Introduction

Meckel’s diverticulum is one of the most common congenital anomalies of the small intestine, which resulted from the incomplete obliteration of the vitelline duct during embryogenesis. It is usually located at the terminal ileum 45–90 cm proximal to the ileocecal valve on its antimesenteric border. Almost half of the patients with this anomaly have ectopic gastric or pancreatic mucosa, which might cause some complications [1].

Patients with Meckel’s diverticulum are usually asymptomatic and are commonly diagnosed as an incidental finding. However, life threatening complications might occur like bleeding, inflammation, intestinal obstruction, and perforation.

Treatment of symptomatic Meckel’s diverticulum is definitive surgery either via diverticulectomy, wedge or segmental resection. Laparoscopically, it can be managed by diverticulectomy with endostaplers, wedge or segmental resection with extracorporeal or intracorporeal anastomosis. Simple diverticulectomy is not advised if the base is broad and/or the diverticulum is noticeably short because of a risk of leaving behind heterotropic tissue [2]. Thus, segmental resection followed by anastomosis is preferable to diverticulectomy and wedge resection or tangential mechanical stapling because of the risk of leaving behind abnormal heterotropic mucosa [3]. Laparoscopic surgery compared to open laparotomy has equivalent outcomes [4]. However, the choice of surgical approach still depends on the patient’s condition, surgeon’s expertise, and the availability of laparoscopic instruments.

Indications

  • Symptomatic patients with Meckel’s diverticulum.

  • Patient fit for general anesthesia.

Contraindications

  • Severe pulmonary disease in whom carbon dioxide pneumoperitoneum may exacerbate their condition.

  • Hemodynamic instability.

  • Patient not fit for general anesthesia.

Preoperative Preparation

  • Fluid resuscitation.

  • Blood transfusion (if needed for bleeding Meckel’s diverticulum).

  • Correction of electrolyte imbalances simultaneously with hydration especially for Meckel’s diverticulum which initially presented as an obstruction.

  • Prophylactic intravenous antibiotics with coverage for gram negative and anaerobes.

Meckel’s diverticulum is difficult to diagnose. It usually mimics other abdominal pathologies like appendicitis and is usually confirmed only during laparotomy. Some imaging studies might help in its diagnosis like technetium pertechnetate/Meckel’s scan, CT scan, colonoscopy, or wireless capsule endoscopy but they yield a high false-negative result [5]. Therefore, its diagnosis requires a high degree of suspicion as the preoperative clinical and investigational diagnosis is difficult to be made with accuracy [6].

Operating Theater Setup

Instruments

  • 10 mm 30° angled laparoscope

  • Trocars.

  • 10 mm optical or Hasson’s trocar

  • 12 mm trocar

  • (2) 5 mm trocar.

  • Graspers and atraumatic graspers.

  • Hook.

  • Scissors.

  • Suction.

  • Endostaplers/Laparoscopic linear cutter staplers.

  • Needle holder.

  • Ultrasonic energy devices (e.g., Harmonic™, Ethicon, Mexico).

  • Specimen bag.

Patient and Surgical Team Positioning

Patient is in supine position in a Trendelenburg position with the right side slightly up to expose the right lower quadrant. The anesthesiologist and the anesthesia machine are at the patient’s head. The surgeon stands on the left side of the patient and the assistant stands on the right side of the surgeon. The video monitor is positioned directly across the surgeon on the right side of the patient (Fig. 1)

Fig. 1
An illustration of an operation process. A patient's open abdomen is depicted while he lies on a surgical table. The patient's right side has two video displays. On the left, among the three surgeons, one is holding a tray. Along with the anaesthetic equipment, the anesthesiologist is standing above the patient's head. Text identified as M. Crespi in the artwork.

OT setup

Full size image

Surgical Technique

The patient is under general anesthesia with arms tucked in. Then a 10 mm port, which will serve as the camera port, is inserted at the left midclavicular line midpoint between the left costal margin level and anterior superior iliac spine (ASIS) level. This can be done using an optical view trocar or via Hasson’s technique. Avoid going too lateral to avoid injuring the descending colon. Pneumoperitoneum is created with CO2 pressure at 12 mmHg and flow rate at medium or 20 L/min. A 5 mm port is then inserted in between the 10 mm port and ASIS and a 12 mm port, which will serve as the working port, in between the 10 mm port and costal margin. The 5 mm and 12 mm ports can be interchanged depending on the preference of the surgeon. Avoid putting it too near the costal margin and the ASIS as the bones might limit your movements. All of this is done under direct vision to avoid injuring any vessels or intestines. A diagnostic laparoscopy is done.

A bowel run from the ileocecal area is done using atraumatic graspers until the Meckel’s diverticulum is located. Dissect free the Meckel’s diverticulum if there are any adhesions using a hook or an ultrasonic energy device.

If a simple diverticulectomy is planned, this can be done using an endostapler/linear cutter stapler. The diverticulum is transected at the base. Making sure not to compromise the lumen of the intestine and not to leave behind a stump of the diverticulum.

On the other hand, if segmental resection is to be done, mesenteric openings are made around 5 cm from the base of the diverticulum proximally and distally. The mesentery connecting to the diverticulum is then serially ligated and transected using an ultrasonic energy device.

The Meckel’s diverticulum is then transected segmentally using linear cutter staplers. The proximal and distal small intestines are then aligned in preparation for a side-to-side anastomosis, and a stay suture is placed at the proximal and distal small intestines to stabilize it. Always make sure that the intestines are not twisted. Another 5 mm port can be inserted so that another grasper can be used to hold the stay suture and lift the intestines to be anastomosed.

A small enterotomy is done at the proximal and distal intestine. Inspect the lumen if there is any bleeding. After which anastomose the proximal and distal intestine using the endostaplers/linear cutter staplers. The common channel is then closed via intracorporeal suturing with 2–0 sutures in a running single layer fashion. Check for any bleeding. The mesenteric defect is closed with figure of 8 sutures to prevent herniation of the intestines. Copious irrigation is done if there is spillage of intestinal contents or if dealing with a perforated Meckel’s diverticulum.

The Meckel’s diverticulum is then placed inside a specimen/collection bag and extracted. Remove the trocars under direct vision to observe for any port side bleeding. Desufflation is then done. The fascia at the 10 mm and 12 mm ports is closed with figure of 8 sutures to minimize the formation of a hernia in the future. Subdermal interrupted skin closure with 4–0, monofilament, absorbable sutures is done to close the skin incisions.

Postoperative Care

Antibiotics is continued to complete for 7 days with adequate pain control. Patient is advised to ambulate as soon as possible. Oral intake is started once return of bowel functions is observed. Patient is discharged once vital signs are stable with complete return of bowel function and able to tolerate oral intake. Patient is then seen after 7–10 days for follow-up.

Complications and Management

One of the possible complications of resecting a Meckel’s diverticulum is anastomosis leakage. If this is suspected immediate repair is warranted either via laparoscopy or open laparotomy. Intra-abdominal abscess might also occur, which can be managed by intravenous antibiotics and percutaneous drainage. Wound infection might also be encountered. This can be treated by antibiotics and drainage. Another possible complication as with other abdominal operations is intestinal obstruction secondary to postoperative adhesions.