Meckel's diverticulum surgery: Difference between revisions
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==Overview== | ==Overview== | ||
[[Surgery]] is the preferred [[modality]] of treatment in [[Patient|patients]] with Meckel's diverticula.<ref name="pmid18216533">{{cite journal |vauthors=Zani A, Eaton S, Rees CM, Pierro A |title=Incidentally detected Meckel diverticulum: to resect or not to resect? |journal=Ann. Surg. |volume=247 |issue=2 |pages=276–81 |year=2008 |pmid=18216533 |doi=10.1097/SLA.0b013e31815aaaf8 |url=}}</ref><ref name="pmid15729078">{{cite journal |vauthors=Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR |title=Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002) |journal=Ann. Surg. |volume=241 |issue=3 |pages=529–33 |year=2005 |pmid=15729078 |pmc=1356994 |doi= |url=}}</ref><ref name="pmid25065089">{{cite journal |vauthors=Lohsiriwat V, Sirivech T, Laohapensang M, Pongpaibul A |title=Comparative study on the characteristics of Meckel's diverticulum removal from asymptomatic and symptomatic patients: 18-year experience from Thailand's largest university hospital |journal=J Med Assoc Thai |volume=97 |issue=5 |pages=506–12 |year=2014 |pmid=25065089 |doi= |url=}}</ref><ref name="pmid28359587">{{cite journal |vauthors=Robinson JR, Correa H, Brinkman AS, Lovvorn HN |title=Optimizing surgical resection of the bleeding Meckel diverticulum in children |journal=J. Pediatr. Surg. |volume=52 |issue=10 |pages=1610–1615 |year=2017 |pmid=28359587 |doi=10.1016/j.jpedsurg.2017.03.047 |url=}}</ref> | [[Surgery]] is the preferred [[modality]] of treatment in [[Patient|patients]] with Meckel's diverticula. | ||
General principles of [[Abdomen|abdominal]] [[surgery]] for [[Pre-operative clearance|preoperative]] (including [[antibiotic]] use), intraoperative and postoperative management of Meckel's diverticulum are followed by [[Surgery|surgeons]]. <ref name="pmid18216533">{{cite journal |vauthors=Zani A, Eaton S, Rees CM, Pierro A |title=Incidentally detected Meckel diverticulum: to resect or not to resect? |journal=Ann. Surg. |volume=247 |issue=2 |pages=276–81 |year=2008 |pmid=18216533 |doi=10.1097/SLA.0b013e31815aaaf8 |url=}}</ref><ref name="pmid15729078">{{cite journal |vauthors=Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR |title=Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002) |journal=Ann. Surg. |volume=241 |issue=3 |pages=529–33 |year=2005 |pmid=15729078 |pmc=1356994 |doi= |url=}}</ref><ref name="pmid25065089">{{cite journal |vauthors=Lohsiriwat V, Sirivech T, Laohapensang M, Pongpaibul A |title=Comparative study on the characteristics of Meckel's diverticulum removal from asymptomatic and symptomatic patients: 18-year experience from Thailand's largest university hospital |journal=J Med Assoc Thai |volume=97 |issue=5 |pages=506–12 |year=2014 |pmid=25065089 |doi= |url=}}</ref><ref name="pmid28359587">{{cite journal |vauthors=Robinson JR, Correa H, Brinkman AS, Lovvorn HN |title=Optimizing surgical resection of the bleeding Meckel diverticulum in children |journal=J. Pediatr. Surg. |volume=52 |issue=10 |pages=1610–1615 |year=2017 |pmid=28359587 |doi=10.1016/j.jpedsurg.2017.03.047 |url=}}</ref> | |||
=== Asymptomatic Meckel’s diverticulum === | === Asymptomatic Meckel’s diverticulum === | ||
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** [[Wedges|Wedge]] [[resection]] of the [[diverticulum]] along with the adjacent [[Small intestine|intestinal wall]], followed by suture closure | ** [[Wedges|Wedge]] [[resection]] of the [[diverticulum]] along with the adjacent [[Small intestine|intestinal wall]], followed by suture closure | ||
Special surgical considerations are required in | * Special surgical considerations are required in case of: | ||
** Meckel's [[diverticulitis]]: In a case of suspected [[appendicitis]] where [[Vermiform appendix|appendix]] is normal on [[Laparotomy|surgical exploration]], the [[Ileum|distal ileum]] must be examined for signs of [[diverticulitis]] | |||
** [[Umbilical]] [[fistula]] and [[sinus]]: In such cases, [[umbilical]] [[excision]] may be necessary | |||
** Broad based [[Diverticular|diverticula]] in children: Segmental [[resection]] is preferred as the risk of [[Ileum|ileal]] [[stenosis]] is high if wedge [[resection]] or diverticulectomy is performed | |||
** [[Bowel obstruction]]: The extent of [[excision]] is determined by the viability of the [[Intestine|intestinal]] wall | |||
** [[Bleeding|Hemorrhage]] : Segmental or [[Wedges|wedge]] [[resection]] may be used for [[excision]] of [[Ulcer|ulcerated]] [[Intestine|bowel]] and [[Stomach|gastric]] [[Mucous membrane|mucosa]] | |||
Principles of surgical treatment include the following: | Principles of surgical treatment include the following: | ||
Revision as of 22:11, 4 January 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]
Overview
Surgery is the preferred modality of treatment in patients with Meckel's diverticula.
General principles of abdominal surgery for preoperative (including antibiotic use), intraoperative and postoperative management of Meckel's diverticulum are followed by surgeons. [1][2][3][4]
Asymptomatic Meckel’s diverticulum
- An asymptomatic Meckel's diverticulum is discovered incidentally on abdominal imaging or exploration( laparoscopy or laparotomy) for an indication such as a presumptive diagnosis of acute cholecystitis.
- Generally, surgical resection is avoided in cases of asymptomatic diverticula as in order to benefit a single patient, 800 incidental diverticula need to be removed.[5]
- In elderly patients, resection of diverticulum may be preferred to prevent complications.
- Removal of an asymptomatic diverticulum is not advised in the presence of complications such as:
- The decision regarding resection is made by the surgeon based on appearance of the diverticulum.
- Indications for surgery include:[6][7][8]
- Absence of a wide mouth
- Diverticula with fibrous bands
- Presence of ectopic gastric tissue
- Length of diverticulum more than 2cm
- Presence of stasis within the diverticulum
- Narrow neck of diverticulum may undergo twisting or obstruction
- Presence of intramural pathology
- Thickened, inflamed diverticulum
- Children
- Elderly patients
- Preferred technique in asymptomatic cases undergoing surgery: Tangential excision with suture closure of the base
Symptomatic Meckel diverticulum
- Absolute indications for resection of a symptomatic Meckel's diverticulum include complications such as:[9]
- Hemorrhage
- Umbilicoileal fistulas
- Inflammation of diverticulum: Diverticulitis
- Bowel obstruction
- Surgical procedures considered in patients with symptomatic Meckel's diverticulum are as follows:
- Fibrous band division
- Diverticulectomy, along with suture closure of the base
- Segmental resection of the diverticulum and the intestine, followed by end-to-end anastomosis
- Wedge resection of the diverticulum along with the adjacent intestinal wall, followed by suture closure
- Special surgical considerations are required in case of:
- Meckel's diverticulitis: In a case of suspected appendicitis where appendix is normal on surgical exploration, the distal ileum must be examined for signs of diverticulitis
- Umbilical fistula and sinus: In such cases, umbilical excision may be necessary
- Broad based diverticula in children: Segmental resection is preferred as the risk of ileal stenosis is high if wedge resection or diverticulectomy is performed
- Bowel obstruction: The extent of excision is determined by the viability of the intestinal wall
- Hemorrhage : Segmental or wedge resection may be used for excision of ulcerated bowel and gastric mucosa
Principles of surgical treatment include the following:
· Ensuring adequate blood supply to the resectional margins
· Recognition of bowel viability
· Awareness of suture-line tension
· Alertness to the potential for intestinal stenosis due to narrowing
Handsewn technique versus stapling
All procedures may be carried out either by handsewn technique or by stapling, depending on the preference of the surgeon. Stapling enables faster resection of a Meckel diverticulum without the need to open the bowel's lumen, thus avoiding potential septic and postoperative complications. Meckel diverticulum, which fits well into the stapling device, is easy to remove, and removal has a low complication rate, especially when the diverticulum was found incidentally.
Laparoscopic management
Laparoscopic techniques are increasingly being used for Meckel diverticulectomy and intestinal resection. [[null 11], [null 12]] With advancements in technology, minimally invasive therapeutic interventions, such as intracorporeal resection or laparoscopic-assisted extracorporeal resection, can easily be performed. At present, laparoscopic management of Meckel diverticulum is largely limited to symptoms of abdominal pain and GI bleeding. For symptoms of obstruction, diagnostic laparoscopy is not recommended, because of difficulties in establishing pneumoperitoneum. null 13
References
- ↑ Zani A, Eaton S, Rees CM, Pierro A (2008). "Incidentally detected Meckel diverticulum: to resect or not to resect?". Ann. Surg. 247 (2): 276–81. doi:10.1097/SLA.0b013e31815aaaf8. PMID 18216533.
- ↑ Park JJ, Wolff BG, Tollefson MK, Walsh EE, Larson DR (2005). "Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950-2002)". Ann. Surg. 241 (3): 529–33. PMC 1356994. PMID 15729078.
- ↑ Lohsiriwat V, Sirivech T, Laohapensang M, Pongpaibul A (2014). "Comparative study on the characteristics of Meckel's diverticulum removal from asymptomatic and symptomatic patients: 18-year experience from Thailand's largest university hospital". J Med Assoc Thai. 97 (5): 506–12. PMID 25065089.
- ↑ Robinson JR, Correa H, Brinkman AS, Lovvorn HN (2017). "Optimizing surgical resection of the bleeding Meckel diverticulum in children". J. Pediatr. Surg. 52 (10): 1610–1615. doi:10.1016/j.jpedsurg.2017.03.047. PMID 28359587.
- ↑ Soltero MJ, Bill AH (1976). "The natural history of Meckel's Diverticulum and its relation to incidental removal. A study of 202 cases of diseased Meckel's Diverticulum found in King County, Washington, over a fifteen year period". Am. J. Surg. 132 (2): 168–73. PMID 952346.
- ↑ Thirunavukarasu P, Sathaiah M, Sukumar S, Bartels CJ, Zeh H, Lee KK, Bartlett DL (2011). "Meckel's diverticulum--a high-risk region for malignancy in the ileum. Insights from a population-based epidemiological study and implications in surgical management". Ann. Surg. 253 (2): 223–30. doi:10.1097/SLA.0b013e3181ef488d. PMC 4129548. PMID 21135700.
- ↑ Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ (1994). "Surgical management of Meckel's diverticulum. An epidemiologic, population-based study". Ann. Surg. 220 (4): 564–8, discussion 568–9. PMC 1234434. PMID 7944666.
- ↑ Gezer HÖ, Temiz A, İnce E, Ezer SS, Hasbay B, Hiçsönmez A (2016). "Meckel diverticulum in children: Evaluation of macroscopic appearance for guidance in subsequent surgery". J. Pediatr. Surg. 51 (7): 1177–80. doi:10.1016/j.jpedsurg.2015.08.066. PMID 26435520.
- ↑ McKay R (2007). "High incidence of symptomatic Meckel's diverticulum in patients less than fifty years of age: an indication for resection". Am Surg. 73 (3): 271–5. PMID 17375785.