J. Surg. 132 (2): 168–73. PMID 952346.
- ↑ Thirunavukarasu P, Sathaiah M, Sukumar S, Bartels CJ, Zeh H, Lee KK, Bartlett DL (2011). "Meckel's diverticulum--a high-risk region for malignancy in the ileum. Insights from a population-based epidemiological study and implications in surgical management". Ann. Surg. 253 (2): 223–30. doi:10.1097/SLA.0b013e3181ef488d. PMC 4129548. PMID 21135700.
- ↑ Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ (1994). "Surgical management of Meckel's diverticulum. An epidemiologic, population-based study". Ann. Surg. 220 (4): 564–8, discussion 568–9. PMC 1234434. PMID 7944666.
- ↑ Gezer HÖ, Temiz A, İnce E, Ezer SS, Hasbay B, Hiçsönmez A (2016). "Meckel diverticulum in children: Evaluation of macroscopic appearance for guidance in subsequent surgery". J. Pediatr. Surg. 51 (7): 1177–80. doi:10.1016/j.jpedsurg.2015.08.066. PMID 26435520.
- ↑ McKay R (2007). "High incidence of symptomatic Meckel's diverticulum in patients less than fifty years of age: an indication for resection". Am Surg. 73 (3): 271–5. PMID 17375785.
- ↑ Hosn MA, Lakis M, Faraj W, Khoury G, Diba S (2014). "Laparoscopic approach to symptomatic meckel diverticulum in adults". JSLS. 18 (4). doi:10.4293/JSLS.2014.00349. PMC 4254485. PMID 25489221.
- ↑ Alemayehu H, Stringel G, Lo IJ, Golden J, Pandya S, McBride W, Muensterer O (2014). "Laparoscopy and complicated meckel diverticulum in children". JSLS. 18 (3). doi:10.4293/JSLS.2014.00015. PMC 4208888. PMID 25392652.
- ↑ Ruscher KA, Fisher JN, Hughes CD, Neff S, Lerer TJ, Hight DW, Bourque MD, Campbell BT (2011). "National trends in the surgical management of Meckel's diverticulum". J. Pediatr. Surg. 46 (5): 893–6. doi:10.1016/j.jpedsurg.2011.02.024. PMID 21616248.
- ↑ Chan KW, Lee KH, Mou JW, Cheung ST, Tam YH (2008). "Laparoscopic management of complicated Meckel's diverticulum in children: a 10-year review". Surg Endosc. 22 (6): 1509–12. doi:10.1007/s00464-008-9832-0. PMID 18322735.