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Vitelline Duct Anomalies 391

Children with Meckel’s diverticulitis or a bleeding Meckel’s Postoperative Complications
diverticulum are operated on by using a transverse appendectomy Postoperative complications are generally the same as that of other
incision with medial extension if necessary. Patients with suspected operations: bleeding, infection, intraabdominal abscess formation,
intestinal obstruction should be explored through a generous wound dehiscence, incisional hernia, and postoperative adhesive intes-
laparotomy incision. tinal obstruction.
An open diverticulectomy includes the following steps: Evidence-Based Research
1. A transverse appendectomy incision or subumbilical incision is made.
The study presented in Table 64.1 is a systematic review that addresses
2. The caecum and ileum are identified. the management of incidentally detected Meckel’s diverticulum.
3. The ileum is followed proximally to find Meckel’s diverticulum, Table 64.1: Evidence-based research.
approximately 60 cm from the ileocaecal valve.
Title Incidentally detected Meckel diverticulum: to resect or not
4. The diverticulum with the ileum are delivered into the wound. to resect?
5. The diverticulum is excised with the adjacent ileum and primary Authors Zani A, Eaton S, Rees CM, Pierro A
ileal end-to-end anastomosis is fashioned. Institution Department of Paediatric Surgery, Institute of Child Health,
In developed countries, some surgeons use linear staplers applied London, England
to the base of the anomaly, allowing complete amputation of the Reference Ann Surg 2008; 247(2):276–281
diverticulum without narrowing the lumen of the ileum. When Problem The management of incidentally detected Meckel’s
ectopic gastric or pancreatic tissues are present near the base of the diverticulum (MD) remains controversial.
diverticulum, or if the base is wide, inflamed, or perforated, resection Intervention The aims of this paper were to establish the prevalence of
of the involved ileum is required with an end-to-end anastomosis. 2–5,10 MD, and the morbidity and mortality due to MD.
If perforation has occurred, thorough peritoneal toileting is done after Comparison/ The prevalence of MD is 1.2%, and historical mortality of
segmental ileal resection. The use of laparoscopy for resection of control MD was 0.01%. The current mortality from MD is 0.001%.
Meckel’s diverticula has been reported by many authors. 11 (quality of The number of MD resections per year per 100,000
Controversy exists about what should be done when a Meckel’s evidence) population decreased significantly after the paediatric age
range (P < 0.001). Resection of incidentally detected MD
diverticulum is encountered during a laparotomy for unrelated has a significantly higher postoperative complication rate
symptoms. The debate focuses on the probability of the Meckel’s than leaving it in situ (P < 0.0001). The long-term outcome
diverticulum becoming symptomatic in the future weighed against the of patients with incidentally detected MD left in situ showed
no complications. To prevent one death from MD, 758
possibility of complications associated with resection. 2,4,5,7,10–13 Lesions patients would require incidentally detected MD resection.
with palpable ectopic mucosa (the consistency of gastric or pancreatic Outcome/ The prevalence of MD is 1.2%, and historical mortality of
tissue differs sharply from that of ileal, jejunal, or colonic mucosal effect MD was 0.01%. The current mortality from MD is 0.001%.
lining), a prominent vitelline artery, a fibrous vitelline artery remnant, The number of MD resections per year per 100,000
evidence of inflammation, or a narrow base may all increase the chance population decreased significantly after the paediatric age
range (P < 0.001). Resection of incidentally detected MD
of bleeding, obstruction, or diverticulitis and should be resected when has a significantly higher postoperative complication rate
encountered. In patients who have abdominal pain, it is prudent to than leaving it in situ (P < 0.0001). The long-term outcome
resect a discovered diverticulum or any lesion with attachments to of patients with incidentally detected MD left in situ showed
no complications. To prevent one death from MD, 758
the umbilicus (to prevent ileal volvulus). Some authors suggest that patients would require incidentally detected MD resection.
resection of asymptomatic vitelline remnants in early childhood is Historical MD is present in 1.2% of the population, it is a very rare
reasonable at the time of laparotomy for other conditions. 10–13 In significance/ cause of mortality, and it is primarily a disease of the young.
developing countries incidental Meckel’s diverticulum should be comments Leaving an incidentally detected MD in situ reduces the
removed in children to prevent later complications. If the diverticulum risk of postoperative complications without increasing late
complications. A large number of MD resections would need
is left in place, it is imperative to alert the patient’s family and to be performed to prevent one death from MD. The above
the primary care physician about the presence of the lesion and its evidence does not support the resection of incidentally
possible symptoms. detected MD, in developed countries.

Key Summary Points

1. A patent vitelline duct with umbilical faecal drainage is the 5. In African children, an incidental Meckel’s diverticulum must be
most symptomatic presentation of vitelline duct anomalies in resected because of the difficulties to rapidly access paediatric
developing countries. surgical heath facilities in case of complications.
2. In developed countries, the main forms of presentation are 6. Resection of asymptomatic vitelline remnants in early childhood
haemorrhage in 40–60%, obstruction in 25%, diverticulitis in at the time of laparotomy or laparoscopy for other conditions is
10–20%, and umbilical drainage. indicated.
3. The most common umbilical lesion is an umbilical granuloma, 7. When ectopic gastric or pancreatic tissues are present near
which secretes a mucoid material. the base of the diverticulum, or if this base is wide, inflamed, or
perforated, resection of the involved ileum is required with an
4. If the umbilical drainage persists despite cauterization of the end-to-end anastomosis.
presumed granuloma with silver nitrate, or if the drainage is
copious, imaging studies are indicated. 8. If the indication of diverticulectomy is bleeding, then segmental
ileal resection should be performed.