Laparoscopic Treatment of Bowel Obstruction Due to
a Bezoar in a Meckel’s Diverticulum
Peter J. Fagenholz, MD, Marc A. de Moya, MD
Background and Objectives: Meckel’s diverticulum is a
common anomaly of the gastrointestinal tract that may
result in gastrointestinal bleeding, diverticulitis, and small
bowel obstruction. This report describes the use of lapa-
roscopy to treat a rare complication of Meckel’s diverticu-
lum–small bowel obstruction due to phytobezoar impac-
tion. More generally, it provides an example of the
feasibility and utility of a laparoscopic approach to small
bowel obstructions of unknown causes.
Methods: A 34-year-old male presented to the emergency
department complaining of episodic abdominal pain and
vomiting. He had no history of abdominal surgery. His
vital signs were stable, and his abdomen was distended,
but only mildly tender. He had no abdominal wall hernias
on examination. Imaging was consistent with small bowel
obstruction. He was brought to the operating room where
laparoscopy revealed a Meckel’s diverticulum with an
impacted phytobezoar as the source of obstruction. The
diverticulum was resected and the phytobezoar removed
on the third postoperative day, tolerating a regular diet.
Conclusions: Phytobezoar impaction in a Meckel’s diver-
ticulum causing small bowel obstruction is a rare event. It
can be effectively treated laparoscopically. This case pro-
vides an example of the potential utility of laparoscopy in
treating small bowel obstructions of unclear etiology.
Key Words: Laparoscopy, Bowel obstruction, Meckel’s
Meckel’s diverticulum is a common congenital anomaly of
the gastrointestinal tract occurring in 2% of the popula-
tion.1Phytobezoar impaction in a Meckel’s diverticulum is
a rare cause of small bowel obstruction (SBO), with ap-
proximately 9 cases reported in the English literature.2–8
We report the first known laparoscopic treatment of this
A 34-year-old male presented to the emergency depart-
ment complaining of episodic abdominal pain and vom-
iting over 24 hours. He had no history of abdominal
surgery. His vital signs were stable, and his abdomen was
distended, but only mildly tender. He had no abdominal
wall hernias on examination. Computed tomography (CT)
revealed a long segment of solid material in the small
bowel as an area of bowel obstruction (Figure 1). He was
brought to the operating room where laparoscopy re-
vealed a Meckel’s diverticulum with an impacted phytob-
ezoar as the source of obstruction. His umbilical trocar site
was extended to a 3-cm midline incision to allow for
externalization of the diverticulum and expulsion of the
phytobezoar mass (Figure 2). A 4-cm small bowel resec-
tion incorporating the base of the diverticulum was per-
formed and the phytobezoar expressed (Figure 2). The
patient made an uneventful recovery and was discharged
home on postoperative day 3. Pathology revealed Meckel’s
diverticulum without ectopic mucosa. Even in retrospect, it
was not possible to identify any unusual dietary habits that
may have predisposed him to phytobezoar formation. Al-
though it was not recognized preoperatively, on postop-
erative review of the CT scan, the Meckel’s diverticulum
could be identified (Figure 1). One year after surgery, the
patient is tolerating a regular diet and has had no evidence
of recurrent SBO.
Meckel’s diverticulum is a relatively common anomaly of
the gastrointestinal tract, occurring in an estimated 2% of
the population, but it is an uncommon cause of SBO.
Bowel obstructions from Meckel’s diverticula most com-
Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of
Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA (all authors).
Disclosure Statement: Neither of the authors have any financial interests relevant to
Financial Support: This report was created without outside financial support.
Address correspondence to: Peter J. Fagenholz, MD, Division of Trauma, Emer-
gency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts
General Hospital, 55 Fruit Street, CPZ 810, Boston, MA 02114-2696, USA. Tele-
phone: (617) 726-9591, Fax: (617) 726-9121, E-mail: email@example.com
© 2011 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
monly occur due to intussusception, volvulus around an
associated omphalomesenteric band, or inflammatory ad-
hesion, or incarceration of the diverticulum within a her-
nia.1Phytobezoar impaction in a Meckel’s diverticulum is
more rare with only 9 reported cases in the English liter-
ature.2–8None of these cases were treated laparoscopi-
cally. We did feel the need to extend one of our port sites
to 3cm to allow the impacted vegetable matter to be
completely expressed from either end of the transected
bowel (Figure 2), though the resection was performed
Although the patient was accurately diagnosed with SBO
and surgically explored on that basis, the precise diagno-
sis of phytobezoar impaction in a Meckel’s diverticulum
was not made preoperatively. Some authors have noted
the utility of CT for making this diagnosis, while others
have not found CT to be effective.2–4This case shows that
abdominal CT has the potential to identify phytobezoar
impaction in Meckel’s diverticulum, but that it may none-
theless be a difficult radiographic diagnosis. In this case,
vegetable matter filled the diverticulum, a short segment
of distal bowel, and a longer segment of proximal bowel,
giving a Y-configuration. This configuration has been pre-
viously described, though it may have contributed to the
difficulty of making a preoperative radiologic diagnosis,
because the diverticulum was not located precisely at the
most distal point of obstruction.5In other cases, the bezoar
has been entirely proximal to the origin of the Meckel’s
diverticulum.7While other obstructing phytobezoars identi-
fied in a Meckel’s diverticulum have been associated with
high fiber or vegetarian diets, no such association was
present in this case.4,7,8None of the other commonly
noted risk factors for bezoar formation, such as prior
gastric surgery, gastrointestinal motility disorders, or poor
dentition, were present.9
While a single case report cannot demonstrate that our
patient’s outcome was better than it would have been
using the standard open approach that has previously
been used to address this problem, this report at least
demonstrates the technical feasibility of a laparoscopic
approach. Potential advantages of laparoscopy include
decreased postoperative pain, quicker return of bowel
function compared to laparotomy, and less adhesion for-
mation. One retrospective study10has indicated that lap-
aroscopy may be superior to laparotomy for surgical treat-
ment of SBO caused by bezoar. Whether these potential
advantages become manifest in the laparoscopic treat-
ment of SBO in general must be evaluated in the context
of randomized clinical trials.11While this case report can-
not demonstrate these advantages or allow wide general-
ization about the role of laparoscopy in the treatment of
SBO, it nevertheless provides an example of the potential
utility of laparoscopy as an approach to SBOs with un-
known causes, and illustrates the flexibility of the tech-
nique in adapting to unusual findings.
Figure 1. Computed tomography scan showing Meckel’s diver-
ticulum (circle) and dilated proximal small bowel (arrows). Both
are filled with impacted vegetable matter.
Figure 2. Phytobezoar being expressed from proximal small
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Laparoscopic Treatment of Bowel Obstruction Due to a Bezoar in a Meckel’s Diverticulum, Fagenholz PJ et al.