Meckel’s Diverticulum was first described about 400 years ago and continues to be a rare congenital disorder. Laparoscopic surgery for Meckel’s Diverticulum has been described in mostly case reports.
We present a case presented with recurrent appendicitis, during appendectomy we found another mass which preoperatively sonologist mentioned as old abscess. On exploration it was drumstick tip of Tubular structure attached to small gut ( Meckles Diverticulum).
After appendectomy we continued Hand Assisted Laparoscopic Meckles Diverticulectomy.
INTRODUCTION
Meckel’s diverticulum is a rare condition. Its incidence is usually quoted as approximately 2% of the population, but the prevalence can vary from 0.2% to 2%.1 The male to female ratio of symptomatic diverticulum is 3:1. It is a diverticular remnant of the omphalomesenteric duct located on the antimesenteric border of the ileum, a short distance from the cecum (60 cm proximal to the ileocecal valve). On average, the diverticulum is 2.99-cm long and 1.92-cm wide. Although jejunal, colonic, rectal, pancreatic, duodenal, and endometrial tissues have all been found in the diverticulum, the heterotopic mucosa is likely to be gastric in origin in 80% of cases.2 As a result, the gastric acid secreted from this lining erodes tissue ultimately causing hemorrhage. Diagnosis of a bleeding Meckel’s diverticulum is established by technetium Tc 99m-pertechnate scan (“Meckel scan”). Laparoscopy, however, is the most accurate diagnostic tool.3 Laparoscopic resection of perforated Meckel’s diverticulum in a patient with clinical symptoms of acute appendicitis was first reported in 1992 by Ng et al.4
Treatment
The open Hasson technique was used to establish pneumoperitoneum the patient, with the intra-abdominal pressure being maintained at 12mm Hg. A 10-mm trocar was inserted into the umbilicus; a 5-mm trocar was introduced in the suprapubic area, and another 10-mm trocar in the left lower quadrant, under direct vision. A 10-mm (30°) laparoscope was introduced into the 10-mm port for diagnostic laparoscopy. An inflammatory mass, drum stick attached to tip of Meckel’s diverticulitis was seen. The bowels were gently separated by using the tip of a suction nozzle, which revealed a pocket of pus. A thorough peritoneal washing was performed, and the decision to resect the diverticulum was made. Left iliac fossa 10 mm port removed, incision enlarged up to 12 mm, Meckel’s diverticulum delivered out . Wedge resection performed, small gut returned back in abdomen. Appendectomy was also performed. A drainage tube was kept in
DISCUSSION
Meckel’s diverticulum is the most common form of congenital abnormality of the small intestine, resulting from an incomplete obliteration of the vitelline duct. Although originally described by Fabricius Hildanus in 1598, it is named after Johann Friedrich Meckel, who established its embryonic origin between 1808 and 1820.4 The tip of the diverticulum is free in 75% of cases, and in 25% the tip is attached to another organ or structure by means of a band.5 Most patients are asymptomatic, and it is usually an incidental finding when a barium study or laparotomy is performed for other abdominal conditions. Complications include bowel obstruction, hemorrhage, diverticulitis, umbilical fistula, perforation, other umbilical lesions, and intussusception.6 Meckel’s diverticulitis may mimic appendicitis, and the correct diagnosis is usually established at the time of laparotomy or laparoscopy. None of the clinical features are pathognomonic, and the diagnosis is rarely made preoperatively. Routine laboratory studies, such as leukocyte and erythrocyte counts, serum electrolytes, blood glucose, and urea serum creatinine, and coagulation screen were helpful in the general workup. These tests showed evidence of acute infection. CT and USG have been used to diagnose Meckel’s diverticulum, but despite the availability of modern imaging techniques, the diagnosis is still challenging. So far, only case reports have been appearing in the literature regarding laparoscopic surgery for symptomatic Meckel’s diverticula. Laparoscopy is especially more useful in this situation as it is clinically difficult to distinguish between diverticulitis and appendicitis.7 Definitive treatment of a complication, such as a bleeding, is the excision of the diverticulum. Successful resection of a Meckel’s diverticulum can also be accomplished through laparoscopy, using endostapling devices or Hand assisted .8The advantages and benefits of minimal access surgery can be truly appreciated in children with symptomatic Meckel’s diverticulum. Excision is mandatory for all symptomatic diverticula. With the advent of gastrointestinal stapling devices, excision has become safer, faster, and more efficient. Another advantage of stapling is that it closes the bowel lumen as it cuts, thereby completely reducing the chance of peritoneal contamination. The only drawback is the high cost.
To summarize, a diagnosis of Meckel’s diverticulitis is rarely made preoperatively, especially in adults. Tangential excision of a symptomatic Meckel’s diverticulum using endostaplers is sufficient, provided the base is normal. Otherwise, wedge resection or segmental bowel resection is recommended. Asymptomatic diverticula can be left in situ. Appendectomy should be performed in all patients with Meckel’s diverticulitis.
CONCLUSION
Laparoscopy seems to have a definite role in both adult and pediatric patients with symptomatic Meckel’s diverticulum, especially when the diagnosis is in doubt. Laparoscopy also provides all the benefits of minimally invasive surgery like reduced morbidity, early discharge, and better cosmesis.
References:
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