Laparoscopic management of Meckel's diverticulum in children

Should an Incidental Meckel Diverticulum Be Resected? A Systematic Review

Background

Meckel Diverticulum [MD), a common congenital anomaly of the gastrointestinal tract, poses a dilemma when incidentally encountered during surgery. Despite historical descriptions and known complications of symptomatic MD, the decision to resect an incidental MD (IMD) lacks clear guidelines. This study aims to assess whether resecting IMDs is justified by synthesizing evidence from studies published between 2000 and 2023. Factors influencing this decision, such as demographic risks, surgical advancements and complications, are systematically examined.

Methods and Material

Following the PRISMA 2020 guidelines, this review incorporates 42 eligible studies with data on outcomes of asymptomatic MD management. Studies, both favoring and opposing resection, were analyzed.

Results

Considering complications, malignancy potential, and operative safety, the risk-benefit analysis presents a nuanced picture. Some authors propose conditional resection based on specific criteria, emphasizing patient-specific factors. Of 2934 cases analyzed for short- and long-term complications, the morbidity rate was 5.69%. Of 571 cases where mortality data were available, all 5 fatalities were attributed to the primary disease rather than IMD resection.

Conclusion

The sporadic, unpredictable presentation of IMD and the variability of both the primary disease and the patient make formulation of definitive guidelines challenging. The non-uniformity of complications reporting underscores the need for standardized categorization. While the balance of evidence leans towards resection of IMDs, this study acknowledges the individualized nature of this decision. Increased safety in surgery and anesthesia, along with better understanding and management of complications favor a judicious preference for resection, while taking into account patient characteristics and the primary disease.

Meckel's diverticulum: Unusual cause of significant bleeding in an adult male

Meckel's diverticulum is a common congenital gastrointestinal malformation affecting 2% of the general population. Most affected patients are asymptomatic, and excessive bleeding causing a significant drop in hemoglobin count is an uncommon complication of Meckel's diverticulum, especially in adult patients. Herein, we present an adult case of Meckel's diverticulum that nearly led to hemodynamic instability. Laparotomy and segmental small bowel resection were critical in treating the patient.

Tc-99m scan for pediatric bleeding Meckel diverticulum:a systematic review and meta-analysis

OBJECTIVE

Meckel diverticulum (MD) is a common malformation of the digestive tract, often accompanied by serious complications. It is important to find safe and effective diagnostic methods for screening MD. The aim of this study was to evaluate the effectiveness of a technetium-99m (Tc-99m) scan for pediatric bleeding MD.

METHODS

The authors conducted a systematic review of studies published in PubMed, Embase, and Web of Science before 1 January 2023. Studies based on PICOS were included in this systematic review. The flow chart was made by PRISMA software. The quality of included studies was assessed by RevMan5 software (QUADAS-2: Quality Assessment of Diagnostic Accuracy Studies-2). The sensitivity, specificity, and other measurements of accuracy were pooled using Stata/SE 12.0 software.

RESULTS

Sixteen studies with 1115 children were included in this systematic review. A randomized-effects model was used for the meta-analysis because of significant heterogeneity. The combined sensitivity and specificity were 0.80 [Confidence Interval (95% CI, 0.73-0.86) and 0.95 (95% CI, 0.86-0.98)], respectively. The area under the curve (AUC) was 0.88 (95% CI, 0.85-0.90). Publication bias (Begg's test p = 0.053) was observed.

CONCLUSION

Tc-99m scan has high specificity, but moderate sensitivity, which is always influenced by some factors. Hence, the Tc-99m scan has some limitations in the diagnosis of pediatric bleeding MD.

Clinical characteristics and treatment outcomes of symptomatic Meckel diverticulum: a comparative study among children, adolescent, and adult patients

Purpose

We investigated the clinical characteristics and treatment outcomes of symptomatic Meckel diverticulum (MD) in adolescents by comparison with children and adults.

Methods

We retrospectively reviewed the medical records of patients who underwent symptomatic MD surgery from January 2002 to December 2019. Demographic information, clinical presentations, preoperative evaluations, operative variables, postoperative outcomes, and pathologic findings were collected. We performed analyses by dividing all patients into three groups according to age at surgery: child group (<10 years), adolescent group (10-19 years), and adult group (≥20 years).

Results

Forty-three patients underwent symptomatic MD surgery (the child group, 14; the adolescent group, 17; and the adult group, 12). Vomiting and intestinal obstruction decreased significantly with age (P = 0.042 and 0.001), whereas hematochezia and gastrointestinal bleeding showed an increasing trend with age, although not statistically significant (P = 0.064 and 0.064). Ultrasound performance decreased significantly with age (P = 0.002), whereas CT performance showed an increasing trend with age, although not statistically significant (P = 0.193). Preoperative diagnosis rate increased significantly with age (P = 0.029). Laparoscopic surgery was performed significantly more in the adult group than in other groups (P = 0.001). The sizes of MD were significantly greater in the adolescent group than in other groups (P = 0.006 and 0.002).

Conclusion

The clinical characteristics and treatment outcomes of symptomatic MD in adolescents exhibit a transitional pattern between children and adults. Therefore, it is important for clinicians to recognize that adolescent patients with symptomatic MD have the characteristics of both children and adult patients to ensure optimal care.

L., Jayaprakash Shetty K., Shreesha Khandige. Asymptomatic pancreatic heterotopia in an incidental Meckel's diverticulum – A rare case report

Pancreatic heterotopia is a rare, unusual finding where pancreatic tissues are found out of the normal anatomical location. Various studies have documented an incidence of 0.5 to 13% in autopsy. The reports on pancreatic heterotopia presence is rare, with an incidence estimated to be around 0.2% of all upper gastrointestinal surgeries. The heterotopic pancreas occurs frequnetly in the stomach, duodenum and proximal jejunum. Remote cases of  pancreatic heterotopia in Meckel's diverticulum is a rare finding. These heterotopias are  often clinically silent and are an  incidental findings  upon pathological examination or autopsy.

Meckel’s Diverticulum in Children: A Monocentric Experience and Mini-Review of Literature

Vitelline duct anomalies (VDA, including Meckel’s diverticulum (MD)) result from failed embryologic obliteration. This study aimed for characteristics in symptomatic versus asymptomatic VDA, analyzing clinico-laboratory data from 73 children, aged 1 day to 17 years, treated at a tertiary Pediatric Surgery Institution from 2002–2017. A male preponderance was obtained (ratio 3.6:1). MD accounted for 85% of VDA. Incidence of symptomatic VDA decreased with older age. Leading symptoms were intestinal obstruction and hemorrhage. Mucosal heterotopia (present in 39% of symptomatic MD) was associated with anemia and lowered CRP-levels. On ROC-analysis, hemoglobin < 8.6 g/dL, CRP < 0.6 mg/dL and MD distance to ileocecal valve >40 cm were predictors of ectopic tissue in symptomatic MD. Our data confirmed known characteristics as male preponderance, declined incidence of symptomatic cases with age and predominance of gastric ectopia in symptomatic MD. Moreover, anemia and prolonged distance of MD to ileocecal valve were predictors of ectopic mucosa in symptomatic MD.

Management of Incidentalomas

Incidental findings are common in the evaluation of surgical patients. Understanding the appropriate assessment and management of these frequent occurrences is important for the provision of comprehensive quality care. This review details the epidemiology, considerations, and recommendations for management of common incidental manifestations in surgical patients, including Meckel diverticulum, adrenal incidentaloma, thyroid nodule, solitary pulmonary nodule, small bowel intussusception, gallstones, and incidental appendectomy.

Outcomes of Laparoscopic Versus Open Resection of Meckel's Diverticulum

BACKGROUND

Meckel's Diverticulum (MD) is a common congenital anomaly accounting for half of pediatric gastrointestinal bleeds. No large-scale studies exist comparing open and laparoscopic surgery and conversion rates remain high. We sought to compare postoperative outcomes associated with each approach and to determine risk factors for conversion.

MATERIALS AND METHODS

NSQIP-Pediatric was used to identify patients who underwent a MD resection from 2012 to 2018. Outcomes between patients treated with a laparoscopic versus open versus laparoscopic converted to open (LCO) surgery were compared. Chi-square tests and adjusted logistic regression analysis were used to determine significance and factors associated with conversion.

RESULTS

Six hundred eighty-one patients were identified, 295 (43.3%) underwent open, 267 (39.2%) laparoscopic, and 119 (17.5%) LCO resection. Patients undergoing laparoscopic compared to open procedures had shorter length of stay (LOS; 3 versus 4, P= 0.009), and similar morbidities (10.5% versus 16.6%, P= 0.164) and operative times (71.6 versus 76.6 mins, P= 0.449) on adjusted analysis. Patients with LCO compared to open procedures had similar LOS (4 versus 4, P= 0.334) and morbidities (14.3% versus 16.6%, P= 0.358), but longer operative times (90.1 versus 76.6 mins, P= 0.002) on adjusted analysis. Patients with laparoscopic and LCO procedures had fewer unplanned intubations compared to open procedures (0.0% versus 0.0% versus 2.4%, P= 0.011) and lower mortality (0.0% versus 0.0% versus 1.7%, P= 0.046) on univariate analysis.

CONCLUSIONS

Laparoscopic MD resection has shorter LOS and similar complications and operative time compared to an open approach while LCO resection increases operative time but not LOS or morbidities.

Subacute Meckel's diverticulum perforation

Meckel's diverticulum is the most common intestinal congenital defect, its prevalence is 0.2%-4.0% and it occurs more commonly in children younger than 2-year old with intestinal bleeding and abdominal pain. Perforation in the elderly is very rare with no more than 35 articles reported worldwide. Here we report the case of a 62-year-old man who was admitted to hospital with a history of acute abdominal pain with a 20-day onset. The patient was treated with laparotomy and 30 cm ileal resection was performed for an 8×5 cm perforated ileum tumour at 50 from ileocecal valve with a side-to-side mechanical anastomosis for reconstruction. Having morbidity Clavien-Dindo scale I in postsurgical and good outcome in 6-month follow-up. Meckel's diverticulum is an infrequent pathology in paediatric and even rarer in adult population, however, it is always important to keep in mind how to act when is seen either as a finding or as a complication.

Complicated Meckel's Diverticulum in Children: Clinical Presentation, Diagnostic Work-Out, Surgical Approach and Postoperative Complications

Introduction Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. The majority of cases are asymptomatic and in cases with complications, the diagnosis may be a challenge and the surgical approach is not obvious. The primary aim of the present study was to evaluate the diagnostic process and surgical approach in relation to clinical presentation. The secondary aim was to evaluate the severity of postoperative complications.  Methods A two-center, retrospective analysis of all children below the age of 15 years, operated for complications to MD during the period from January 2003 to December 2016. Results A total of 58 patients were included. In the 40 patients presenting with an acute abdomen an average of 2.3 preoperative diagnostic investigations was performed. In only five cases an MD was recognized preoperatively. In the 18 patients presenting with rectal bleeding or melaena an average of 3.2 preoperative investigations were performed and in only one case the MD was recognized preoperatively. Laparoscopy was the surgical approach in 36 patients (62%) with a conversion in 8. Postoperative complications were seen in two patients (Clavien-Dindo II and IIIb). Conclusion Despite extensive diagnostic work-out an MD was recognized in only a few patients preoperatively. Laparoscopy was the surgical approach in two-thirds of the patients.

Laparoscopic Management of Mechanical Small Bowel Obstruction Secondary to Meckel's Diverticulum with a Double Basis. A Rare Anatomic Presentation

Meckel's diverticulum (MD) is the most common congenital abnormality of the gastrointestinal tract. Intestinal occlusion due to MD is a commonly observed consequence of intussusception or volvulus. Here, we report a case of an 11-year-old boy who presented to the emergency department with acute abdominal pain, bilious vomiting, and abdominal rebound tenderness. Computed tomography scan concluded a diagnosis of intestinal occlusion with no apparent cause. The patient was submitted to diagnostic laparoscopy, and mechanical occlusion by the permeable Meckel with double base was identified. A diverticulectomy by staplers was performed, and occlusion was alleviated. MD is a rare disease (for only 0.3–2.9% of the general population), and only 4.2 to 9% of patients diagnosed with MD have associated complications. MD can be a large base or a narrow base, with a mesodiverticular band but the diverticulum is usually a blind recess. In our case, the tube connected two intestinal segments. To the best of our knowledge, we have reported the first case of an MD-like permeable tube with a double basis.

Clinical outcomes of minimally invasive surgery for Meckel diverticulum: a multicenter study

Purpose

Meckel diverticulum (MD), caused by an obliteration defect of the omphalomesenteric duct, is one of the most common congenital anomalies of small intestines. The objective of this study was to review surgical outcomes of MD and evaluate the feasibility of minimally invasive surgery (MIS) in MD.

Methods

We performed a retrospective analysis of the medical records of patients who underwent diverticulectomy for MD at 6 Hallym University-affiliated hospitals between January 2008 and December 2017. All patients underwent either open surgery or MIS. Patients who underwent MIS were subdivided into laparoscopic only diverticulectomy (LOD) or laparoscopic-assisted diverticulectomy (LAD).

Results

Of 64 patients, 21 underwent open surgery and 43 underwent MIS. Time to flatus, time to soft food intake, and length of hospital stay were shorter in the MIS group than in the open surgery group (P = 0.047, P = 0.005, and P = 0.015, respectively). Among patients who underwent MIS, the time to flatus and time to soft food intake were longer in the LAD group than in the LOD group (0.3 and 0.9 days, respectively). Multivariate analysis showed that old age and preoperative ileus were independent predictors of complications (P = 0.030 and P = 0.013, respectively). Operation type (open surgery, LOD, or LAD) was not associated with complications.

Conclusion

The present study showed that MIS is associated with quicker recovery without increasing complications. Therefore, MIS may be a safe alternative to open surgery for MD. An old age and preoperative ileus were associated with a risk of postoperative complications.

Laparoscopic diverticulectomy or laparoscopic-assisted resection of symptomatic Meckel diverticulum in children? A systematic review

Recent reports have recommended laparoscopic diverticulectomy for symptomatic Meckel diverticulum (MD) rather than laparoscopic-assisted extracorporeal resection. This technique may risk leaving residual ectopic mucosa leading to complications. This systematic review attempts to quantify the relative risks of both approaches. A systematic review was conducted according to PRISMA guidelines. Articles were eligible for inclusion if they reported data on the laparoscopic management of symptomatic MD in children. Eleven reports were identified, all of which were institutional retrospective studies. Pooled outcome data on 248 children showed no statistically significant difference in complications between laparoscopic diverticulectomy (n = 133) and laparoscopic-assisted segmental resection (n = 115) (3% vs. 6.1%, p = 0.39). One patient from the diverticulectomy group re-presented with recurrent bleeding necessitating segmental small bowel resection. Conclusions are limited by the number of patients and variable follow up. Short, wide MD with a height:base ratio of < 2; diverticula with thickening or ischemia at the base and those complicated by volvulus or small bowel obstruction are probably best treated by laparoscopic-assisted extracorporeal resection. For other symptomatic diverticula laparoscopic diverticulectomy is a reasonable approach with a less than 1% risk of leaving residual ectopic gastric mucosa.

[Complications of Meckel's diverticulum in children: about 18 cases]

Meckel's diverticulum (MD) is a remnant of omphalomesenteric channel. It is often asymptomatic but it can be responsible for various clinical complications and variable clinical status especially in children. We conducted a retrospective study on complications of MD among children hospitalized in the division of Paediatric Surgery at the University Hospital Hassan II, Fez, Morocco. The study aimed to describe the clinical, radiological and therapeutic features of MD. The study was conducted over a period of 10 years (January 2009 - December 2018) and involved 18 children (15 boys and 3 girls) aged 1 day - 15 years (with an average age of 5 years) who had undergone surgery for complications of MD. Acute intussusception and intestinal occlusion were the most frequent complications. Other complications included: infection of the MD (1 case) and digestive hemorrhage (2 cases). Two rare types of neonatal Meckel's diverticulum were described (neonatal occlusion and fistula associated with omphalocele). In no case, abdominal X-ray without treatment, ultrasound and CT scan showed MD. Scintigraphy was performed in 2 patients with hematochezia and it helped to make the diagnosis of MD in one case. Three patients underwent laparoscopic surgery with resection of the MD and intestinal anastomosis with laparoscopy. The other patients underwent laparotomy. Ileostomy was performed in one case, followed by secondary recovery. Patient's outcome was good, except for one case of anastomotic leakage. Anatomopathological examination showed two cases of heterotopia.

Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century

BACKGROUND

The contemporary demographics and prevalence of Meckel's diverticulum, clinical presentation and management is not well described. Thus, this article aims to review the recent literature concerning Meckel's diverticulum.

METHODS

A systematic PubMed/Medline database search using the terms "Meckel" and "Meckel's" combined with "diverticulum." English language articles published from January 1, 2000 to July 31, 2017 were considered. Studies reporting on the epidemiology of Meckel's diverticulum were included.

RESULTS

Of 857 articles meeting the initial search criteria, 92 articles were selected. Only 4 studies were prospective. The prevalence is reported between 0.3% and 2.9% in the general population. Meckels' diverticulum is located 7 to 200 cm proximal to the ileocecal valve (mean 52.4 cm), it is 0.4 to 11.0 cm long (mean 3.05 cm), 0.3 to 7.0 cm in diameter (mean 1.58 cm), and presents with symptoms in 4% to 9% of patients. The male-to-female (M:F 1.5-4:1) gender distribution is reported up to 4 times more frequent in men. Symptomatic patients are usually young. Of the pediatric symptomatic patients, 46.7% have obstruction, 25.3% have hemorrhage, and 19.5% have inflammation as presenting symptom. Corresponding values for adults are 35.6%, 27.3%, and 29.4%. Ectopic gastric tissue is present in 24.2% to 71.0% of symptomatic Meckel's diverticulum, is associated with hemorrhage and is the most common form of ectopic tissue, followed by ectopic pancreatic tissue present in 0% to 12.0%.

CONCLUSION

The epidemiological patterns and clinical presentation appears stable in the 21st century. A symptomatic Meckel's diverticulum is managed by resection. The issue of prophylactic in incidental Meckel's diverticulum resection remains controversial.

Multifaceted behavior of Meckel's diverticulum in children

PURPOSE/BACKGROUND

Meckel's diverticulum (MD) is one of the most common congenital malformations of gastrointestinal tract in children. However, the nonspecific clinical manifestations of MD often cause a diagnostic as well as therapeutic challenge to pediatric surgeon. This study aimed to review our experience in managing this disease while evaluating the management strategies.

METHODS

We retrospectively analyzed the clinical data of all patients diagnosed with MD admitted to our center between January 2010 and December 2015. Factors documented including demographic criteria, clinical manifestations, preoperative examinations, surgical methods, histopathological characteristics, postoperative complications, and outcomes.

RESULTS

The patients included 210 males and 76 females, aged from 1day to 15years. In fifty three patients, the MD was an incidental finding at laparotomy or laparoscopy. The remaining 233 patients were symptomatic and presented with various clinical features. Ninety nine patients presented with episodes of bleeding per rectum or melena. Fifty six patients demonstrated symptoms of diverticulitis or perforated MD. Forty patients were diagnosed as intestinal obstruction, and 35 patients with intussusception requiring surgical reduction. Two cases of Littre hernia and one case of foreign body trapped in MD were also observed in this group. Six patients misdiagnosed as appendicitis at another institution were reoperated in our department. Among the 99 patients with bleeding per rectum, 78 underwent a Tc-99m scan that showed a positive tracer in 55 patients and negative in 23. All patients underwent resection of the diverticulum, except for 2 cases of postponed resection. Histology revealed ectopic gastric mucosa or ectopic pancreatic tissue in 154 patients; significant differences were observed between the symptomatic group and the accidentally found group. One patient died of peritonitis and sepsis postoperatively; one case of anastomotic leak and one case of adhesive intestinal obstruction were reoperated.

CONCLUSION

Meckel's diverticulum has various clinical presentations and it is difficult to make a precise diagnosis preoperatively. It is necessary to maintain a high suspicion of MD in the pediatric age group with symptoms of abdominal pain, gastrointestinal hemorrhage or intestinal obstruction. Heterotopic tissue is the main cause of complicated diverticulum, and it is safe and feasible to remove the incidentally found MD. Laparoscopy should become the first choice of methods in diagnosis and treatment of MD.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level IV.

Simple diverticulectomy is adequate for management of bleeding Meckel diverticulum

PURPOSE

It is unclear whether simple diverticulectomy, rather than segmental bowel resection (SBR), is adequate treatment for gastrointestinal bleeding (GIB) secondary to Meckel diverticulum (MD). There is concern that ulcers in the adjacent bowel may continue to bleed if only the diverticulum is removed. This study seeks to determine if diverticulectomy is satisfactory treatment for bleeding MD.

METHODS

A multi-institution, retrospective review was performed for patients with a diagnosis of MD and GIB who underwent simple diverticulectomy or small bowel resection. Exclusion criteria were comorbid surgical conditions and other causes of GIB. The primary outcome was post-operative bleeding during the initial hospitalization. Secondary outcomes were bleeding after discharge, transfusion or additional procedure requirement, re-admission, and overall complications.

RESULTS

There were 59 patients who met study criteria (42 diverticulectomy, 17 SBR). One patient in the SBR group had early post-operative bleeding (p = 0.288). There was one re-admission (p = 0.288) and three total complications in the SBR group (p = 0.021). There were no cases of bleeding or other complications in the diverticulectomy group.

CONCLUSION

This study suggests that simple diverticulectomy is adequate for treatment of GIB caused by MD. Furthermore, diverticulectomy appears to have a lower overall complication rate.

Meckel's Diverticulum: a Systematic Review

Meckel's diverticulum is the most common congenital malformation of gastrointestinal tract. It can cause complications in the form of ulceration, haemorrhage, intussusception, intestinal obstruction, perforation and, very rarely, vesicodiverticular fistulae and tumours. These complications, especially bleeding, are more common in the paediatric age group than in adults; however it is not uncommon to miss the diagnosis of Meckel's diverticulum in adults. Here, we reviewed the literature regarding the complications of this forgotten clinical entity in adults with potential diagnostic difficulties and management strategies.

Obstructive internal hernia caused by mesodiverticular bands in children: Two case reports and a review of the literature

INTRODUCTION

The mesodiverticular band (MDB) is an embryologic remnant of the vitelline circulation, which carries the arterial supply to the Meckel diverticulum. In the event of an error of involution, a patent or nonpatent arterial band persists and extends from the mesentery to the apex of the antimesenteric diverticulum. This creates a snare-like opening through which bowel loops may herniate and become obstructed. This report describes 2 rare cases of small bowel occlusion owing to an internal hernia caused by a MDB.

CASES

Case 1 was a 5-year-old boy who presented to our Emergency Department with colicky abdominal pain diffused to all abdominal quadrants. He also had 5 episodes of emesis, the last with bilious vomiting. Case 2, a 12-year-old boy, presented to our Emergency Department complaining of colicky abdominal pain. He had 2 episodes of nonbilious emesis. On physical examination, both children showed distension and tenderness of the abdomen and abdominal x-ray and ultrasound confirmed an occlusive picture without an apparent etiology. In case 1, an urgent laparotomy was performed and the MDB was ligated and cut, whereas in case 2 diagnosis and excision were performed in laparotomy. In both patients, there was a positive clinical evolution.

CONCLUSION

Although MDB causing internal hernia is very rare, it should be considered in patients with a clinical picture of small bowel obstruction. In these cases, early surgery is important to prevent strangulation and gangrene of the bowel and to avoid dramatic events. Moreover, laparoscopy seems a safe and effective technique in these patients, especially in children with mild abdominal distention without surgical or trauma history, highlighting that further studies on the value of laparoscopy for the treatment of small bowel obstruction in pediatric patients are urgently needed.

A faster and simpler way of operation for Meckel's diverticulum: basal ligation combined with intraoperative frozen section

BACKGROUND

The key step in Meckel's diverticulectomy (MD) is to achieve complete resection of MD along with the ectopic epithelium. Currently main treatment methods for Meckel's diverticulum are either intestinal resection and anastomosis or wedge resection. Here we introduced a new method to treat MD. The goal of this study was to investigate the clinical effects and advantages of a new operation method for Meckel's diverticulum: basal ligation combined with intraoperative frozen section.

METHODS

262 cases of Meckel's diverticulum were resected with simple basal ligation operation. Intraoperative frozen pathological section was performed to determine surgery strategies. Based on the existence of basal residual ectopic mucosa, surgery was either terminated or further wedge intestinal resection or bowel resection was performed.

RESULTS

All 262 surgeries were successfully completed. Additional wedge resection or bowel resection was performed in only 23 of them due to the presence of ectopic basal residual gastric mucosa. No ectopic mucosa was found for the other cases, and the operation ended after basal ligation. All patients had no complications such as intestinal fistula, bleeding for 6 months-7.6 years after surgery.

CONCLUSIONS

Intraoperative frozen pathological examination can well determine whether ectopic Meckel's diverticulum mucosa locates at the basal part. Basal ligation is a safe and effective operation method, and it can significantly shorten the operation time and postoperative fasting time.

Perforated Meckel's Diverticulum in a 3-day-old Neonate; A Case Report

Perforation of Meckel’s diverticulum is a rare complication in neonatal period. A 3-dayold term male neonate was transferred to our emergency room due to bowel perforation. Surgical exploration was done and perforated Meckel’s diverticulum was detected. Pathological report of the tissue showed inflamed diverticulum with heterotopic gastric mucosa. This is the first report of Meckel’s diverticulum perforation in a neonate in our country

Complicated Meckel diverticulum in a 15-year-old boy

Meckel diverticulum is the most common gastrointestinal (GI) anomaly, occurring in 2% of the population. This condition often presents symptomatically similar to acute appendicitis in children. The most common presentation is GI hemorrhage, followed closely by obstruction due to intussusception. Laparoscopy is the standard in both diagnosing and treating a complicated Meckel diverticulum.

Ileal stricture following Meckel's diverticulitis: a rare cause of intestinal obstruction

We report a very rare case of Meckel's diverticulitis with ileal stricture at the base of the diverticulum in a young adult as a cause of recurrent small bowel obstruction lasting for 7 years. None of the pre-operative investigations were able to diagnose the cause of obstruction. The patient had undergone appendicectomy 3 years ago but without any relief. Thereafter he was given a therapeutic trial of anti-tubercular drugs, but his symptoms rather worsened with this treatment. Finally, the diagnosis of Meckel's diverticulitis with ileal stricture was made on exploratory laparotomy. The patient recovered well following segmental ileal resection including the stricture and inflamed Meckel's diverticulum. This unusual case highlights that such a rare clinical entity should be considered as a differential diagnosis while dealing with cases of recurrent distal ileal obstruction so as to avoid misdiagnosis and mismanagement as happened in the present case.

Laparoscopy and complicated meckel diverticulum in children

Background and Objectives:

Meckel diverticulum can present with a variety of complications but is often found incidentally during other surgical procedures. The role of laparoscopy in the management of Meckel diverticulum is established. We reviewed our experience with complicated cases of Meckel diverticulum in children managed with laparoscopy.

Methods:

A 15-year retrospective chart review revealed 14 cases of complicated Meckel diverticulum managed with laparoscopy. Incidentally found Meckel diverticulum and cases done by laparotomy were excluded. Ages varied from 2 years to 16 years old. There were 10 males and four females. Eight cases had small bowel obstruction; of those, three had extensive intestinal gangrene. Four cases had significant rectal bleeding, three had acute diverticulitis, and two had intussusception caused by the diverticulum.

Results:

Eleven cases were treated with laparoscopic Meckel diverticulectomy and three with laparoscopic-assisted bowel resection because of extensive gangrene of the intestine. Two of the three cases with significant intestinal gangrene returned several weeks later with small bowel obstruction secondary to adhesions. They were successfully managed with laparoscopic lysis of adhesions. There were no other complications.

Conclusions:

Laparoscopy is safe and effective in the management of complicated Meckel diverticulum in children. Most cases can be managed with simple diverticulectomy. Laparoscopy is useful when the diagnosis is uncertain. When extensive gangrene is present, laparoscopy can help to mobilize the intestine and evaluate the degree of damage, irrigate and cleanse the peritoneal cavity, and minimize the incision necessary to accomplish the bowel resection.

Symptomatic paediatric Meckel's diverticulum: stratified diagnostic indicators and accuracy of Meckel's scan

PURPOSE

The aim of the study was to delineate stratified diagnostic indicants and evaluate the diagnostic accuracy of technetium-99m (Tc)-pertechnetate scintigraphy in children with symptomatic Meckel's diverticulum (MD).

MATERIALS AND METHODS

This was a prospective linear observational study conducted over a period of 5 years on 73 children with a diagnosis of symptomatic MD. The independent variables assessed were age, sex, weight-for-age z-scores, clinical presentation, complications of MD, laparoscopic findings, haematologic and biochemical results, radiological results, and histological findings. Stepwise multiple logistic regression analysis was performed to determine the diagnostic markers. The sensitivity and specificity of Tc-pertechnetate scintigraphy were assessed.

RESULTS

The incidence of MD with complications was 44%. The prevalence of ectopic gastric mucosa in histological specimens was 84%. There was a good correlation between rectal bleeding and the presence of ectopic gastric mucosa [r=0.94; 95% confidence interval (CI): 0.77-0.98]. Haematochezia associated with a drop in haemoglobin (>2 g/dl) was diagnostic of MD with ectopic gastric mucosa in children (n=42, 58%; P=0.006; odds ratio 1.99; 95% CI: 1.14-2.42). Bilious vomiting was diagnostic of complicated MD (n=12, 16%; P=0.007; odds ratio 1.89; 95% CI: 1.12-3.22). The sensitivity of Tc-pertechnetate scintigraphy was 84% and specificity was 22%. The positive predictive value was 0.64 and the negative predictive value was 0.22. The sensitivity and specificity of Tc-pertechnetate scintigraphy were dependent on the quantity and functional quality of the heterotopic gastric mucosa. The preoperative median z-score was -1.4 and the postoperative median z-score was -1.2.

CONCLUSION

Tc-pertechnetate scintigraphy had a truncated predictive value. Its contribution in clinical decision making was poor. Clinical suspicion of MD should be high in children presenting with haematochezia associated with a drop in haemoglobin by more than 2 g/dl. Laparoscopy is an effective diagnostic and therapeutic tool.

Laparoscopic excision of Meckel's diverticulum in children: What is the current evidence?

Complications aroused from Meckel’s diverticulum tend to developed in children. Children presented with abdominal pain, intestinal obstruction, intussusception or gastrointestinal bleeding may actually suffered from complicated Meckel’s diverticulum. With the advancement of minimally invasive surgery (MIS) in children, the use of laparoscopy in the diagnosis and subsequent laparoscopic excision of Meckel’s diverticulum has gained popularity. Recently, single incision laparoscopic surgery (SILS) has emerged as a new technique in minimally invasive surgery. This review offers the overview in the development of MIS in the management of children suffered from Meckel’s diverticulum. The current evidence in different laparoscopic techniques, including conventional laparoscopy, SILS, the use of special laparoscopic instruments, intracorporeal diverticulectomy and extracorporeal diverticulectomy in the management of Meckel’s diverticulum in children were revealed.

Laparoscopic approach to Meckel's diverticulum

AIM: To retrospective review the laparoscopic management of Meckel Diverticulum (MD) in two Italian Pediatric Surgery Centers.

METHODS: Between January 2002 and December 2012, 19 trans-umbilical laparoscopic-assisted (TULA) procedures were performed for suspected MD. The children were hospitalized for gastrointestinal bleeding and/or recurrent abdominal pain. Median age at diagnosis was 5.4 years (range 6 mo-15 years). The study included 15 boys and 4 girls. All patients underwent clinical examination, routine laboratory tests, abdominal ultrasound and technetium-99m pertechnetate scan, and patients with bleeding underwent gastrointestinal endoscopy. The abdominal exploration was performed with a 10 mm operative laparoscope. Pneumoperitoneum was established based on the body weight. Systematic overview of the peritoneal cavity allowed the ileum to be grasped with an atraumatic instrument. The complete exploration and surgical treatment of MD were performed extracorporeally, after intestinal exteriorization through the umbilicus. All patients’ demographics, main clinical features, diagnostic investigations, operative time, histopathology reports, conversion rate, hospital stay and complications were registered and analyzed.

RESULTS: MD was identified in 17 patients, while 1 had an ileal duplication and 1 a jejunal hemangioma. Fifteen patients had painless intestinal bleeding, while 4 had recurrent abdominal pain and exhibited cyst like structures in an ultrasound study. Eleven patients had a positive technetium-99m pertechnetate scan. In the patients with bleeding, gastrointestinal endoscopy did not name the source of hemorrhage. All patients were subjected to a TULA surgical procedure. An intestinal resection/anastomosis was performed in 14 patients, while 4 had a wedge resection of the diverticulum and 1 underwent stapling diverticulectomy. All surgical procedures were performed without conversion to open laparotomy. Mean operative time was 75 min (range 40-115 min). No major surgical complications were recorded. The median hospital stay was 5-7 d (range 4-13 d). All patients are asymptomatic at a median follow up of 4, 5 years (range 10 mo-10 years).

CONCLUSION: Trans-umbilical laparoscopic-assisted Meckel’s diverticulectomy is safe and effective in the treatment of MD, with excellent results.

Diagnostic laparoscopy in a twelve year old girl with right iliac fossa pain: A life changing diagnosis of complete androgen insensitivity syndrome

INTRODUCTION

Right iliac fossa (RIF) pain is one of the most common presenting complaints faced by general surgeons in the emergency department. Correct diagnosis and appropriate surgical intervention can often pose a challenge.

PRESENTATION OF CASE

A 12-year-old girl presented to the emergency department with a four day history of initially central acute abdominal pain, now localised in the RIF. During laparoscopy, the following findings were made: macroscopically dilated appendix, right and left gonads at the internal opening of the inguinal canal, empty pelvis with a rudimentary uterus on the right side. No evidence of fallopian tubes or connection of uterus to the vagina and broad based, non-inflamed Meckel's diverticulum. An incidental diagnosis of complete androgen insensitivity syndrome was made.

DISCUSSION

Androgen insensitivity syndrome (AIS) is a disorder of hormone resistance characterised by a female phenotype in an individual with an XY karyotype and testes producing age-appropriate normal concentrations of androgens.

CONCLUSION

This case report highlights the advantage of laparoscopy as a diagnostic and treatment tool in a twelve year old girl with multiple intra-abdominal findings. While the ultimate diagnosis responsible for her symptom of RIF pain was acute appendicitis, the additional diagnosis of CAIS and incidental Meckel's would have otherwise likely gone undetected.

Meckel's diverticulum and ectopic epithelium: Evaluation of a complex relationship

INTRODUCTION

Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract. Currently, for any incidentally discovered Meckel's diverticulum, the management approach is based on weighing the statistical odds of future complications against the risks of a diverticulectomy.

MATERIALS AND METHODS

The temporal relationship between age at Meckel's diverticulectomy and the presence of ectopic epithelium was evaluated in our series. A meta-analysis of all reported recent literature on this condition was subsequently performed to evaluate the strength of the relationship between ectopic epithelium and symptomatic Meckel's diverticulum.

RESULTS

There was a paucity of ectopic epithelium in Meckel's diverticulectomy specimens in infants operated on at less than 1 year of age. Having two or more ectopic epithelia in a diverticulum does not appear to carry an additive risk for complications. The meta-analysis confirmed that ectopic epithelium was the most significant factor that influenced surgical intervention in all series of Meckel's diverticulum.

CONCLUSION

The relationship between ectopic epithelium and the development of symptomatic Meckel's diverticulum is complex. Further understanding of the development of ectopic rests in the diverticulum will facilitate elucidating the pathophysiology in symptomatic cases.

Symptomatic Meckel's diverticulum in newborn: two interesting additional cases and review of literature

OBJECTIVES

This study aimed to review the literature about symptomatic Meckel's diverticulum (MD) in the neonatal period with 2 additional uncommon cases.

METHODS

The authors describe 2 interesting neonatal cases of symptomatic MD and analyze the literature on this topic, with particular reference to the prevalence of sex, age at presentation, most common signs and symptoms, treatment, histology, associated anomalies, and outcome.

RESULTS

The first patient was a term newborn with bowel obstruction by a pseudocystic MD. The second patient was a preterm infant with double perforation of the MD and ileum. Literature search for published case reports and case series on this topic reveals only 18 cases of neonatal symptomatic MD. Males are more frequently involved than females, and even preterm infants may be affected. Bowel obstruction (58.3%) and pneumoperitoneum (33.3%) are the most frequent clinical manifestation. Acute inflammation of the MD is the prominent histopathological finding (75%), although it does not seem to be related with the presence of heterotopic tissue within the MD. Surgical treatment is essential. The association of neonatal symptomatic MD with other anomalies is exceptional but is otherwise life threatening despite surgery.

CONCLUSIONS

Bowel obstruction and pneumoperitoneum are the most frequent clinical manifestations of symptomatic MD in the newborn. Surgery is required for a definitive diagnosis and successful outcome.

Single-trocar transumbilical laparoscopy-assisted management of complicated jejunal diverticula

Small-intestinal nonmeckelian diverticula are very uncommon and are considered to be acquired pulsion diverticula. Most of these diverticula are asymptomatic and are simply incidental findings. Complicated-acquired diverticular disease of the jejunum and ileum is a diagnostic dilemma. Small-bowel diverticulum is diagnosed with the aid of radiography techniques, such as small-bowel contrast series or enteroclysis. Laparotomy remains the gold standard for a definite diagnosis of asymptomatic and complicated diverticula, but laparoscopy is also very useful in the diagnosis and treatment of this condition. A surgical approach is the best form of treatment for complicated jejunoileal diverticula. The current report is about a patient who presented with iron deficiency anemia caused by a complicated jejunal diverticulum and managed with single-trocar transumbilical laparoscopy.

A common case of gastroenteritis in a child followed by an axial torsion of Meckel diverticulum: a rare and unusual complication

A 1-year-old boy presented at our hospital with common gastroenteritis symptoms such as fever, vomiting and diarrhoea. Clinical and laboratory findings were normal. An emergency ultrasound examination was performed and excluded abdominal complications. After 2 days of complete regression of symptoms, the patient began to vomit again, diarrhoea stopped with a sudden worsening of clinical conditions. Laboratory and radiological findings showed signs of an acute abdomen with differential diagnosis between an infectious and an obstructive cause. Owing to the rapid and progressive toxic condition, an emergency laparoscopy was performed. An axial torsion of a swollen and gangrenous Meckel's diverticulum was detected.

Torsion of Meckel's Diverticulum in a Child

Meckel's diverticulum (MD) is a common congenital anomaly of the gastrointestinal tract, the majority of cases of which are clinically silent. Patients with asymptomatic MD can unexpectedly develop acute abdominal pain. Making a diagnosis of MD is often difficult due to the lack of specific symptoms caused by this condition. Diagnostic laparotomy can be useful for making an accurate and prompt diagnosis of complicated MD. We herein describe a pediatric case of torsion of a MD in whom we performed laparoscopic-assisted emergency surgery. The patient was an 11-year-old male who developed sudden severe right lower abdominal pain. Clinical and laboratory findings were suggestive of appendicitis, however computed tomography scans showed a large cystic mass in the pelvis. Exploratory laparoscopy led to a diagnosis of torsion of a MD, and wedge resection of the gangrenous MD was performed through an umbilical port incision. The patient's postoperative course was uneventful. We conclude that diagnostic laparoscopy followed by laparoscopy-assisted Meckel's diverticulectomy via an umbilical incision is useful in the treatment of acute abdomen caused by MD.

Diagnosis and management of pediatric appendicitis, intussusception, and Meckel diverticulum

Three of the most common causes of surgical abdominal pain in pediatric patients include appendicitis, Meckel diverticulum, and intussusception. All 3 can present with right lower quadrant pain, and can lead to significant morbidity and even mortality. Although ultrasound is the preferred method of diagnosis with appendicitis and intussusception, considerable variety exists in the modalities needed in the diagnosis of Meckel diverticulum. This article discusses the pathways to diagnosis, the modes of treatment, and the continued areas of controversy.

Meckel's diverticulum causing severe hemorrhage

Meckel's diverticulum has varied presentations in children and often becomes a diagnostic challenge. The authors present a 10-year-old boy with abdominal pain and one episode of melena. His symptoms were undervalued during two previous hospitalizations in pediatric units until his hemoglobin level dropped from 8.2 to 3.5 g/dL. The laparoscopic intervention performed in emergency identified a bleeding Meckel's diverticulum that was resected after being exteriorized from the umbilicus. Our observation shows that severe hemorrhage due to a Meckel's diverticulum is possible albeit exceptional.

Laparoscopic management of perforated Meckel's diverticulum in adults

OBJECTIVE

To determine the role of laparoscopy in diagnosis and surgical treatment of perforated Meckel's diverticulum (MD) in adults.

METHODS

Between July 2003 and July 2011, fifteen patients were seen with perforated MD. Eleven were male and four were female. The median age was 38 years (range, 21-68). All patients presented with a sudden onset of pain. Among them 9 had a past medical history of bloody stools and /or chronic recurrent abdominal pain. 2 were preoperatively diagnosed with perforated MD confirmly and 4 suspiciously, 9 with perforated acute appendicitis. All 15 patients underwent exploratory laparoscopy.

RESULTS

4 patients with broad-base(≧ 2 cm) and 2 patients with narrow-base(<2 cm) whose perforative site was near the base underwent laparoscopically assisted extracorporal bowel segment resection, the other 9 patients with narrow-base(<2 cm) underwent laparoscopically intraabdominal wedge resection of the MD. No intraoperative or postoperative complications occurred. The median hospital stay was 4 days (range, 2-7 days). The histopathologic studies showed heterotopic gastric mucosa (HGM) in 10 cases (66.7%). All patients recovered uneventfully.

CONCLUSION

To patients with sudden abdomen pain mimic acute appendicitis accompanied by a past medical history of bloody stools and/or chronic recurrent abdominal pain, proferated MD should be kept in mind as a differential diagnosis. Laparoscopy is a safe and effective surgical modality for diagnosis of proferated MD and has a therapeutic role that results in an excellent cosmetic result.

National trends in the surgical management of Meckel's diverticulum

BACKGROUND

Treatment recommendations for Meckel's diverticulum (MD) come mostly from single-institution case series. The objective of this study was to review the surgical management and outcomes of children undergoing Meckel's diverticulectomy using contemporary data from a national database.

METHODS

We queried 2007 to 2008 data from the Pediatric Health Information System database and analyzed demographic and outcome variables for patients undergoing surgical resection of MD. Cases were classified as primary (symptomatic MD) or secondary (incidental MD). Outcomes in primary cases were compared between open and laparoscopic approaches. Statistical analyses were performed using SPSS (Chicago, IL).

RESULTS

Eight hundred fifteen children underwent Meckel's diverticulectomy. Meckel's diverticulectomy was more common in boys (boy-girl, 2.3:1), and half (53%) of the children required surgery before their fourth birthday. More cases (n = 485; 60%) were classified as primary, and most children were approached by laparotomy (75%). The most common presentations for primary cases were obstruction (30%), bleeding (27%), and intussusception (19%). In the primary group, patients treated with the laparoscopic approach had a shorter length of stay (open approach, 5.7 ± 5.2 days; laparoscopic approach, 4.3 ± 2.7 days; P < .02).

CONCLUSION

These data describe current trends in the surgical treatment of MD in the United States. Laparoscopic Meckel's diverticulectomy appears to shorten length of stay but is used much less frequently than the traditional open approach.

Asymptomatic Meckel's diverticulum in adults: is diverticulectomy indicated?

BACKGROUND/AIM

The objective of this study was to estimate the incidence of the Meckel's diverticulum (MD) and to study its clinical profile and surgical outcome, as well as to check whether diverticulectomy is indicated for asymptomatic MD in adults.

MATERIALS AND METHODS

This is a prospective study of 1332 patients who were operated upon for acute abdomen during the period August 1999 to July 2009 in a single surgical unit. Preoperative abdominal ultrasonography and plain x-ray abdomen (erect) were done depending on the necessity. These patients were subjected to laparotomy/ appendicectomy depending on the case. A search for MD was done, and if found, surgical resection and analysis by histopathological confirmation of the resected MD were performed.

RESULTS

During the operation, this study detected 15 (1.13%) patients with MD. In none of these cases, preoperative diagnosis of Meckel's diverticulitis was made. The age of the patients ranged from 18 to 68 years (mean age, 32.9 years). Out of 15 patients, 9 (60%) were males; 6 (40%) were females. Seven (46.7%) cases were symptomatic due to MD and 8 (53.3%) were asymptomatic. One patient presented with hematochezia; 2, with intestinal obstruction due to gangrene of the MD; and 4, with Meckel's diverticulitis. One patient had duplication of (double) Meckel's diverticulum without any inflammation in both the diverticulae. Histopathological examination of these specimens confirmed 4 cases with inflammation; 2, with gangrene; and 1, with ulcerated gastric mucosa in the MD. Among these, in 2 (13.3%) cases there was heterotopic epithelium (ulcerated gastric mucosa- 1, colonic mucosa- 1).

CONCLUSION

We recommend that a search for MD in every case of appendicectomy/ laparotomy done for acute abdomen should be conducted, and if found, Meckel's diverticulectomy or resection should be performed to avoid secondary complications arising from it.

Meckel's diverticulum-Revisited

Meckel's diverticulum is a true intestinal diverticulum that results from the failure of the vitelline duct to obliterate during the fifth week of fetal development. In about 50% cases, it contains ectopic or heterotopic tissue which can be the cause of complications. A systematic review of literature was undertaken to study the history, incidence, embryoanatomy, clinical presentation, complication and management of Meckel's diverticulum. Although Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract, it is often difficult to diagnose. It may remain asymptomatic or it may mimic disorders such as Crohn's disease, appendicitis and peptic ulcer disease.

Clinical and diagnostic relevance of Meckel's diverticulum in children

Meckel's diverticulum (MD) has varied clinical manifestations and is a diagnostic challenge for pediatricians. This study investigates the clinical and diagnostic characteristics of MD in children with different presentations. We retrospectively reviewed the medical records of pediatric patients diagnosed with MD from 1988 to 2008. The data including the age, sex, clinical features, laboratory data, sensitivity of diagnostic methods, and pathological finding were recorded. These patients were classified into three groups: diverticulitis, intestinal obstruction, and intestinal bleeding. A total of 47 children (35 boys and 12 girls) with a median age of 5.6 years were enrolled and categorized as follows: diverticulitis (n = 12), obstruction (n = 12), bleeding (n = 21), and two diagnosed incidentally. Patients with intestinal obstruction were significantly younger than those with bleeding (3.7, 95% CI, 1.6-5.7 vs. 6.6, 95% CI, 4.5-8.7, P = 0.04). In the obstruction group, intussusception was found in eight of 12 patients, of whom 62.5% were aged older than 3 years. Heterotopic tissues were found in 46.3% of surgical specimens and more frequently existed in patients with bleeding than those with diverticulitis (P = 0.02) and obstruction (P = 0.047). Tc-99m scans yielded a diagnostic sensitivity of about 65% in bleeding patients. Repeated Tc-99m scans and red blood cell (RBC) scans can be good supplementary tools in Tc-99m scan-negative bleeding patients. In conclusion, manifestations of childhood MD are variable and may depend on the presence of heterotopic tissues and the patients' age. Tc-99m scans supplemented with RBC scans are appropriate to diagnose childhood MD with bleeding.

Meckel’s diverticulum masked by a long period of intermittent recurrent subocclusive episodes

Meckel’s diverticulum (MD) is the most frequent congenital abnormality of the small bowel and it is often difficult to diagnose. It is usually asymptomatic but approximately 4% are symptomatic with complications such as bleeding, intestinal obstruction, and inflammation. The authors report a case of a 7-year-old boy with a one-year history of recurrent periumbilical colicky pain with associated alimentary vomiting, symptoms erroneously related to a cyclic vomiting syndrome but not to MD. The clinical features and the differential diagnostic methods employed for diagnosis of MD are discussed.

Technetium-99m scan in the laparoscopic management of a misdiagnosed Meckel's diverticulum: a case report

Introduction

Although Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract and modern imaging techniques are available, its diagnosis remains problematic.

Case presentation

A technetium-99 scan was performed in an 18-year-old man with abdominal pain, vomiting and rectal bleeding to confirm the presence of a Meckel's diverticulum which was not diagnosed laparoscopically elsewhere. The technetium-99 scan was positive and a diagnostic laparoscopy was re-performed which revealed a Meckel's diverticulum that was subsequently resected.

Conclusion

We suggest that a technetium-99m scan should be performed before laparoscopy in children and adolescents with suspected Meckel's diverticulum. A positive technetium-99m scan may significantly contribute to the laparoscopic definitive diagnosis and treatment of a bleeding Meckel's diverticulum. However, diagnostic laparoscopy should only be performed by experienced surgeons.

Inflammation of ectopic pancreatic tissue in a Meckel's diverticulum causing acute abdominal symptoms: a case report and review of the literature

An unusual case of acute abdomen was caused by the inflammation of ectopic pancreatic tissue in a Meckel's diverticulum. A 49-year-old man presented with acute abdominal pain, and the clinical diagnosis of acute appendicitis was established. During laparotomy, a normal appendix of unusual localization near the gallbladder and a Meckel's diverticulum with an inflamed tip were found. Histological examination showed acute inflammation of heterotopic pancreatic tissue along with normal ectopic gastric and duodenal mucosa within the wall of the diverticulum. Fat necrosis was also ascertained. The authors believe that this is the first report of acute inflammation of ectopic pancreatic tissue and the presence of normal ectopic gastric and duodenal tissue in the same Meckel's diverticulum.

Incarcerated femoral Littre's hernia-transperitoneal preperitoneal hernia repair (TAPP) and laparoscopic resection of the necrotic diverticulum

Littre's hernias in the region of a femoral hernial orifice have been described in numerous cases in the literature. Open inguinal or femoral access was selected for all surgical procedures. We are describing the first case of an incarcerated Littre's hernia in the region of a femoral hernial orifice treated by means of transperitoneal preperitoneal hernia repair with simultaneous laparoscopic resection of the diverticulum. On the basis of the example, it is shown that the laparoscopic procedure is safe and efficient when performed by an experienced laparoscopic surgeon, even for treating incarcerated hernias, including the resection of necrotic tissue.

Emergency surgery for Meckel's diverticulum

The current work attempts to highlight the various life threatening complications of Meckel's diverticulum and to present the surgical strategies used in the emergency conditions so far in the form of a review of the works presented in the literature. Our aim behind this presentation is to cover the possible indications, methods, their complications and the outcome of these surgical techniques. For this, we made an extensive literature search using Google and Pubmed with the words-"Meckel's diverticulum", "Complications", "Management" and "Emergency surgery". All the relevant articles containing the surgical aspects of symptomatic Meckel's diverticulum till May 2008 were collected and analyzed. Meckel's diverticulum is the remains of the prenatal yolkstalk (Vitellointestinal duct). Although it generally remains silent but life threatening complications may arise making it an important structure for having a detailed knowledge of its anatomical and pathophysiological properties to deal with such complications.

Presumed appendiceal abscess discovered to be ruptured Meckel diverticulum following percutaneous drainage

A Meckel diverticulum is an embryonic remnant of the omphalomesenteric duct that occurs in approximately 2% of the population. Most are asymptomatic; however, they are vulnerable to inflammation with subsequent consequences including diverticulitis and perforation. We report an 11-year-old boy who underwent laparoscopic appendectomy for perforated appendicitis at an outside institution. During his convalescence he underwent percutaneous drainage of a presumed postoperative abscess. A follow-up drain study demonstrated an enteric fistula. The drain was slowly removed from the abdomen over a period of 1 week. Three weeks following drain removal the patient reported recurrent nausea and abdominal pain. A CT scan demonstrated a 3.7-cm rim-enhancing air-fluid level with dependent contrast consistent with persistent enteric fistula and abscess. Exploratory laparoscopy was performed, at which time a Meckel diverticulum was identified and resected. This case highlights the diagnostic challenge and limitations of conventional radiology in complicated Meckel diverticulum.