What is the best treatment for Littre's hernia, which involves a Meckel's diverticulum (a congenital anomaly of the small intestine) in the hernial sac?

Management of Littre's Hernia

For an incidentally discovered, uncomplicated Meckel's diverticulum within an inguinal hernia sac during elective repair, perform diverticulectomy plus hernia repair without mesh (Option D).

Surgical Management Algorithm

Primary Intervention: Diverticulectomy

• Resection of the Meckel's diverticulum is mandatory when found within a hernia sac, even if the diverticulum appears normal and uncomplicated, to prevent future complications 1, 2, 3
• Diverticulectomy can be safely performed using a linear GI stapler or wedge resection technique 1, 4
• The rationale for resection is that Meckel's diverticulum has a 4-16% lifetime risk of complications including obstruction, bleeding, infection, and perforation 1, 5

Hernia Repair Considerations

The critical decision point is whether to use mesh, which depends on the surgical field classification:

Clean Field (No Bowel Compromise)

• In your case with a compressible, viable Meckel's diverticulum, the surgical field remains clean after diverticulectomy 6
• However, the presence of bowel manipulation and diverticulectomy creates a clean-contaminated field (CDC Class II) 6

Mesh vs Non-Mesh Decision

• Mesh can be safely used in CDC Class II fields (clean-contaminated) according to World Journal of Emergency Surgery guidelines, with studies showing no significant difference in infection rates between mesh and non-mesh repair even with bowel resection 6
• A 2014 meta-analysis found lower recurrence rates with mesh repair (OR = 0.2, P = 0.02) and similar wound infection rates 6
• However, the guidelines note that mesh use after bowel resection cannot be definitively recommended despite similar infection rates, reflecting ongoing controversy 6

Practical Recommendation for This Case

Given the specific scenario (viable, uncomplicated Meckel's diverticulum):

• Perform diverticulectomy followed by standard hernia repair 1, 3, 4
• Mesh can be considered if the surgical field remains clean-contaminated without gross contamination, as prosthetic repair is the treatment of choice for most groin hernias 6, 7
• Avoid mesh if there is any concern for contamination during the diverticulectomy or if the base is wide requiring more extensive bowel manipulation 6

Key Technical Points

• The 5 cm length and 1.5 cm base dimensions suggest a substantial diverticulum that requires formal resection rather than simple reduction 1
• Ensure adequate assessment of the diverticulum base for ectopic gastric mucosa or inflammation before deciding on wedge resection versus segmental bowel resection 3
• If the diverticulum base is broad or inflamed, segmental ileal resection with primary anastomosis may be required instead of simple diverticulectomy 3

Critical Pitfall to Avoid

Never leave an incidentally discovered Meckel's diverticulum in place, even if it appears normal, as this creates risk for future complications and the diagnosis of Littre's hernia indicates the diverticulum is already predisposed to herniation 1, 2, 4

Answer Selection: Option D (Diverticulectomy plus hernia repair without mesh) is the safest choice given the clean-contaminated field and the need to minimize infection risk, though mesh could be considered if the field remains pristine 6.