Int. J. Med. Sci. 2012, 9
I In nt te er rn na at ti io on na al l J Jo ou ur rn na al l o of f M Me ed di ic ca al l S Sc ci ie en nc ce es s
2012; 9(3):243-247. doi: 10.7150/ijms.4170
Laparoscopic Management of Perforated Meckel’s Diverticulum in Adults
Yinlu Ding1, Yong Zhou1, Zhipeng Ji1, Jianliang Zhang1, Qisan Wang 2
1. Department of General Surgery, The Second Hospital of Shandong University, Shandong 250033, China.
2. Department of Gastrointestinal Surgery, The Tumor Hospital of Xinjiang Medical University, Xinjiang 830000, China.
Corresponding author: Qisan Wang, E-mail: firstname.lastname@example.org; Tel.: 0086-991-7819132; Fax: 0086-991-7968111.
© Ivyspring International Publisher. This is an open-access article distributed under the terms of the Creative Commons License (http://creativecommons.org/
licenses/by-nc-nd/3.0/). Reproduction is permitted for personal, noncommercial use, provided that the article is in whole, unmodified, and properly cited.
Received: 2012.01.31; Accepted: 2012.05.01; Published: 2012.05.04
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 laparoscopi-
cally intraabdominal wedge resection of the MD. No intraoperative or postoperative com-
plications occurred. The median hospital stay was 4 days (range, 2-7days). The histopathologic
studies showed heterotopic gastric mucosa (HGM) in 10 cases (66.7%). All patients recovered
Conclusion: To patients with sudden abdomen pain mimic acute appendicitis accompa-
nied 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.
Key words: Meckel’s diverticulum; Perforation; Laparoscopy
Meckel’s diverticulum (MD), first described in
1808, results from failure of complete obliteration of
the vitelline duct. It is a common anomaly of the small
intestine that occurs in approximately 2% of the pop-
ulation, often found incidentally at the time of ab-
dominal exploration [1,2]. The complications associ-
ated with MD include inflammation, perforation,
hemorrhage, intussusception, volvulus, intestinal ob-
struction, and malignant transformation. The total
lifetime complication rate has been reported to be
around 4% [3,4]. Most patients with MD are asymp-
tomatic, but in those that develop symptoms, it has
been estimated that more than 50% are less than 10
years of age [1, 6-7]. Perforation, a rare uncommon
complication of MD in adults, is often caused by di-
verticulitis, which occurs in 12.7% to 30.9% of cases
. Perforated MD presents a diagnostic as well as a
therapeutic challenge. Conventional
methods including plain abdominal radiographs,
abdominal ultrasound, technetium 99mTc pertechne-
Int. J. Med. Sci. 2012, 9
tate scintigraphy, angiography, and exploratory lap-
arotomy have several limitations . The aim of this
study is to review our experience using laparoscopy
in the management of perforated MD.
Patients and methods
Between July 2003 and July 2011, 15 patients
were seen with perforated MD in the Second Hospital
of Shandong University. 11 were male and 4 were
female. The median age was 38 years (range, 21–68).
All patients presented with a sudden onset of pe-
ri-umbilical or right lower quadrant pain. Among
them 9 had a past medical history of bloody stools
and /or chronic recurrent abdominal pain. Physical
examination showed abdominal rigidity, guarding to
palpation in the peri-umbilical area and right lower
quadrant in these 15 patients. On laboratory tests,
white blood cell count of all the 15 patients exceed
14.6×109/L with higher neutrophil granulocyte ratio,
and 7 of the 9 patients presented with bloody stools
showed hypochromic anemia. In all patients with
bloody stools and /or chronic recurrent abdominal
pain, upper and lower gastrointestinal endoscopy
were done in past but failed to find the source of
bleeding. A technetium 99mTc pertechnetate scan was
performed in five patients with bloody stools, only 2
patients had ectopic uptake in the right lower quad-
rant. All of the 15 patients underwent ultrosound
examnination and 12 showed free fluid and among
them 4 with normal appendix ultrasonographic char-
acteristics, 8 of the 15 patients underwent Computed
Tomography scan of abdomen and pelvis which
showed free fluid.
As to preoperative diagnosis of the 15 patients, 2
were diagnosed with perforated Meckel’s diverticu-
lum confirmly and 4 suspiciously, 9 with perforated
acute appendicitis. All 15 patients underwent explor-
atory laparoscopy. General anesthesia was utilized.
Pneumoperitoneum was created by open Hasson’s
technique using a 10-mm port to a pressure of 12
mmHg. Through this port, a 10-mm telescope was
used for initial visualization of the whole abdomen.
Two 5-mm accessory ports were inserted n the left
and right lower abdomen. Our procedure started with
complete visualization of the whole abdomen and
then identification of the ileocecal segment. The ter-
minal ileum was examined stepwise from ileocecal
junction proximally using atraumatic grasping for-
ceps. If an perforated MD with narrow-base(＜2 cm,
Fig. 1) was identified, a 12-mm trocar was placed
through the right accessory port for replacement of
the 5-mm one, allowing the right port for the applica-
tion of Endo Linear cutter stapler (Endo LCS), exteri-
orization of MD, and extraction of the specimen.
Laparoscopically intraabdominal wedge resection of
the MD was performed by firing Endo LCS across the
bowl wall near the base of MD. To perforated MD
with broad-base (≧2 cm, Fig. 2) or perforated-base
(Fig. 3), a laparoscopically assisted extracorporal
bowel segment resection with end-to-end anastomosis
was performed. Before terminating the procedure, the
resected diverticulum was opened and carefully in-
spected for confirmation of complete removal of ec-
topic gastric mucosa.
Fig. 1 perforated MD with narrow-base(＜2 cm)
Fig. 2 perforated MD with broad-base (≧2 cm )
Fig. 3 Laparoscopic view of a Meckel’s diverticulum with a per-
oration near the base(↘ site of peroration)
Int. J. Med. Sci. 2012, 9
The distance from the diverticulum to the ile-
ocecal valve, in our study, was from 40 to 95cm with
the mean of 62cm. All of the diverticula were detected
on the antimesenteric border of the ileum. The length
and the base diameter was 3.6±1.2cm (range, 3- 8cm)
and 1.7±0.9cm (range, 1 to 4cm), respectively. 4 pa-
tients with broad-base(≧ 2 cm) and 2 patients with
narrow-base(＜2 cm) whose perforative site was near
the base underwent laparoscopically assisted extra-
corporal bowel segment resection, the other 9 patients
with narrow-base(＜2 cm) underwent laparoscopi-
cally intraabdominal wedge resection of the MD. The
mean operative time for laparoscopic wedge bowel
resection of the MD was 52 minutes, whereas the
mean operative time for laparoscopically assisted
bowel segment resection was 68 minutes. No in-
traoperative or postoperative complications occurred.
The median hospital stay was 4 days (range, 2-7days).
The histopathologic studies showed heterotopic gas-
tric mucosa (HGM) in 10 cases (66.7%%) and no pan-
creatic tissue or colonic mucosa, no ectopic tissues
were found in the other 5 patients. All patients re-
covered uneventfully and were discharged 1 to 2 days
after the procedure. All patients remained well at
Fewer than 10% of symptomatic MD are diag-
nosed preoperatively . In general, upper and lower
gastrointestinal endoscopy play no role as they are
inaccessible to ileum suffering from MD. CT and so-
nography are usually of little value because distinc-
tion between a diverticulum and intestinal loops is
(99mTc-pertechnetate) may diagnose MD when uptake
occurs in ectopic gastric mucosa or by identifying the
site of gastrointestinal bleeding. But accuracy, re-
ported to be around 90% in pediatric series , drops
to only 46% in the adult group . HGM and the
posittive 99mTc pertechnetate scan was found in only
10 and 2 (out of 5) patients in our series, respectively.
Furthermore, perforated MD often presents as acute
abdomen, doctors might not have sufficient time to
take various diagnostic measures. The correct diag-
nosis is usually confirmed by operation. Laparoscopic
surgery is propitious to avoid not only negative ex-
ploratory laparotomies for patients with false-positive
radionuclide scan but also delayed surgical treat-
ments for patients with false-positive scan . Our 15
patients obtained definite diagnosis by diagnostic
laparoscopy, and then received timely treatment
Length and width of the diverticulum are also
felt to be determinant in symptomatology. Mackey et
al found that symptomatic diverticula were more
likely to be 2 cm or greater in length . It had been
felt that broad-based diverticula were less likely to be
symptomatic because of a lower risk of obstruction.
Mackey et al did not find any correlation between
width and symptomatology . In our series, 11 cases
with narrow-base (＜2 cm) and the diverticulum,s
length of all patients were more than 2 cm with MD
diverticulitis, Hence we infer that long diverticula
with narrow-base(＜2 cm) are more predisposed to
MD diverticulitis, clinically undistinguishable
from acute appendicitis, occurs in about 20% of pa-
tients. As in acute appendicitis, diverticular obstruc-
tion results in distal inflammation, necrosis, or even
perforation, leading to abscess or peritonitis. Ulcera-
tion of ectopic gastric tissue, ingestion of foreign
bodies, Littre’s hernia, tumors such as leiomyosar-
coma, lymphatic sarcoma, and poorly differentiated
stromal tumor were also pathologies leading to per-
foration . In our fifteen patients, perforation was
secondary to diverticulitis but not other pathologies.
Among them 9 had manifestation of bloody stools and
/or chronic recurrent abdominal pain in past medical
The management of incidental MD remains
controversial. Most published reports opponent to
incidental diverticulectomy have included only pa-
tients undergoing diverticulectomy or bowel resection
through laparotomy . Prophylactic diverticulec-
tomy laparoscopically was believed to be a safe pro-
cedure in face of potential risk of future complications
and the higher morbidity associated with complicated
MD . There is general agreement that sympto-
matic MD should be resected by either open or lapa-
roscopic procedures. As to perforated MD in opera-
tion, to survey the small intestine beginning from the
ileocecal valve is necessary, especially when the ap-
pendix looks normal. Laparoscopic treatment of MD
has been increasingly reported with techniques in-
cluding intraabdominal wedge resection or extracor-
poreal/intracorporeal bowel segment resection .
Compared to conventional open procedures, lapa-
roscopy is a safe diagnostic and the therapeutic tool
that can decrease the time spent for diagnosis and
theoretically avoids the morbidity and mortality of a
delayed diagnosis while keeping costs at a minimum.
Following the recent development of stapler de-
vices, laparoscopic tangential resection with a linear
cutting and stapling device across the base of the di-
verticulum or wedge resection across the bowl wall
near the base has become feasible. To avoid narrow-
Int. J. Med. Sci. 2012, 9
ing the ileal lumen, transverse suturing is preferred by
us under the condition of wedge bowel resection.
However, the extent of resection is still a matter of
controversy, since the surgeon has a narrow margin
for safe resection; there is a risk for impinging on the
lumen of the ileum or performing an insufficient re-
section that leaves ectopic tissue on the ileal stump.
Therefore, inspection of the specimen is obligatory to
ensure the complete resection of ectopic mucosa. An
additional frozen section may be helpful . Because
of the possibility of ectopic tissue extending beyond
the diverticulum , bowel segment resection is a safe
therapeutic alternative. In cases of bleeding divertic-
ulum, inflammatory or perforated base, or in case of
tumor, particularly in those where the lumen is nar-
rowed, a formal segmental bowel resection after lap-
aroscopic proof of an MD should also be considered
. Laparoscopically extracorporeal bowel segment
resection was employed by us because of its equal
extent of safety and lower cost compared to intracor-
poreal bowel segment resection. We performed lapa-
roscopically intraabdominal wedge resection of the
MD and laparoscopically assisted extracorporal bowel
segment resection acording to size of base or perfo-
rated site, but bowel segment resection was not re-
ported by Palanivelu C et al  who argued that
tangential resection of the lesion alone would suffice
provided the base of the diverticulum was not in-
volved, while Craigie RJ et al  performed laparo-
scopically assisted extracorporal resection for all of
their 3 patients without using either the endoGIA
stapler or an endoloop technique.
The key procedural step in Meckel’s diver-
ticulectomy is to achieve complete resection of MD
along with the ectopic epithelium and peptic ulcers on
the adjacent ileum. Emergency procedures have to be
performed for cases with perforated MD and the
pathologists may be often absent for frozen section of
the specimen to assess the gastric mucosa of the
presence of malignancy. HGM cannot reliably be de-
tected intraoperatively, although a mass may be pal-
pated. Certainly, if the diverticulum is associated with
hemorrhage from an adjacent ulcer, or if it is broad
based, a bowel resection is indicated . Because the
presence of functioning HGM is often associated with
bleeding, perforation due to acid secretion  and
even ectopic mucosal tumor , It is our contention
that re-operation should be done in case of residual
functioning HGM. MD is a “hot-spot” where adjusted
risk of cancer was at least 70 times higher than any
other ileal site . Under the condition of Meckel’s
diverticulum cancer (MDC) proved by pathologist
postoperatively, a second selective operation should
be considered according to the type of tumor and the
extent of primary resection. For example, simple di-
verticulectomy is incomplete for MD-associated gas-
trointestinal stromal tumor (GIST) . In our series,
no residual gastric mucosa or MDC was found.
In conclusion, perforated MD often presents as
acute abdomen and its preoperative diagnosis is dif-
ficult. To patients with sudden abdomen pain mimic
acute appendicitis accompanied by a past medical
history of bloody stools and/or chronic recurrent
abdominal pain, perforated MD should be kept in
mind as a differential diagnosis. Exploratory lapa-
roscopy decreases the time spent for diagnosis and
theoretically avoids the morbidity and mortality of a
delayed diagnosis. Diagnostic laparoscopy has played
a keystone in reaching the definite diagnosis, and ac-
cordingly, a definite treatment of our 15 patients
safely in emergency. We can conclude that laparos-
copy is a useful tool in the diagnostic as well as ther-
apeutic treatment of perforated MD in adults.
This work was supported in part by Independ-
ent Innovation Foundation of Shandong University
number 2010TS009 awarded by Shandong University,
The authors have declared that no competing
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