*Sławomir Glinkowski, Daria Marcinkowska
Meckel’s diverticulum: an unusual finding during inguinal hernioplasty
Uchyłek Meckela – rzadkie znalezisko podczas planowej operacji przepukliny pachwinowej
Department of General and Oncologic Surgery, Health Centre in Tomaszów Mazowiecki
Head of Department: Włodzimierz Koptas, MD, PhD
Streszczenie
Uchyłek Meckela jest najczęstszą wrodzoną wadą przewodu pokarmowego, dotyczącą 2-4% populacji. Występuje jako pozostałość płodowego przewodu żółtkowego. Może zawierać różnorodne utkanie histologiczne. Zwykle jest możliwy do rozpoznania jedynie autopsyjnie lub śródoperacyjnie. Rzadko daje objawy pod postacią krwawienia, zapalenia lub perforacji.
Autorzy prezentują przypadek pacjenta operowanego planowo z powodu przepukliny pachwinowej prawostronnej. Śródoperacyjnie w worku przepuklinowym rozpoznano uchyłek Meckela, który w całości wycięto do badania histopatologicznego. Pacjent wcześniej nie miał postawionego rozpoznania, nie odczuwał dolegliwości z tego powodu. Wykonano klinową resekcję i plastykę przepukliny sposobem Lichtensteina. Plastyka z użyciem siatki oraz naruszenie ciągłości przewodu pokarmowego mogą być związane z większym ryzykiem zakażenia, dlatego pacjentowi włączono profilaktyczną antybiotykoterapię przedoperacyjną (stosowaną w każdym przypadku plastyki przepukliny pachwinowej operowanej na oddziale), natomiast po operacji dołączono antybiotyk B-laktamowy. Przebieg operacji i dalsza hospitalizacja przebiegały bez powikłań. Nie zaobserwowano cech zakażenia rany, gojenie przebiegało prawidłowo. Wynik badania histopatologicznego potwierdził rozpoznanie uchyłka Meckela. Przepuklina zawierająca uchyłek Meckela, nazywana przepukliną Littrego, jest bardzo rzadkim rozpoznaniem. W bazie medycznej PubMed opisywany jest średnio jeden przypadek rocznie. W 50% przypadków lokalizuje się w przepuklinie pachwinowej prawostronnej, jak u opisanego pacjenta. Standardowa metoda postępowania obejmuje resekcję uchyłka i – w zależności od stanu miejscowego – w niektórych przypadkach również resekcję przyległego fragmentu jelita.
Summary
Meckel’s diverticulum is the most common congenital malalignment of the gastrointestinal tract, present in 2-4% of population. It occurs as an embryologic remnant of the vitelline duct. It may have different histological texture. Usually it is diagnosed only during autopsy or intraoperatively. Symptoms such as haemorrhage, inflammation or perforation are possible but very rare. The authors present a case of a patient who received scheduled surgical treatment due to right inguinal hernia. Meckel’s diverticulum was intraoperatively identified in the hernial sac. It was resected and sent for histopathological examination. Before the operation, the patient reported no history of diverticulum and no symptoms. A wedge resection and hernioplasty by Lichtenstein’s method were performed. Hernioplasty with mesh implantation and gastrointestinal tract discontinuity may be associated with a greater risk of infection; therefore prophylactic pre- and post-operative antibiotic therapy was administered. The surgery and the hospitalisation period were uneventful. No symptoms of wound infection were observed, and the healing process was proper. Histopathology findings confirmed the diagnosis of Meckel’s diverticulum. The herniation of a Meckel’s diverticulum – the so-called Littre hernia, is a very rare condition. On average, one case is described every year. In 50% of cases, it is localised in right inguinal hernia, as in the described case. Standard treatment involves diverticulum resection and, depending on the local condition, resection of the adjacent fragment of intestine in some cases.
Introduction
Meckel’s diverticulum – a true diverticulum of the ileum – is the most common congenital malalignment of the gastrointestinal tract. It occurs as an embryologic remnant of the vitelline duct, which should undergo physiological atrophy at 5-10 weeks of the embryonic development (1). It has an incidence of 2-4% and occurs with similar frequency among men and women. Due to the pluripotent nature of cells lining the vitelline duct, the wall of diverticulum may contain a part of the gastric mucosa (50% cases), liver, pancreas or even large bowel (2). It may manifest with ulcerations, haemorrhage or it may perforate, producing symptoms similar to those in appendicitis. Inflammation of the diverticulum is estimated to account for 28% of all identifiable symptoms (3). A volvulus around the diverticulum may lead to mechanical intestinal obstruction.
An inguinal hernia containing a Meckel’s diverticulum in the hernial sac is a rare type of hernia. It is known as Littre hernia after the author of the first description. Clinically, it is indistinguishable from a hernia involving the small bowel. The preoperative diagnosis is often impossible. Usually, it is associated with minor pain, while other disturbing clinical symptoms occur at a later time.
We present a case of right inguinal, oblique, non–strangulated hernia containing Meckel’s diverticulum in the hernial sac.
Case report
A 61-year-old man was admitted to the Department of General and Oncologic Surgery in Tomaszów Mazowiecki for a scheduled surgery due to right inguinal hernia. Four months earlier, the patient was hospitalised in the Internal Medicine Department due to increased breathing problems and reduced tolerance of physical exercise. Atrial fibrillation and fluttering, as well as undefined heart failure were diagnosed. Medical history of nicotine and alcohol dependence. Physical examination revealed free inguinal hernia in the right inguinal region. After hospitalisation in the Internal Medicine Department, the patient was referred for a consultation in the Surgical Department.
On admission to Surgery Department, the patient reported no symptoms. The abdomen was soft, painless, with no signs of peritonitis. The inguinal region was painless with palpable, reducible hernia on the right side. No significant preoperative laboratory abnormalities were found.
The patient was qualified for hernioplasty. According to the current standards accepted in the Department, the patient received preoperative prophylactic antibiotic therapy in the form of 1 gram of intravenous cefazolin less than 30 minutes before the operation (4). After identification and separation of the hernia sac from the spermatic cord and opening the sac, a 4 cm Meckel’s diverticulum with a wide base facing the small intestine was found intraoperatively. A decision was made to perform wedge resection. Two layers of sutures were used to provide the continuity of the small intestine. Then, Lichtenstein hernioplasty using a polypropylene mesh (SuruMesh 7.5 x 15 cm) was performed. The resected tissue was sent for histopathological examination.
Due to the interrupted gastrointestinal continuity, the patient was placed on the diet “0” until day 4 after operation. Intravenous fluid therapy was included – 2,500 mL per day (1000 mL Ringer sol. + 1000 ml 0.9% NaCl + 500 ml 5% glucose). Oral fluids were administered from day 4 after the surgery and liquid diet from day 5. Both, the interrupted GI continuity and mesh stitching may be associated with an increased risk of infection. During the follow-up period, the patient received amoxicillin with clavulanic acid at an intravenous dose of 1.2 g every 8 hours. Antibiotic and antithrombotic therapy was continued throughout hospitalisation. On the day of admission, enoxaparin 40 mg subcutaneous 1 x day was included. The patient also received intravenous metamizol 2.5 g on demand to manage pain.
The patient was discharged home on day 5 after the surgery, with recommendations for a follow-up in the Surgical Clinic. On the day of discharge, the patient was in good condition; the wound was in the proper phase of healing. The sutures were removed on day 10 after the surgery. The wound haled properly, without any signs of infection. The patient did not report any pain or local symptoms.
Histopathological findings were as follows: macroscopically: diverticulum length 3.5 cm; microscopically: Meckel’s diverticulum with typical mucosa.
Discussion
Inguinal hernioplasty is the most common currently performed surgical intervention. The lifetime risk of inguinal hernia repair is estimated to be 27% for men and 3% for women (5). In 2003 in USA, 800,000 inguinal hernioplasty procedures were performed. More than 90% of these were performed in an outpatient setting using a mesh (6). In Poland, about 65,000 surgeries of inguinal hernia were performed in 2001 (7).
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