Page 15 - Journal of Laparoscopic Surgery

WJOLS

Current Laparoscopic Management of Symptomatic Meckel’s Diverticulum

management. Search revealed 20 articles, of which those reported, neither was there any need for conversion to open
published after the year 2000 were reviewed, and the search surgery in any of the procedures. The hospital stay ranged
further expanded to include related citations. Articles describing from 3 to 9 days (mean 5.3 ± 1.2). There were three (8.3%) cases
laparoscopic management of Meckel’s diverticulum were then of postoperative adhesive intestinal obstruction; two
selected for analysis. A description of the various procedures, underwent successful laparoscopic adhesiolysis and one
as provided by the various authors is included. Attention is necessitated conversion to suprapubic laparotomy to release
paid to key variables namely, mean operative time, intraoperative the pelvic adhesions. Over the 16 months median follow-up
complications, duration of postoperative hospitalization and period, no other complications were reported.
results tabulated to allow for easy comparison. Ranitidine augmented 99mTc scintigraphy was performed
in 14 out of the 16 patients presenting with lower GI bleeding
RESULTS
and was suggestive of gastric heterotopia in 12 patients (85.7%).
The largest published series since 2000, was that by Sai Prasad Histopathological analysis found 15 out of the 16 patients
2
et al. This was a review of 36 patients (27 males and 9 females) (93.7%) to have gastric with or without pancreatic heterotopia.
who underwent laparoscopic-assisted transumbilical Meckel’s Overall, this study found ectopic gastric, pancreatic or duodenal
diverticulectomy (LATUM) between October 2002 and April epithelium in 25 patients (69.4% of the study population). Five
2006. (50%) of the incidentally detected MD showed gastric
The procedure described in this series was a two or three heterotopia.
port technique using first a 10 mm umbilical port for the Shalaby et al reviewed the clinical data of 33 children
3
laparoscope inserted by the Hassan technique and combined who were admitted with rectal bleeding and/or recurrent
with two 5 mm operating ports inserted in the left iliac fossa and abdominal pain with no identifiable cause, over a period of
suprapubically. The second operating port being omitted for 8 years, at their institution. This study group consisted of
cases of bleeding MD. 23 male patients and 10 females with a mean age of 5.12 years
After systematic laparoscopic examination of the intra- (range, 3-12 years). In 21 cases, Meckel’s diverticulum was an
abdominal contents, Meckel’s diverticular complications when incidental finding on laparoscopic appendectomy and
present were managed laparoscopically, following which the symptomatic in 12 cases. Preoperative workup for patients with
freed MD was delivered through an extension of the linea alba, rectal bleeding included upper gastrointestinal endoscopy;
while maintaining the skin incision within the umbilical cicatrix,
to allow extracorporeal diverticulectomy and hand-sewn colonoscopy and technetium Tc 99m-labeled pertechnetate scan
in the addition to the routine investigations performed for all
intestinal anastomosis. The authors describe their procedure
as LATUM. In this study, one patient with a torted MD other patients.
underwent intracorporeal diverticulectomy after endoloop Pneumoperitoneum was created by open Hasson’s
ligation of the base. technique using a 12 mm port to a pressure of 12 mm Hg.
Clinical presentation of patients in this study population Through this port, a 10 mm telescope was used for initial
was as follows: visualization of the whole abdomen and two 3 mm accessory
• Sixteen (44.4%) patients presented with lower ports were inserted on both sides of the lateral borders of the
gastrointestinal bleeding (14 with painless bleed and 2 with rectus muscle below the level of the umbilicus. Following
perforated peptic ulcer in the ileum adjacent to the MD). complete laparoscopic visualization of the abdomen, the
• Six (16.7%) patients presented with intestinal obstruction ileocecal segment was identified and the terminal ileum was
(four due to a mesodiverticular band and one each due to examined stepwise from ileocecal junction proximally using
intussusception and floppy giant cystic dilatation of MD atraumatic graspers.
causing intestinal compression) Laparoscopy was able to make a correct diagnosis in all 12
• Four (11.1%) patients presented with features masquerading symptomatic patients. These included MD (n = 8),
as appendicitis (one with Meckel’s diverticulitis and intussusception secondary to M (n = 1), duplication of distal
perforation, one with perforated peptic ulcer adjacent to ileum (n = 1) and no pathology was identified on detailed laparos-
MD and two with a torted and gangrenous MD) copic examination.
• Ten (27.8%) patients, incidental MD with a narrow, base If a Meckel’s diverticulum was identified, a 3.3 mm telescope
were noted at laparoscopic exploration for suspected was placed through the left accessory port leaving the umbilical
appendicitis. port free for either application of a endostapler-cutter and
All patients underwent successful LATUM along with specimen extraction (LMD-Laparoscopic Meckel’s
appendicectomy. Diverticulectomy) or for exteriorization of the diverticulum to
LATUM along with appendicectomy was successfully facilitate laparoscopy-assisted Meckel’s diverticulectomy
performed in all patients. (LAMD).
Mean operative duration was 125.9 ± 48.4 minutes, ranging The choice of whether LAMD or LMD was based on the
from 72 to 266 minutes. No intraoperative complications were appearance of the MD.

World Journal of Laparoscopic Surgery, September-December 2011;4(3):140-145 141