Page 17 - Journal of Laparoscopic Surgery

WJOLS

Current Laparoscopic Management of Symptomatic Meckel’s Diverticulum

performed in seven patients and excision of diverticulum postoperative complications are likely to occur in approximately
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performed in two. The mean operative time was 70 minutes 7% of patients. Significantly, this study also showed that even
(range, 40-100 minutes). There were no operative complications. incidental diverticulectomies carried an operative surgical
The histology of the resected MDs showed ectopic gastric mortality and morbidity risk of 1 and 2% respectively as well as
mucosa in all eight patients, associated with focal ulceration in a risk of long-term complications in 2% of patients.
two. The authors reported no operative complications. Median Complicated Meckel’s diverticulum is thus by no means an
hospital stay was four days (range, 3-7 days). At a median innocuous diagnosis and highlights the need for both a reliable
follow-up of 24 months (range, 3-51 months), all patients were diagnostic and therapeutic tool to optimize management in these
asymptomatic. patients. Advances in minimal access surgery, we may now
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The series by Palanivelu et al 2008 included 12 patients provide us with such a tool. The low incidence of symptomatic
with symptomatic Meckel’s diverticulum treated from 1994 to Meckel’s diverticulum in the general population implies that
2006. All the patients presented with features of either high-powered randomized controlled trials comparing various
appendicitis or peritonitis, some with a vague abdominal mass. modes of laparoscopic and even open surgical procedures are
Clinical diagnosis of Meckel’s diverticulum was made in only unlikely to occur. As such institutional experience becomes
four patients. Diagnostic laparoscopy confirmed Meckel’s increasingly significant in determining optimal management of
diverticulitis in all patients. The open Hasson technique was this condition.
used to establish pneumoperitoneum. A 10 mm trocar was As laparoscopic appendicectomy and diagnostic
inserted into the umbilicus followed by two working ports, a laparoscopy increasingly gain popularity, it is more likely that
5 mm suprapubic port and another 5 mm port in the right lower the diagnosis of complicated Meckel’s diverticulum will be made
quadrant; both introduced under vision. A 10 mm (300) with the use of a laparoscope, particularly in patients presenting
laparoscope was introduced into the 10 mm port for diagnostic with an acute abdomen. At this point, the surgeon has three
laparoscopy. Laparoscopic stapler resection of the lesions was therapeutic options, namely proceed with LMD which implies
performed for all patients using an endostapler-cutter which intracorporeal diverticulectomy; LAMD; or if the pathology
was introduced into a 12 mm trocar, replacing the 10 mm umbilical warrants conversion to open surgery. Conversion to open
trocar. Tangential excision was performed in 10 patients and surgery is likely to be required in patients with gangrenous
wedge excision in two patients in whom the base of the bowel, irreducible intussusception or alternate diagnosis.
diverticulum was thought to be inflamed. Routine Diverticulum morphology may also influence surgical
appendicectomy was performed for all patients. management. Mukai et al suggest that the external appearance
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No cases of staple line leaks were reported in this study. of the diverticulum indicates the distribution of the HGM and
One patient had infection of the umbilical wound, which was as such would influence the choice of laparoscopic procedure.
treated with the appropriate antibiotics. One patient had According to their results, long diverticula (more than 1.6 HD
postoperative pneumonitis, treated with intravenous antibiotics ratio) have HGM only in the distal area, while short diverticula
for 5 days. Histopathology of the diverticulum showed (less than 1.6 HD ratio) have HGM in almost all areas. In long
heterotopic gastric mucosa in 11 (73%) patients, pancreatic diverticula, simple transverse resection with a stapling device
tissue in one (27%) patient, evidence of acute inflammation in would be acceptable provided immediate frozen section analysis
nine patients and perforation in three patients. The day of is present to ensure that the stump does not contain HGM. For
discharge was in the range of the fourth to the seventh short diverticula, wedge resection or ileal resection with end-
postoperative day. Eight patients were followed up for 24 months to-end anastomosis after exteriorization would be more
and four patients reported for follow-up after 45 months. All appropriate. Adequate resection of heterotropic mucosa is
were found to be symptom free. mandatory, not only because residual mucosa may result in
persistence of symptoms following surgery, but also because
DISCUSSION
of its possible neoplastic potential. 10
Meckel’s diverticulum, even today still presents as a diagnostic The incidence of heterotropic mucosa in the analysis of the
and therapeutic challenge. As already stated, the majority of studies included in this review is calculated to be 78.2%. As
people with Meckel’s diverticulum are asymptomatic. Cullen such LAMD with exteriorization of the diverticulum, wedge
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et al found the lifetime risk of complications in people with resection and ileal repair would be the preferred procedure,
Meckel’s diverticulum to be 6.4%. The potential for given that it allows for tactile examination of the diverticulum,
complications though may be greater in people who are less wedge excision, without significant differences in outcome and
than 50 years of age; male; have diverticuli greater than 2 cm in has the added cost-saving benefit of avoiding use of an
length; and in diverticuli that contain heterotropic mucosa. 1 endostapler-cutter device (Table 1).
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Cullen et al also showed that surgery for complicated A second distinct group of patients are those in whom the
Meckel’s diverticulum is associated with significant operative diagnosis of Meckel’s diverticulum is suspected preoperatively.
mortality and morbidity, 2 and 12% respectively. Long-term These patients are more likely to have presented with lower

World Journal of Laparoscopic Surgery, September-December 2011;4(3):140-145 143