How to manage a Meckel's diverticulum found in the hernial sac during a right inguinal hernia repair?

From the Guidelines

When a Meckel's diverticulum is incidentally discovered in the hernial sac during a right inguinal hernia repair, the most appropriate management is to perform a diverticulectomy and then proceed with hernia repair, as this approach minimizes the risk of complications and promotes optimal outcomes in terms of morbidity, mortality, and quality of life. The management of a Meckel's diverticulum found in the hernial sac during a right inguinal hernia repair depends on several factors, including the appearance of the diverticulum and the presence of any complications such as inflammation, ischemia, or perforation 1.

Key Considerations

• The presence of a Meckel's diverticulum in the hernial sac is a rare occurrence, and its management should be tailored to the individual patient's needs.
• If the diverticulum appears asymptomatic and non-inflamed, it may be possible to simply reduce it back into the peritoneal cavity and complete the hernia repair.
• However, if the diverticulum shows signs of complications, resection is warranted to prevent further morbidity and mortality.
• The use of prosthetic mesh in hernia repair, even in the presence of a Meckel's diverticulum, is supported by recent studies, which have shown that mesh repair can be safely performed without an increase in wound-related or additional early patient morbidity or mortality 1.

Management Approach

• Diverticulectomy followed by hernia repair is the recommended approach, as it minimizes the risk of complications and promotes optimal outcomes in terms of morbidity, mortality, and quality of life.
• The resection should be performed through a separate lower midline or infraumbilical incision to access the small bowel properly, rather than attempting removal through the hernia defect.
• A segmental ileal resection with primary anastomosis may be preferred over simple diverticulectomy, especially if heterotopic tissue is present.
• Postoperatively, patients should receive standard care, including early mobilization, pain management, and resumption of oral intake as tolerated. Some studies have shown that the use of prosthetic mesh in hernia repair, even in the presence of a Meckel's diverticulum, does not increase the risk of complications, and may actually reduce the risk of recurrence 1. However, the management of a Meckel's diverticulum found in the hernial sac during a right inguinal hernia repair should be individualized, taking into account the patient's overall health status, the appearance of the diverticulum, and the presence of any complications. In general, the goal of management is to minimize the risk of complications and promote optimal outcomes in terms of morbidity, mortality, and quality of life, and diverticulectomy followed by hernia repair is the recommended approach to achieve this goal.

From the Research

Management of Meckel's Diverticulum in Hernial Sac

• The management of a Meckel's diverticulum found in the hernial sac during a right inguinal hernia repair involves several considerations, including the risk of complications such as necrosis, perforation, and intestinal obstruction 2, 3, 4.
• The treatment options for a Meckel's diverticulum in a hernial sac include:
  • Diverticulectomy only: This involves removing the Meckel's diverticulum, but not necessarily repairing the hernia 2, 5.
  • Hernia repair with mesh: This involves repairing the hernia using a mesh, but not necessarily removing the Meckel's diverticulum 3, 4.
  • Resection anastomosis with hernia repair: This involves removing the Meckel's diverticulum and a portion of the intestine, and then repairing the hernia 6, 4.
  • Diverticulectomy plus hernia repair: This involves removing the Meckel's diverticulum and repairing the hernia 2, 3, 5.

Considerations for Management

• The choice of treatment depends on the presence of complications such as necrosis, perforation, or intestinal obstruction 2, 3, 4.
• The size and location of the Meckel's diverticulum, as well as the presence of ectopic tissue, may also influence the treatment decision 5.
• Laparoscopic approaches may be used for the treatment of Meckel's diverticulum in a hernial sac, including diverticulectomy and hernia repair 3.
• The use of mesh for hernia repair may be considered, but the risk of implant infection should be weighed against the benefits of mesh repair 4.