Meckel's Diverticulectomy

Excision of a Meckel's diverticulum is performed when the diverticulum is found to cause an acute abdominal condition. Frequently excision is a benign incidental procedure during a laparotomy for other causes. The majority of these diverticula cause no symptoms, but a diseased one can successfully mimic many other intestinal diseases, any of which would require exploratory laparotomy.

The presence of gastric mucosa in the diverticulum can produce ulceration with massive intestinal hemorrhage with brick-red stools, inflammation, or a free perforation with peritonitis, particularly in children. Although similar complications can occur in adults, intestinal obstruction caused by fixation of the tip of the diverticulum or a connecting band running to the umbilicus is not uncommon. The diverticulum may become inverted and form the starting point of an intussusception. Benign diverticula should be removed as incidental procedures unless contraindicated by a potentially complicating disease elsewhere in the abdomen. These congenital anomalies are remnants of the embryonic omphalomesenteric duct arising from the midgut, are found in 1 to 3 percent of patients, principally males, and are located usually 20 to 35 cm above the ileocecal valve. The terminal ileum should be routinely examined for a Meckel's diverticulum as part of a thorough abdominal exploration.

Preoperative preparation is devoted chiefly to the restoration of blood, fluids, and electrolytes. Nasogastric suction is advisable in the presence of obstruction or peritonitis, which may require additional blood, plasma, and antibiotics.

General inhalation anesthesia is preferred; however, spinal or local anesthesia may be indicated under special circumstances.

The patient is placed in a comfortable supine position.

The skin is prepared with antiseptic, then draped with towels or an adhesive plastic drape. A large sterile laparotomy sheet completes the draping.

A midline incision is preferred because of its maximum flexibility. However, incidental excision of a Meckel's diverticulum may be performed through any incision that exposes it.

The segment of the terminal ileum involved with the Meckel's diverticulum is delivered into the wound by Babcock forceps for stabilization. The Meckel's diverticulum may be as far as 20 to 35 cm back from the level of the ileocecal valve. If a mesodiverticulum is present, it should be freed, divided between hemostats, and ligated as a mesoappendix (Figure 1). If the diverticulum has quite a wide neck, it may be excised either by oblique or cross clamping of the base, by wedge or V-shaped excision of the base, or by segmental resection of the involved ileum with end-to-end anastomosis (Figure 2). The base is double clamped with noncrushing Potts-type clamps in a direction transverse or diagonally across to the bowel. The specimen is excised with a scalpel. Traction sutures, A and B, of 00 silk are placed to approximate the serosal surface of the intestinal wall just beyond either end of the incision (Figure 3). When tied, these sutures, A and B, serve to stabilize the intestinal wall during the subsequent closure. Sutures of 00 silk are placed at either end of the incision, and a row of interrupted 0000 silk horizontal mattress sutures is placed beneath the clamp (Figure 4). The clamp is then removed, the sutures tied, and any excess intestinal wall excised. Then an inverting layer of interrupted 0000 silk horizontal mattress sutures is placed (Figures 5 and 6). The patency of the lumen is then tested between the surgeon's thumb and index finger (Figure 7). Alternatively, some surgeons prefer to amputate the diverticulum with a stapling instrument. The diverticular mesentery is divided and its vessels are ligated, as in Figure 1. The diverticulum is splayed transversely to the axis of the bowel using a pair of stay sutures at either side. A linear stapling device (GIA) may be used, according to the surgeon's preference. After removal of the diverticulum, the transverse staple line is then inverted with a series of 000 silk mattress sutures. Again, the patency and integrity of the suture line is tested by the surgeon.

The usual laparotomy closure is performed.

Postoperative care is similar to that for appendectomy or small bowel anastomosis. Fluid and electrolyte balance is maintained intravenously until intestinal motility returns. The nasogastric tube is then removed and progressive alimentation begun. Any subsiding inflammation, peritonitis, or drained abscess is treated with the appropriate systemic antibiotics plus blood and plasma replacement. The major postoperative complications are obstruction, peritonitis, and wound infection, which may require further appropriate surgical therapy.