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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 27-30

Laparoscopic diverticulectomy for a gangrenous Meckel's diverticulitis mimicking acute appendicitis in an adult


1 Department of General and Laparoscopic Surgery, Sriram Hospital Pvt. Ltd., Patna, Bihar, India
2 Consultant Surgeon, Shrinivas Hospital Pvt. Ltd., Patna, Bihar, India

Date of Submission17-Jun-2020
Date of Acceptance14-Sep-2020
Date of Web Publication06-May-2021

Correspondence Address:
Dr. Neeti Neha
Consultant Surgeon, Shrinivas Hospital Pvt. Ltd., Patna, Bihar- 800 020
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_28_20

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  Abstract 


Johann Friedrich Meckel was the first to feature the anatomy and embryology of a diverticulum in 1809, as an incomplete obliteration of the omphalomesenteric duct, and named this as Meckel's diverticulum. Since then, lots of facts have been gained about its presentations and treatments. When a surgeon encounters a Meckel's diverticulitis with a normal base instead of an inflamed appendix in a patient with acute pain in the right iliac fossa, diverticulectomy should suffice. We present a patient with clinical features of acute appendicitis but was found to have torsion and gangrene of a Meckels diverticulum. This was successfully managed by laparoscopic diverticulectomy with a hand-sewn technique. Laparoscopy has utility in the treatment of complicated Meckel's diverticulitis.

Keywords: Appendicitis, diverticulectomy, laparoscopic diverticulectomy, Meckel's diverticulitis


How to cite this article:
Sinha NK, Neha N. Laparoscopic diverticulectomy for a gangrenous Meckel's diverticulitis mimicking acute appendicitis in an adult. Arch Int Surg 2020;10:27-30

How to cite this URL:
Sinha NK, Neha N. Laparoscopic diverticulectomy for a gangrenous Meckel's diverticulitis mimicking acute appendicitis in an adult. Arch Int Surg [serial online] 2020 [cited 2021 Jun 16];10:27-30. Available from: https://www.archintsurg.org/text.asp?2020/10/1/27/315396




  Introduction Top


Meckel's diverticulum represents an embryonic remnant of the omphalomesenteric duct, after 10th intrauterine week. Omphalomesenteric duct is defined as a tubular structure joining fetal midgut to yolk sac. While Meckel's diviticulum constitute about 98% of all resulting anomalies, others may include Omphaloileal fistula, Umbilical sinus, Duct cyst and Fibrous cord.

Johann Friedrich Meckel classified the diverticulum as true diverticulum, containing derivations of ectoderm, mesoderm, and endoderm. A chain of “2”s have been linked to the entity. This occurs in 2% of population, situated more commonly 2 feet (60 cm) from the ileocecal valve, 2 inches (5 cm) length, 2 cm diameter, often is symptomatic before 2 years of age, usually lined by 2 types of heterotypic tissue (gastric and pancreatic), and 2 times more common in males than in females. Studies have shown that the possibility of Meckel's becoming symptomatic is 4% under 20 years of age, reducing to 2% at 40 years and nil in elderly age group. The diverticulum derives its blood supply from the vestige of the vitelline artery, derived from superior mesenteric artery or ileocolic artery to be precise. Two types of bands are common accompaniments of this clinical condition:

  • Mesodiverticular band connects it to retroperitoneum or mesentery
  • Omphalodiverticular band joins it to umbilicus[1],[2],[3]


Management has been debated for long, until a consensus came. If obscured without symptoms and found in surgical theater, prophylactic diverticulectomy is warranted only when having a narrowed neck, in younger age group <50 years, diverticulum length >2 cm, or with palpable or visual abnormality ascertained. When overt, Meckel's diverticulum is usually associated with complications including bleeding (due to heterotopic mucosa) in children, intestinal obstruction and diverticulitis in adults. Rare presentations are perforation, intussusception, hernia, and tumor. Accordingly, surgical options have been standardized as diverticulectomy with closure of intestine, and wedge or segmental resection and anastomosis, if base of diverticulum is resected from the adjacent ileum or there is definite presence of ectopic tissue. Imaging modalities range from sonography, computer-assisted tomography scan and conclusive nuclear technetium 99 m scan, but only when a Meckel's diverticulum is foreseen.[4]


  Case Report Top


We would restrict our discussion to a case encountered and therapeutic option planned. A 30-year-old febrile young man presented to emergency department with severe pain right iliac fossa, nausea and anorexia of 2 days duration. There was no history of vomiting, diarrhea, melena or hematochezia, or urinary complaints. There was no previous medical or surgical history. On examination, pulse rate was 120/min, with other vitals stable. Abdominal evaluation revealed tenderness at the right iliac fossa with guarding. Bowel sounds were normal. Hernial orifices and per rectal examinations were within normal limits. Other systemic examination did not show any clinical abnormality. Lab reports had shown leukocytosis with neutrophilia and raised ESR. Blood sugar, SGPT, and serum creatinine were within normal range. Ultrasound scan suggested 10.5-mm-sized inflamed retrocaecal appendix with a surrounding phlegmon. Multiple reactive lymphadenopathy were present. A diagnosis of acute appendicitis was made which mandated us to plan laparoscopic appendectomy. We proceeded with the conventional 3 ports, one 5 mm supraumbilical camera port, and other two 5 mm working channels in right and left lower quadrants to obtain a proper triangulation. On exploration, an axially torsed gangrenous diverticula situated around 2 feet from ileocaecal junction left no doubts about the diagnosis of Meckel's diverticulitis. A mesodiverticular band was found as the culprit and primitive vitelline artery was so very obvious. After dividing the band harmonically and detorsing, we found a gangrenous Meckel's with narrowed base, but clearly intact with the adjoining ileum [Figure 1]. We tied the Meckel's base like a sac to avoid the toxic fluid contamination. Patient having no clinical history of bleeding per rectum, we opined to do a laparoscopic diverticulectomy and hand sewing the ileal defect transversely intracorporeally, because of unavailability of staplers [Figure 2]. A prophylactic appendectomy followed by peritoneal toileting was performed. The entire surgery was concluded laparoscopically. The suture used was vicryl (polyglactin 910), number 2-0. Appendix was delivered from the 5 mm left lower quadrant port. The other specimen was delivered after converting a 5 mm left lower quadrant port to 10 mm [Figure 3]. We restricted ourselves not beginning the surgery with 10 mm umbilical port to avoid the extra wear shear forces applicable. Alternatively, both can be delivered in a single endobag. Postoperative biopsy reports were favorable, suggesting no heterotopic mucosa [Figure 4]. The pathologist also reported a normal-appearing appendix specimen. Patient was allowed liquids orally on postoperative day 1, had an uneventful hospital course, and discharged on postoperative day 3.
Figure 1: (From upper left clockwise) Photographs showing a band attached to tip of a gangrenous structure, which revealed a tubular structure, probably vestigial vitelline artery; axially torsed diverticulum, the culprits concluded were mesodiverticular band and narrowed neck; its attachment to ileum

Click here to view
Figure 2: (From upper left clockwise) Photographs showing tied neck of gangrenous Meckel's, avoiding toxic fluid contamination; post diverticulectomy, transverse suturing second layer (first-full thickness continuous; second-seromuscular interrupted with vicryl number 2-0 polyglactin 910) to avoid gut lumen narrowing

Click here to view
Figure 3: (From upper left clockwise) Photographs showing prophylactic appendectomy, the specimens kept in right iliac fossa; Meckel's being taken out in endobag, through left lower quadrant. The transected appendix was delivered earlier. Matching surgeon's convenience, both can be put in endobag

Click here to view
Figure 4: (From upper left clockwise) Preoperative sonographic scan showing clear cut features of appendicitis; postoperative specimen (hematoxylin eosin stained)-40× view showing normal ileal mucosa [a] and pathologic [b]-focal desquamation (solid arrow), dense inflammatory cells infiltrate (broken arrow), no heterotopia

Click here to view



  Discussion Top


Laparoscopy has definite advantages over open techniques in all sectors of surgery. To enumerate are broader field of vision, less hospital stay, better cosmesis and last but not the least, herniation complications. This relies on a magnified vision with precise hand eye co-ordination for dissection. Laparoscopic diverticulectomy with hand sewing of the ileum renders an economically sound surgical option with all benefits of laparoscopy.[5],[6],[7],[8] Motta Ramirez et al. in a study of 7 patients in 2014 stated that in cases of high suspicion, computer-assisted tomography scan is the best to look for Meckel's diverticulum and rule out acute appendicitis.[9] Rivas et al.[10] in 2003 reported a study on 4 patients of Meckel's and described laparoscopy as a safe, cost effective, efficient in diagnosis and management and propagated the practice of exploratory laparoscopy over nuclear scintigraphy. Smoot et al. in 2007 studied the common occurrence in adults and also reported laparoscopy as a mode of diagnosis and therapeutics, however, suggested that a successful outcome depends upon the ability to predict the extent of resection based on the external appearance of the diverticulum.[11] Laparoscopy-assisted Meckel's diverticulectomy, by delivering through transumbilical incision and extracoporeal anastomosis was described by Papparella et al. in 2014.[5] Complications were the same as could be imagined in any open technique, with added dismay of increased herniation chances and poor cosmesis, losing the charm of minimal access surgery.

Limitations

Laparoscopy, since its infancy, has called for high precision and longer learning curve, lest there is always a fear of a mishap or longer operative times. This would in turn curtail the advantages of doing a minimal access surgery. One very obvious prerequisite in our case is basic acquaintance with intracorporeal knotting techniques.


  Conclusion Top


This study adds to the existing literature on laparoscopic surgery. Laparoscopic diverticulectomy with hand sewing of ileum can be offered as a surgical option, where limited finances are involved or where there is lack of conviction of any sort in using endostaplers.

Acknowledgement

We feel indebted to the radiologist, pathologist, anesthetist, OT staff, and the patient for all the assistance provided. The surgery was performed in the theater of Sriram Hospital Pvt. Ltd., Patna, Bihar- 800020, India by Dr. Nawneet Kumar Sinha.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Barolia DK, Singh AP, Tanger R, Gupta AK, Chaturvedi V, Tuteja N. Demography of the remnant of omphalomesenteric duct. Formosan J Surg 2019;52:201-6.  Back to cited text no. 1
    
2.
Markogiannakis H, Theodorou D, Toutouzas KG, Drimousis P, Panoussopoulos SG, Katsaragakis S. Persistent omphalomesenteric duct causing small bowel obstruction in an adult. World J Gastroenterol 2007;13:2258-60.  Back to cited text no. 2
    
3.
Celebi S, Ozaydin S, Polat E, Basdas C, Alim ER, Sander S. Vitelline duct pathologies in neonates. North Clin Istanb 2018;5:211-5.  Back to cited text no. 3
    
4.
Walsh D. Meckel's diverticulectomy. Available from: sages.org/wiki/meckels-diverticulectomy/.  Back to cited text no. 4
    
5.
Papparella A, Nino F, Noviello C, Marte A, Parmeggiani P, Martino A, et al. Laparoscopic approach to Meckel's diverticulum. World J Gastroenterol 2014;20:8173-8.  Back to cited text no. 5
    
6.
Wong CS, Dupley L, Varia HN, Golka D, Linn T. Meckel's diverticulitis: A rare entity of Meckel's diverticulum. J Surg Case Rep 2017;2017:rjw225.  Back to cited text no. 6
    
7.
Blouhos K, Boulas KA, Tsalis K, Barettas N, Paraskeva A, Kariotis I, et al. Meckel's diverticulum in adults: Surgical concerns. Front Surg 2018;5:55.  Back to cited text no. 7
    
8.
Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ 3rd. Surgical management of Meckel's diverticulum. An epidemiologic, population-based study. Ann Surg 1994;220:564-9.  Back to cited text no. 8
    
9.
Motta-Ramírez GA, Reyes-Méndez E, Campos-Torres J, García-Ruiz A, Rivera-Méndez VM, García-Castellanos JA, et al. Meckel's diverticulum in adults. An Radiol Mexico 2015;14:20-30.  Back to cited text no. 9
    
10.
Rivas H, Cacchione R, Allen J. Laparoscopic management of Meckel's diverticulum in adults. Surg Endosc 2003;17:620-2.  Back to cited text no. 10
    
11.
Smoot RL, Peoples JT, Hanson GJ, Zietlow SP, Donnelly SF. Meckel's diverticulum in adults: More common than you think. HCP Live. December 10, 2007.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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