What is the treatment approach for Meckel's diverticulum?

Treatment of Meckel's Diverticulum

Symptomatic Meckel's diverticulum requires surgical resection via segmental small bowel resection with primary anastomosis, while incidentally discovered asymptomatic diverticula should be resected in patients under 50 years of age. 1, 2, 3

Symptomatic Meckel's Diverticulum

All symptomatic Meckel's diverticula mandate surgical removal with segmental ileal resection and primary anastomosis. 1, 4

• Open or laparoscopic small bowel segmental resection with primary anastomosis is the definitive treatment for symptomatic cases. 1
• Segmental resection (rather than simple diverticulectomy) is preferred because it removes the entire pathologic segment including any heterotopic tissue and ensures adequate margins. 4
• Symptomatic presentations include painless rectal bleeding (especially in children and young adults), small bowel obstruction from volvulus around fibrous bands, diverticulitis, or perforation. 5, 6, 7

Surgical Approach Selection

• Both open and laparoscopic approaches are acceptable, with choice based on clinical presentation and surgeon expertise. 1, 4
• In cases of perforation or peritonitis, open surgery may be preferred for adequate source control and peritoneal lavage. 1
• Laparoscopic resection can be performed successfully in stable patients without perforation or extensive inflammation. 4

Incidentally Discovered Asymptomatic Meckel's Diverticulum

Resection of incidentally found asymptomatic Meckel's diverticulum is strongly recommended in patients under 50 years of age. 2, 3

Age-Based Decision Algorithm

• Patients <50 years: Resect the diverticulum, as 70% of symptomatic cases occur in this age group. 2
• Patients ≥50 years: Only 10% will develop symptoms, making prophylactic resection less beneficial; consider leaving it in place unless high-risk features are present. 2

High-Risk Features Favoring Resection (Any Age)

• Diverticulum length >2 cm with narrow base (diameter ≤2 cm), which significantly increases complication risk. 3
• Palpable heterotopic tissue or thickened diverticular wall suggesting gastric mucosa. 2, 3
• Diverticulum that easily fits within a stapling device without technical difficulty. 4

When to Leave Asymptomatic Diverticula Alone

• Broad-based or very short diverticula that cannot be easily stapled or resected without difficulty are unlikely to become symptomatic and should be left undisturbed. 4
• Patients over 50 years with normal-appearing diverticula without high-risk features. 2

Surgical Technique Considerations

Segmental ileal resection is preferred over simple diverticulectomy for both symptomatic and resected asymptomatic cases. 4

• Segmental resection removes the entire pathologic segment and any associated heterotopic tissue. 4
• Stapling devices facilitate safe resection with low complication rates when the diverticulum easily fits within the device. 4
• Resection of incidentally found diverticula does not increase operative morbidity or mortality compared to leaving them in place. 3

Diagnostic Considerations

Preoperative diagnosis is challenging and often only confirmed at surgery, but specific imaging can aid in suspected cases. 5, 3

• Meckel's scan (99mTc pertechnetate scintigraphy) is the diagnostic test of choice for young patients with painless rectal bleeding and negative endoscopy, with 89% sensitivity and 98% specificity. 5
• CT enterography can identify Meckel's diverticulum when bleeding is not active and helps exclude other etiologies. 5
• CT scan with IV contrast is highly accurate for diagnosing complications like diverticulitis or perforation. 5

Common Pitfalls to Avoid

• Do not perform simple diverticulectomy alone—segmental resection ensures complete removal of heterotopic tissue and reduces recurrence risk. 4
• Do not leave symptomatic diverticula untouched—four patients in one series had Meckel's diverticula found and left during previous laparotomy, only to present later with complications. 3
• Do not assume older patients are immune—while less common, complications can still occur after age 50. 2
• Do not force resection of broad-based diverticula—if stapling is technically difficult, the diverticulum is unlikely to become symptomatic and should be left alone. 4