Surgical Management of Symptomatic Meckel's Diverticulum
For symptomatic Meckel's diverticulum, resection with anastomosis (segmental resection) is the preferred approach over simple stapling at the base, particularly when there is complicated diverticulitis with perforated base, bleeding, or suspicion of ectopic tissue at the diverticulum base. 1, 2
Decision Algorithm Based on Clinical Presentation
When to Perform Segmental Resection with Anastomosis
Segmental resection with anastomosis is mandatory in the following scenarios:
- Complicated diverticulitis with perforated base - the base integrity is compromised and cannot be safely stapled 1
- Gastrointestinal bleeding - ectopic gastric mucosa may extend to the base, requiring wider resection 1, 2
- Complicated intestinal obstruction - when the adjacent ileum is involved or compromised 1
- Presence of tumor or mass at the base - requires oncologic resection principles 1
- Short, broad-based diverticula - these have wide distribution of ectopic tissue including the base, making simple diverticulectomy inadequate 1
When Simple Diverticulectomy (Stapling at Base) May Be Acceptable
Simple tangential stapler excision can be performed only when:
- Simple diverticulitis without base involvement - the base and adjacent ileum are intact 1
- Long diverticula (height-to-diameter ratio >2) - ectopic tissue is located at the body and tip, sparing the base 1
- The diverticulum easily fits in the stapling device without difficulty or tension 2
- No palpable mass or induration at the base 3
Critical Technical Considerations
Intraoperative Assessment Limitations
The presence and location of ectopic tissue cannot be accurately predicted by palpation or macroscopic appearance alone. 1 This is a critical pitfall - heterotopic gastric mucosa was found in the majority of resected symptomatic diverticula (33% in one series), but only in symptomatic cases. 4, 5
Height-to-Diameter Ratio as a Decision Tool
- Long diverticula (ratio >2): Ectopic tissue concentrated at body and tip → diverticulectomy acceptable 1
- Short diverticula (ratio ≤2): Ectopic tissue widely distributed including base → wedge or segmental resection required 1
Morbidity and Mortality Considerations
Segmental resection carries acceptable morbidity when performed for symptomatic disease. 2 The use of stapling devices for either approach has demonstrated low complication rates with no staple-line leaks reported in specialized centers. 4 However, leaving ectopic tissue behind by performing inadequate diverticulectomy risks recurrent bleeding or inflammation, which would necessitate reoperation with higher morbidity. 1, 2
Common Pitfalls to Avoid
- Do not perform simple diverticulectomy for bleeding diverticula - ectopic gastric mucosa may extend to the base and cause recurrent hemorrhage 1, 2
- Do not attempt stapling of broad-based or short diverticula - this risks inadequate resection of ectopic tissue and potential staple line compromise 3, 1, 2
- Do not rely on visual inspection alone to determine extent of resection - ectopic tissue distribution cannot be accurately assessed intraoperatively 1
Recommended Surgical Approach by Indication
| Clinical Scenario | Preferred Technique | Rationale |
|---|---|---|
| Simple diverticulitis, long MD | Diverticulectomy | Base likely free of ectopic tissue [1] |
| Simple diverticulitis, short MD | Wedge resection | Ectopic tissue may involve base [1] |
| Bleeding | Wedge or segmental resection | Ensure complete removal of gastric mucosa [1,2] |
| Perforated base | Segmental resection | Base integrity compromised [1] |
| Obstruction with ileal involvement | Segmental resection | Adjacent bowel requires resection [1] |
In summary, while simple stapling may be technically feasible for uncomplicated, long diverticula, segmental resection with anastomosis provides definitive treatment with complete removal of all potentially symptomatic tissue and should be strongly considered as the default approach for symptomatic Meckel's diverticulum. 1, 2