Page 16 - Journal of Laparoscopic Surgery

Morvendhran Moodley

LAMD was performed for bleeding and for those patients trocars are inserted in the lower quadrants. The MD is pulled
with short incidental MDs, with height-to-width ratio (HD ratio) through the umbilical incision and resected extracorporeally.
less than 1.6, so as to ensure complete removal of ectopic mucosa The umbilical incision is slightly enlarged to accommodate the
that may line the proximal end of MD and adjacent ileal mucosa. bowel.
The intestinal segment bearing MD was delivered through the Four patients underwent the three-trocar technique
umbilical port site to the abdominal surface. Small bowel (LAP, n = 4). The remaining five underwent the video-assisted
resection and anastomosis were then accomplished transumbilical single-trocar technique (VAT, n = 5) procedure.
extracorporeally either by manual suturing or by an endostapler- In this study, the choice of the technique of resection was left
cutting device. to the discretion of the surgeon. Indications for surgery included
LMD was performed for long MDs, either symptomatic or gastrointestinal bleeding (VAT, n = 3; LAP, n = 2), malrotation
incidental with HD ratio greater than 1.6. The tip of the MD was (LAP, n = 2), intussusception (VAT, n = 1) and abdominal pain
held and pulled toward the anterior abdominal wall and an (VAT, n = 1). All patients were male, and age ranged from
endolinear-stapler-cutter device was applied obliquely to its 7 months to 17 years for the VAT group and 8 months to
base to remove all the diverticular tissue without threatening 15 years for the LAP group.
the ileal lumen. The average length of surgery for the LAP vs VAT was
In those cases where no lesions were found on diagnostic 128 minutes (94-170 minutes) and 81.4 minutes (42-96 minutes)
laparoscopy, laparoscopic appendectomy (LA) alone was respectively. Of the five patients undergoing LAP, two Ladd’s
carried out. procedures and three appendectomies were included during
In all, LMD and LAMD were done for 18 and 12 MDs, the same anesthesia. Only a single appendectomy procedure
respectively. was performed during a VAT. The average time until full feeds
The mean operative time was as follows: with the LAP and VAT was 4.3 days (2-8 days) and 2.0 days
• 45 minutes for LA and LMD was 45 minutes (1-3 days) respectively. The overall length of stay with LAP vs
• 55 minutes for LA and LAMD was 55 minutes VAT was 4.3 days (2-8 days) and 3.7 days (2-5 days). Only one
• The mean operative time for LA and laparoscopic release case using the LAP method required conversion to an open
of intussusception was 30 and 35 minutes respectively. laparotomy because of unclear anatomy. The only complication
Long MD with HD ratio greater than 1.6 was found in reported was a single patient who developed postoperatively
18 cases. Short MD with HD ratio less than 1.6 was found in ileus in the LAP group.
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12 cases. The histopathologic studies confirmed heterotopic Chan et al report their 10-year experience with laparoscopic
gastric mucosa (HGM) in 13 cases (43.3%). HGM was present management of complicated Meckel’s diverticulum cases
in the distal end of six long cases and in seven short MDs; it presenting in childhood from 1998 to 2007. Their study group
was found in the proximal end. contained 20 children (17 males and 3 females), with a mean age
No intraoperative or postoperative complications occurred. of 5 years, ranging from 7 months to 13 years.
Mean hospital stay in this study group was 1.66 ± 0.8 days Diagnostic laparoscopy was performed on all patients and
(range, 1-5 days). No postoperative complications were reported. proceeded successfully to laparoscopically-assisted
All patients were reported to be asymptomatic after 1 year of transumbilical Meckel’s diverticulectomy in 18 patients. Two
follow-up. patients required conversion to open surgery due to nature of
4
Clark et al conducted a retrospective chart review of patients the pathology. The mean operative time was 115 minutes with a
who underwent laparoscopic excision of MD from 2000 to 2005 range from 50 to 190 minutes. All the children had an uneventful
at their center. Nine patients were identified. They describe a recovery, except one, who experienced a postoperative wound
3 port, laparoscopy-assisted procedure (LAP) and a single port infection. Ectopic gastric mucosa was found in 14 cases. Mean
video-assisted transumbilical procedure (VAT). hospital stay reported was 6.9 days (range of 5-9 days).
6
Cobellis et al describe their experience with nine patients
VAT Technique with a median age of 6.1 years (range, 6 months to 13.6 years)
A 10 mm trocar is placed through a vertical, transumbilical incision who underwent single trocar transumbilical laparoscopic-
and a pneumoperitoneum is established. A 10 mm, zero degree, assisted procedures for Meckel’s diverticulum between January
operative laparoscope with a 400 mm atraumatic grasper is used 2001 and December 2004. They used an intraumbilical Hassan
to run the bowel and to locate the MD. The MD is pulled through 10 mm trocar inserted in an open fashion after which a 10 mm
the umbilical incision and resected extracorporeally. The operative laparoscope was introduced. Using an atraumatic
umbilical incision is slightly enlarged to accommodate the bowel. instrument, the terminal ileum was grasped exteriorized through
the umbilicus allowing ileal exploration and treatment to be
LAP Technique performed extracorporeally.
A 10 mm trocar is placed through a vertical, transumbilical incision Meckel’s diverticulum was identified in eight patients and
and a pneumoperitoneum is established. Two working 5 mm ileal duplication in one patient. Resection/anastomosis was

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