What is the management for incidental finding of multiple diverticula at the mesenteric border of the jejunal loop during a laparotomy for hepatic (liver) resection?

Management of Incidental Jejunal Diverticula During Laparotomy

For incidental finding of multiple jejunal diverticula at the mesenteric border during hepatic resection, the appropriate management is to leave them without intervention (option C) unless they are symptomatic or complicated.

Understanding Jejunal Diverticula

• Jejunal diverticula are uncommon acquired lesions that are usually asymptomatic and discovered incidentally during laparotomy or imaging studies 1
• They are more common in elderly patients (60-70 years) and are typically multiple in the jejunum 1
• These are false diverticula consisting of mucosa and serosa without the muscular layer, typically found at the mesenteric border 2

Management Approach for Incidental Jejunal Diverticula

Asymptomatic Incidental Findings

• Asymptomatic jejunal diverticula discovered during surgery for other conditions should be left without intervention 1
• The World Society of Emergency Surgery (WSES) guidelines support that asymptomatic diverticula discovered on routine studies or incidentally during surgery need not be resected 3

When Intervention Is Necessary

• Surgical intervention is only indicated for jejunal diverticula in cases of complications such as:
  • Active diverticulitis 3
  • Perforation with peritonitis 3, 4
  • Obstruction 1, 5
  • Significant hemorrhage 1
  • Failure of medical management for symptomatic disease 1

Evidence Supporting Non-intervention

• In a case report of giant and multiple jejunal diverticula found incidentally during laparotomy for peritonitis due to ileal perforation, the jejunal diverticula were left untouched as they were multiple and non-obstructive, with good outcomes at 16-month follow-up 4
• Surgical resection of asymptomatic diverticula carries unnecessary risks including:
  • Prolonged operative time during an already complex procedure (hepatic resection) 3
  • Increased risk of anastomotic complications 3
  • Potential for short bowel syndrome if extensive small bowel resection is required for multiple diverticula 1

Special Considerations

• If the diverticula show evidence of inflammation, perforation, or bleeding, then resection of the involved segment would be indicated 2, 6
• In cases where diverticula are associated with dilated, hypertrophied loops of small bowel, surgical intervention might be considered 1
• When resection is necessary, the preferred approach is segmental resection with primary anastomosis rather than simple diverticulectomy 1

Conclusion for Clinical Practice

• For the scenario described - incidental finding of multiple jejunal diverticula during hepatic resection without evidence of complications - the correct management is to leave them without intervention (option C) 1
• Biopsy (option A) is unnecessary for typical-appearing diverticula and adds risk without changing management 1
• Resection of the loop (option B) would be excessive and potentially harmful for asymptomatic diverticula, increasing operative time and risks during an already complex procedure 3, 1