Meckel's diverticulum surgery

Surgery is the primary treatment modality in patients with Meckel’s diverticula. Asymptomatic patients are treated in the presence of features such as narrow diverticular mouth, fibrous bands, ectopic gastric tissue, diverticular length >2cm, stasis, narrow neck, intramural pathology, thickening and inflammation of the diverticulum. On the other hand, absolute indications for resection of a symptomatic Meckel’s diverticulum include complications such as hemorrhage, umbilico ileal fistulas, diverticulitis and bowel obstruction. Fibrous band division, diverticulectomy, segmental resection of the diverticulum with end-to-end intestinal anastomosis and wedge resection are the various surgical procedures performed, whenever indicated.

• 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]

• 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:
  • Inflammatory Bowel Disease:
    • Ulcerative colitis
    • Crohn’s disease
  • Peritonitis
• 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 2 cm
  • 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

• 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    
• Care must be taken during surgical management of Meckel’s diverticulum to ensure:
  • Decreased incidence of intestinal stenosis due to narrowing
  • Awareness of tension of suture-line
  • Bowel viability
  • Adequate blood supply to resectional margins

• Advantages of stapling over handsewn technique :
  • Low rate of complications
  • Easy fit into stapling device, facilitating easy removal
  • Quicker resection of Meckel’s diverticulum
  • Decreased postoperative and septic complications as the intestinal lumen is not opened
• Laparoscopic treatment of Meckel’s diverticulum is restricted to symptoms of bleeding and abdominal pain.^{[10][11][12][13]}
• Postoperative complications of Meckel’s diverticulum:
  • Early post-operative complications:
    • Ileus
    • Intra-abdominal abscess
    • Pulmonary embolism
    • Anastomotic leakage
    • Suture-line leakage
  • Late post-operative complications:
    • Intestinal stenosis
    • Intestinal obstruction due to postoperative adhesions

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