Meckel Diverticulum Surgery Treatment & Management

Medical treatment has no role in the management of a Meckel diverticulum.

Indications for surgery

Indications for operative treatment depend on the patient's presentation, as follows.

Painless bleeding

Because initial bleeding from a Meckel diverticulum can be massive, it is essential that the patient be adequately resuscitated. This may require the transfusion of packed red blood cells (RBCs) to return the hematocrit level to approximately 30%. Two large-bore intravenous (IV) lines must be in place in case bleeding recurs, and crossmatched blood should be available.

If Meckel diverticulum bleeding is suspected, technetium-99m pertechnetate radioisotope scanning (see Workup) is the test of choice. This isotope is readily taken up by the ectopic gastric mucosa within the Meckel diverticulum. Once a positive result is obtained, the patient can be taken to the operating room for a Meckel diverticulectomy. False-negative results occur less than 2% of the time. The accuracy of such scanning may be increased with the use of pentagastrin, histamine blockers, and glucagon.

Bowel obstruction

Patients present with bowel obstruction due to volvulus, intussusception, a mesodiverticular band, or incarceration of the Meckel diverticulum in a hernia (though the presence of a Meckel diverticulum in a hernia does not actually increase the risk of incarceration).

Despite these different causes, the clinical presentation is bowel obstruction. Patients present with obstipation, crampy abdominal pain, and vomiting, which may be bilious. Plain abdominal radiographs reveal dilated loops of small bowel with air-fluid levels and a paucity of gas distally. This classic presentation of bowel obstruction is all that is necessary to warrant transporting the patient to the operating room for an urgent laparotomy.

Meckel diverticulitis

The presentation of Meckel diverticulitis may be indistinguishable from that of appendicitis. As with appendicitis, the course is progressive and may result in perforation, diffuse peritoneal contamination, and septic shock. Exploration is usually performed for suspected appendicitis; an inflamed Meckel diverticulum must be sought if a normal-appearing appendix is discovered.

Umbilical drainage

Drainage of succus entericus or feculent material indicates a persistent connection between the intestine and the umbilicus. Ultrasonography (US) or contrast studies may be used to confirm the diagnosis. An exploration can then be performed to resect the fistula.

Contraindications for surgery

Because many of the operations for omphalomesenteric remnants are used in emergency situations, surgery has relatively few contraindications. However, patients must be adequately prepared for surgery, even given short notice. In patients who are bleeding, the blood volume must be returned to acceptable levels, and adequate IV access must be obtained. In patients with bowel obstruction and repeated emesis, electrolyte abnormalities must be corrected while hydration is restored.

The indications for surgical intervention in Meckel diverticulum vary according to the patient's presentation. In all cases, patients should be adequately resuscitated, and prophylactic antibiotics should be administered. ^[20]

Procedure

Painless bleeding

Once a Meckel diverticulum has been diagnosed, laparotomy or laparoscopy can be used for resection. The goal is to resect the Meckel diverticulum, all ectopic gastric mucosa, and any ulcerated intestine to prevent recurrent bleeding.

A number of authors have maintained that laparoscopy is not adequate because it involves stapling the diverticulum at its junction with the ileum. Although most ectopic mucosa is at the tip of the diverticulum, this is not always the case. Furthermore, using laparoscopy may leave ulcerated ileum, which may bleed.

To avoid these problems, the author uses a technique of laparoscopic-assisted bowel resection. A large umbilical port is placed, and the Meckel diverticulum is identified, grasped, and brought up to this umbilical incision. The port is then removed as the Meckel diverticulum and ileum are brought up through the umbilical incision (the incision is widened as needed).

The author then resects the Meckel diverticulum and ileum with primary anastomosis. A wedge resection of the diverticulum with inspection of the ileal mucosa to look for ulceration can also be performed. This wedge can then be closed, avoiding a circumferential suture line.

The laparoscopic-assisted approach was found to be safe and effective in a series of 20 children with complicated Meckel diverticulum over a 10-year period. ^[21]  A subsequent study of 14 children with complicated Meckel diverticulum over a 15-year period also found laparoscopy to be safe and effective. ^[22]

A retrospective study that used data from the National Surgical Quality Improvement Program-Pediatric (NSQIP-Ped) to compare laparoscopic treatment (n = 73) of Meckel diverticulum with open surgical treatment (n = 75) found a high (27.4%) rate of conversion from laparoscopy to laparotomy but noted that the two approaches had equivalent outcomes. ^[23]

Another study using NSQIP-Ped data to compare open and laparoscopic resection of Meckel diverticulum found that laparoscopic resection was associated with a shorter length of stay than open resection, a comparable complication rate, and a similar operating time. ^[2] Laparoscopic procedures converted to open ones, as compared with purely open procedures, were associated with an increase in operating time but no increases in length of stay or morbidity.

Bowel obstruction

Laparotomy is the procedure of choice for bowel obstruction. It typically involves a midline or transverse incision, which is cosmetically superior in children.

If the volvulus is around a fibrous Meckel band, the bowel must be untwisted and observed after the band is divided. Frankly necrotic intestine must be resected.

Another cause of bowel obstruction is an intussuscepted Meckel diverticulum. The Meckel diverticulum sags into the bowel lumen and then serves as a lead point and allows telescoping of the small intestine into first the distal ileum and then the large intestine. Attempts to reduce such a mass are sometimes difficult. Typically, the intussuscepted mass must be resected, and primary anastomosis must be performed.

A third cause of bowel obstruction is an incarcerated hernia that contains a Meckel diverticulum, also called a Littre hernia. ^[24] The hernia is reduced, and the Meckel diverticulum is resected.

For a mesodiverticular band, the small bowel is reduced, and the diverticulum and its blood supply are resected.

Meckel diverticulitis

The surgical approach is similar to the one used in acute appendicitis. Open or laparoscopic surgery can be used, and the diverticulum is divided at its base. The closure is performed perpendicular to the axis of the intestine to avoid any narrowing of the ileum. If perforation has occurred, the abdomen is copiously irrigated after resection of the diverticulum has been completed.

Umbilical drainage

A periumbilical incision is made, and the abdomen is entered. The fistulous tract is identified and removed. After its connection with the ileum is divided, the enterotomy is closed with interrupted absorbable sutures in one or two layers (according to the surgeon's preference).

Surgical controversies

There are two major controversies surrounding surgical treatment of Meckel diverticulum. The first involves the use of laparoscopy. Laparoscopy for diagnosis or excision of an inflamed diverticulum is not controversial. However, questions arise when laparoscopy is used in the setting of a bleeding Meckel diverticulum. Some have advocated routinely using laparoscopy in this situation.

Opponents of this view, however, argue that because the base of the diverticulum and the ileum cannot be palpated, ectopic mucosa could be left behind. Some surgeons routinely send the diverticulum for frozen-section examination of the margin to determine that no ectopic mucosa remains. Others argue that ulcerated areas of the ileum remain, and, thus, the patient is still at risk for bleeding episodes in the immediate postoperative period. No randomized controlled studies have been performed to answer these questions.

The other major controversy involves what to do with a Meckel diverticulum when it is discovered during an exploration for other reasons. The argument weighs the probability for future complications from a currently asymptomatic Meckel diverticulum against the potential morbidity of incidental Meckel diverticulectomy.

If a thickening appears to be present upon palpation, the diverticulum may contain ectopic mucosa. These patients are at greater risk for complications, and resection is warranted. Likewise, if the diverticulum has a narrow base, the likelihood of luminal obstruction and diverticulitis may be higher, and resection is appropriate. In most other cases, the diverticulum may be left in situ.

A population-based study indicated an increasing lifetime risk of operation for Meckel diverticulum-related complications and suggested removing an incidentally detected Meckel diverticulum, regardless of age. ^[25]

Postoperative care depends on the type of procedure performed. Patients with a relatively minor procedure such as diverticulectomy for diverticulitis or umbilical exploration for persistent fistula can resume a regular diet soon after surgery. Those with bowel obstruction or peritoneal contamination must wait until bowel function has returned to resume a regular diet.

Complications are rare but may include the following:

• Bleeding
• Infection
• Wound dehiscence
• Intra-abdominal abscess formation

A standard postoperative follow-up visit 7-10 days after surgery is recommended. If no problems are reported, no further tests or additional visits are required.