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Case 30: An incidental finding

During an open cholecystetomy in a 35 year old woman the intern assiting you finds something unusual.

1. What is the abnormality?

Meckel's diverticulum. A true diverticulum consisting of all layers of the bowel wall it projects from the antimesenteric side of the distal ileum. It is said to occur in 2% of the population, 2 feet from the ileocaecal valve and be 2 inches long. These figures are approximations only.

2. What is the origin of the abnormality?

A Meckel's diverticulum is a rvestigial remnant of the vitello-intestinal duct present during foetal development. It connects the midgut to the embryonic yolk sac during the early weeks of gestation. By 5 weeks placental nutrition is established and normally the ducts degenerates by the end of the 7th week. If this obliterative process is arrested various abnormalities may occur. Meckel's diverticulum is the most common. Other abnomalities include vitelline fistula and vitelline cyst.

3. What would you do at operation?

This Meckel's is asymptomatic and not associated with a band. If a band were present it should be divided to prevent bowel obstruction. The Meckel's should also be palpated for any abnormal mass which would than require resection. Assuming there are no visible or palpable abnormalities then the next issue is the patient's age. The risk of complications from Meckel's diverticulum decreases with age. Thus many surgeons would leave an incidental Meckel's in a patient over 30-40 years of age but remove it in patients under 30 years.

The proviso for resection is that it must be able to be performed without adding morbidity to the operation being performed. Typically the diverticulum is able to be transected at it's neck and does not require formal small bowel excision with anastomosis.

The final consideration is the Meckel's identified at exploratory surgery where no other pathology is identified. In this situation most surgeons would agree that even in the absence of obvious pathology in the Meckel's it should be resected.

Wikipedia - Meckel's diverticulum