Diagnostic Laparoscopy and Small Bowel Resection for a Large Meckel's Diverticulum in Adult with Persistent GI Bleed

CHAPTER 1

My name is Nicole Cherng. I am an assistant professor at University of Massachusetts Medical School. I am a general surgeon who specializes in minimally invasive surgery as well as bariatric surgery. The case that we're going to discuss is a laparoscopic resection of a diverticulum. This is a 20-year-old gentleman who initially presented many months ago to the emergency department after fainting while exercising. He was found to be severely anemic requiring multiple blood transfusions and he was subsequently admitted. He underwent an upper endoscopy and a colonoscopy, both of which were negative. Then he underwent a CTA to look for a bleed, which was also negative. There was also no signs of any sort of a mass or intra-abdominal pathology. He then underwent a Meckel's scan, which was negative and underwent a video capsule endoscopy, which did show some specs of blood in the distal small bowel, but no masses were seen. He responded appropriately to blood products and was subsequently discharged home. He represented multiple times to the emergency department with the same thing, feeling lightheaded, dizzy, requiring blood transfusions 'cause he was found to be severely anemic even on iron transfusions as an outpatient. Multiple endoscopies were repeated, including a push enteroscopy and his video capsule endoscopy. Given that the video capsule endoscopy did see some specks of blood in the distal small bowel. The thought was that there was likely some sort of a small bowel pathology and the decision was made for myself and a gastroenterologist to proceed to the operating room for a diagnostic laparoscopy and a laparoscopic-assisted enteroscopy. So in the operating room, we did not do a bowel prep on the patient. We started laparoscopically and we placed four five-millimeter trocars to look at the small bowel and what you'll see is that we immediately are able to identify a Meckel's diverticulum approximately 120 centimeters proximal to the ileocecal valve. Given how large it is, you'll see that we decide to perform a small bowel resection that encases the diverticulum opposed to a simple diverticulectomy.

CHAPTER 2

We first entered the abdomen by inserting a Veress needle at Palmer's point. Once we reach adequate pneumoperitoneum, a five-millimeter trocar is placed. We then placed two additional five-millimeter trocars. For the positioning of this patient, we did tuck the left arm. And at this point, we are positioning the patient in Trendelenburg.

CHAPTER 3

Immediately we can see where the previously placed tattoo by the gastroenterologist is somewhere in the small bowel. Also unexpectedly, given that this patient has had no prior surgeries and is a virgin abdomen, we did see some of these adhesions of the mesentery to the small bowel to other portions of the small bowel as well. These adhesions were taken down with laparoscopic scissors, being careful not to injure any of the surrounding small bowel. Additionally, we did not use any cautery while lysing these adhesions. These adhesions did appear to be chronic and perhaps even congenital, and they were also primarily located within the right lower quadrant.

CHAPTER 4

Once the lysis of adhesion was performed, we were now able to mobilize the small bowel and then we immediately identified a Meckel's diverticulum. This was located just 10 centimeters proximal to the tattoo that had been placed by the gastroenterologist during their push enteroscopy. We continued to run the small bowel proximally to ensure that the small bowel itself was quite free. Here we can see that the Meckel's diverticulum is quite broad based and quite large, measuring to be approximately seven to eight centimeters. At this point, we were debating between either performing a diverticulectomy or a small bowel resection and doing a small bowel to small bowel anastomosis.

CHAPTER 5

Given how large the diverticulum is, we elected to perform a small bowel resection. We therefore place an additional five-millimeter trocar for an assist port and we also upsized one of our trocars to a 12-millimeter port in order to fit a stapler. We select points both proximal and distal to the diverticulum on the small bowel as our resection sites. We use the Maryland, the laparoscopic Maryland in order to create our window and then we elect to transect the small bowel, both proximal and distal to the diverticulectomy with an Endo-GIA 60 stapler using a white load. For the small bowel mesentery, this was transected using the laparoscopic Harmonic scalpel.

CHAPTER 6

For anastomosis, we elected to do a side-to-side functional end-to-end stapled anastomosis. We chose spots on the small bowel that was antimesenteric approximately one to two centimeters away from our staple line to create our enterotomies. We used the hot blade of the laparoscopic Harmonic scalpel to create our enterotomies and then used our laparoscopic Maryland forcep to widen the enterotomies to fit the Endo-GIA 60 stapler. We aligned the two limbs of the small bowel to ensure that there was no twisting of the mesentery as well. We used the Endo-GIA 60 stapler using a blue load to create our stapled anastomosis. We align the two limbs such that it was the antimesenteric side that would be used for the anastomosis as well. Once the stapler was fired, we looked on the inside to ensure that we had a wide open anastomosis and there was no bleeding at the staple line as well. For the common enterotomy, we elected to close this using a running 2-0 V-Loc suture in two layers. The next stitch that's placed is a 3-0 Vicryl as a crotch stitch to reduce the tension on the anastomosis. Laparoscopically, these sutures are cut to approximately six to seven inches.

CHAPTER 7

Here, we see that the mesentery is clearly not twisted. However, there is a mesenteric defect that needs to be closed to prevent any future internal hernias in this potential space. We closed the mesenteric defect with multiple figure-of-eight 2-0 Vicryl sutures. These mesenteric defects can be closed in multiple ways. Either interrupted figure-of-eight sutures such as this or a running 2-0 Vicryl would also be adequate, or also a purse-string would've worked as well.

CHAPTER 8

On final examination of our anastomosis, we see that it is clearly pink with no signs of ischemia. There is very minimal tension on the small bowel. The mesenteric defect is nice and closed, and the mesentery itself is not twisted. We then run the distal limb of the small bowel towards the terminal ileum and the ileocecal valve. We measure this to be approximately 90 to 100 centimeters to the ileocecal valve.

CHAPTER 9

Hemostasis is achieved, and we remove our specimen with a 10-millimeter Endo Catch Bag through the 12-millimeter trocar. This was sent off for final pathology. We close our 12-millimeter trocar with a 0 Vicryl using the suture passer. All trocars were then removed, and the abdomen was deflated. All skin incisions were then injected with local anesthetic, and closed with 4-0 Monocryl and then Dermabond. The patient tolerated the procedure well.

CHAPTER 10

[No Dialogue.]

CHAPTER 11

You saw in this case that this was a successful small bowel resection and we were able to identify the source of the bleed, which was a Meckel's diverticulum. In this case, I think, key points are that - first is identifying that a patient who has a persistent GI bleed, even though he went through exhaustive workup including multiple endoscopies, the suspicion was so high for some sort of a small bowel pathology as well as a Meckel's diverticulum, even though his Meckel's scan was negative, that we elected to proceed with a diagnostic laparoscopy, which I think is not very common but should be offered for these type of patients. In this case, also, having a combined effort with a gastroenterologist I think is the key, even though they were not needed since we found the obvious pathology right away. I think it's important to have that as a plan in case there is no obvious pathology right away. Postoperatively, the patient did great. He had return of bowel function after a few days and was subsequently discharged home on a regular diet and his repeat blood counts two months later were normal. Meckel's scan to look for a Meckel's diverticulum, its sensitivity is fairly high, but its specificity is fairly low. Meaning that if the test itself is negative, it doesn't necessarily mean there's absolutely no existence of that pathology. It is more sensitive in children compared to adults. Now he's 20 years old, so he's kind of on that cusp. So for a Meckel's diverticulum, it's well written in the literature that a simple diverticulectomy, so just transecting the diverticulum is sufficient. In this case, we did choose to do a small bowel resection because of the size of the diverticulum. We felt fairly strongly that if I resected just the diverticulum, that I would be narrowing the small bowel and that this would become a point of obstruction. And so I felt safer to perform a primary anastomosis even with the risk of an anastomosis would be more appropriate for this patient. I would say this case, I did choose to do a small bowel resection, and you'll see that the small bowel anastomosis that we do is intracorporeal. Now this is something that I prefer to do in the cases of decompressed small bowel where the pathology itself is quite small. If this was a point of obstruction where he had very dilated small bowel, I would err likely more towards doing an extracorporeal anastomosis and performing a mini-laparotomy. But I felt that given how decompressed the small bowel was that we could easily do this purely minimally invasive.