Diagnostic Laparoscopy and Small Bowel Resection for a Large Meckel's Diverticulum in Adult with Persistent GI Bleed
Main Text
Table of Contents
Symptomatic Meckel’s diverticulum is a diagnosis most commonly associated with male children under two years old. It typically presents with painless hematochezia and is diagnosed with a Meckel’s scan, which uses Technetium-99 to detect ectopic gastric tissue. In an adult with gastrointestinal bleeding, the differential is far broader, including an extensive and at times, inconclusive, work-up. Here, we describe a diagnostic laparoscopy for suspicion of Meckel’s diverticulum in a young adult male whose work-up showed evidence of small bowel bleeding without a definitive source. A large 6.2-cm, broad-based Meckel’s diverticulum was identified about 90 cm proximal to the ileocecal valve and resected via small bowel resection.
Laparoscopy; Meckel’s diverticulum; small bowel resection; gastrointestinal bleeding.
An otherwise healthy 20-year-old male presented to the Emergency Department after he fainted while exercising. He had three days of multiple melanotic stools, lightheadedness, and shortness of breath. He denied recent trauma, daily NSAID use, frequent alcohol use, other drug use, and family history of bleeding or gastrointestinal disorders aside from polyps and colon cancer at an advanced age. He received a blood transfusion for symptomatic anemia in the setting of gastrointestinal bleed of unknown etiology and was admitted for further workup.
Over the next several months, he presented to the Emergency Department four times with the same symptoms and underwent extensive inpatient and outpatient work-up to determine the source of gastrointestinal bleeding. All laboratory values were normal, including a Coombs test. The imaging and procedures in chronological order included:
- Upper endoscopy (negative).
- CT angiogram of abdomen and pelvis (negative).
- Colonoscopy (negative).
- CT enterography (negative).
- Video capsule endoscopy (negative for bleeding, positive for mild NSAID gastropathy).
- Meckel’s scan (negative).
- Repeat video capsule endoscopy (plume of blood in terminal ileum and blood in colon, but no source).
- Double-balloon retrograde enteroscopy (negative, although two red spots cauterized and a tattoo placed at the most distal scope point).
Given high suspicion for the source being within the distal small bowel, he was taken to the operating room electively for a planned diagnostic laparoscopy, possible laparoscopic-assisted enteroscopy, and possible small bowel resection with general surgery and gastroenterology.
Intraoperatively, the abdomen was insufflated after insertion of the Veress needle at Palmer’s point. Four 5-mm ports were placed. After lysis of adhesions, the small bowel was run from the ileocecal valve proximally, where a large ~10-cm ileal diverticulum with a broad base was identified about 90 cm proximal to the ileocecal valve (about 10 cm proximal to the tattoo). Given the large size and broad base, the decision was made to proceed with a small bowel resection rather than a simple diverticulectomy. An intracorporeal stapled side-to-side functional end-to-end primary small bowel anastomosis was performed. The common enterotomy was closed with a running 2-0 V-Loc in two layers, and the mesenteric defect was closed with a figure-of-eight 2-0 Vicryl suture. The patient recovered well and was discharged on postoperative day two after slow diet advancement. Pathology revealed an approximately 6.2-cm long Meckel’s diverticulum with a 2.5-cm base. No ulcers or heterotopic mucosa were noted in the pathology report.
Physical exam revealed a well-nourished, healthy-appearing male in no apparent distress with normal vital signs. No abdominal tenderness on exam.
The differential diagnosis for a young adult with gastrointestinal bleeding is broad and a detailed clinical history is critical. Etiologies are typically divided into upper and lower sources of bleeding depending on whether the bleeding originates proximal or distal to the ligament of Treitz. Causes of gastrointestinal bleeding include peptic ulcer disease, inflammatory bowel disease (specifically Crohn’s), angiodysplasia, Dieulafoy lesions, tumors, foreign body ingestions, Meckel’s diverticulum, and many others.1 Meckel’s diverticulum, a true diverticulum, is the most common gastrointestinal congenital malformation.2 It is found in 1–2% of the population and males are about 2 times more likely to be symptomatic.3 Typically it is diagnosed in children less than 2 years of age and is rarely symptomatic in adults.2 In fact, only 4–6% of the population with Meckel’s diverticulum will be symptomatic.3,4 Diagnosis is challenging because it can easily be overlooked on CT abdomen and pelvis and instead, mistaken for a normal loop of bowel, unless an intestinal obstruction or foreign body retention is present.2 A Meckel’s scan is the gold standard for diagnosis in children with a sensitivity of 85% and specificity of 95%, but is much less accurate in adults.2 It identifies ectopic gastric mucosa, which is ultimately shown on pathology in about 98% of resected Meckel's diverticulum.1 The gastric mucosa causes an ulcer on the mesenteric side of the ileal lumen and results in painless bleeding.3 Those diverticula without heterotopic mucosa are less likely to be symptomatic and subsequently resected. Within the last decade, balloon-assisted enteroscopy has emerged as a useful non-operative diagnostic procedure because most Meckel’s diverticulum are within 100 cm of the ileocecal valve, which is accessible via this advanced endoscopic procedure.2 Ultimately, diagnostic laparoscopy should be pursued if the index of suspicion is high.
As stated in the case overview, the patient underwent an exhaustive work up for gastrointestinal bleeding with both non-invasive and invasive studies. Most notably, Meckel’s scan was negative, video capsule endoscopy showed blood in the terminal ileum and colon without source, and double-balloon retrograde enteroscopy also showed evidence of blood in the terminal ileum without source. Although a Meckel’s Technetium-99 scan is the imaging of choice used to diagnose symptomatic Meckel’s diverticulum, it is not without limitations. It can be influenced by factors such as medications, and the lower diagnostic accuracy in adults is well-documented.2,5
A symptomatic Meckel’s diverticulum can be removed either by small bowel resection or diverticulectomy. If only performing a diverticulectomy, the surgeon must first inspect the intestinal mucosa for an ulcer and then suture the bowel closed in a transverse fashion to avoid narrowing the lumen.3 Classically, a diverticulum with a broad base was removed via small bowel resection to fully remove the abnormal tissue and prevent narrowing of the intestinal lumen. Newer studies have shown no difference in outcomes for those undergoing diverticulectomy or segmental resection regardless of the base width.6,7 That said, laparoscopic diverticulectomy versus small bowel resection is a decision specific to each surgeon, patient, and clinical picture.7
Resection of an asymptomatic Meckel’s diverticulum discovered incidentally during an unrelated operation (e.g. appendectomy) has remained controversial. The risk-benefit of resection is nuanced and no clear guidelines have been established. Historically, the consensus was that the risk of complications from prophylactic resection is greater than the risk of future diverticulum-related complications.3 However, a recently published systematic review by Yganik et al. suggests otherwise.8 They looked at over two decades of studies on the management of incidentally found Meckel’s diverticulum and found that the evidence may slightly favor resection.8 Other studies concur that while routine resection is not indicated, it may be appropriate to consider diverticulectomy in a patient with multiple risk factors for future symptomatic Meckel’s diverticulum.9
Meckel’s diverticulum is often challenging to diagnose in adult patients. A Meckel’s scan has significantly lower sensitivity in adults and the diverticulum may be too proximal to identify with endoscopy. In such cases, when non-operative work-up remains inconclusive but clinical suspicion persists—particularly in the setting of unexplained gastrointestinal bleeding—diagnostic laparoscopy becomes an essential next step. As demonstrated in this case, despite multiple negative studies including upper endoscopy, colonoscopy, CT angiogram, Meckel’s scan, and both capsule and double-balloon enteroscopy, laparoscopy enabled direct visualization of the bowel and ultimately led to diagnosis. The small bowel was carefully run from the ileocecal valve proximally, revealing a large, broad-based Meckel’s diverticulum approximately 90 cm upstream—just beyond the reach of prior endoscopy. This case highlights the unique diagnostic value of laparoscopy in evaluating the distal small bowel when all other modalities have failed, particularly in young adults with obscure but persistent GI bleeding. The decision to perform diverticulectomy versus segmental resection is at the discretion of the surgeon. Both options are curative and with complete diverticulectomy without narrowing of the intestinal lumen, studies suggest that outcomes are similar.
The surgical field was visualized by an Olympus high-resolution video endoscopy system, including two high-resolution color monitors. Olympus laparoscopic tools were used for mobilization. A linear Ethicon Endo GIA 60 stapler with a white load was used to transect the small bowel, followed by an Ethicon Harmonic scalpel to divide the mesentery. The ileo-ileostomy was created using a linear Endo GIA 60 stapler with a blue load and the common channel was closed using a 2-0 V-Loc suture.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- DiGregorio AM, Alvey H. Gastrointestinal Bleeding. In: StatPearls. Treasure Island (FL): StatPearls Publishing; June 5, 2023.
- Hong SN, Jang HJ, Ye BD, et al. Diagnosis of bleeding Meckel's diverticulum in adults. PLoS One. 2016 Sep 14;11(9):e0162615. doi:10.1371/journal.pone.0162615.
- Stallion A, Shuck JM. Meckel's diverticulum. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: https://www.ncbi.nlm.nih.gov/books/NBK6918/.
- Lequet J, Menahem B, Alves A, Fohlen A, Mulliri A. Meckel's diverticulum in the adult. J Visc Surg. 2017 Sep;154(4):253-259. doi:10.1016/j.jviscsurg.2017.06.006.
- Yan P, Jiang S. Tc-99m scan for pediatric bleeding Meckel diverticulum:a systematic review and meta-analysis. J Pediatr (Rio J). 2023 Sep-Oct;99(5):425-431. doi:10.1016/j.jped.2023.03.009.
- Tree K, Kotecha K, Reeves J, et al. Meckel's diverticulectomy: a multi-centre 19-year retrospective study. ANZ J Surg. 2023 May;93(5):1280-1286. doi:10.1111/ans.18351.
- Brungardt JG, Cummiskey BR, Schropp KP. Meckel's diverticulum: a national surgical quality improvement program survey in adults comparing diverticulectomy and small bowel resection. Am Surg. 2021 Jun;87(6):892-896. doi:10.1177/0003134820954820.
- Yagnik VD, Garg P, Dawka S. Should an incidental meckel diverticulum be resected? A systematic review. Clin Exp Gastroenterol. 2024 May 7;17:147-155. doi:10.2147/CEG.S460053.
Cite this article
Thomann J, Cherng NB. Diagnostic laparoscopy and small bowel resection for a large Meckel's diverticulum in adult with persistent GI bleed. J Med Insight. 2025;2025(510). doi:10.24296/jomi/510.
Procedure Outline
Table of Contents
- 1. Introduction
- 2. Surgical Approach and Laparoscopic Access to the Abdomen
- 3. Lysis of Adhesions
- 4. Small Bowel Mobilization and Identification of Meckel's Diverticulum
- 5. Resection of Small Bowel with Meckel's Diverticulum
- 6. Side-to-Side, Functional End-to-end Stapled Anastomosis
- 7. Closure of Mesenteric Defect
- 8. Final Examination and Running the Small Bowel
- 9. Hemostasis and Specimen Extraction
- 10. Port Site closure
- 11. Post-op Remarks
Transcription
CHAPTER 1
My name is Nicole Cherng. I am an assistant professor at University of Massachusetts Medical School. I am a general surgeon who specializes in minimally invasive surgery as well as bariatric surgery. The case that we're going to discuss is a laparoscopic resection of a diverticulum. This is a 20-year-old gentleman who initially presented many months ago to the emergency department after fainting while exercising. He was found to be severely anemic requiring multiple blood transfusions and he was subsequently admitted. He underwent an upper endoscopy and a colonoscopy, both of which were negative. Then he underwent a CTA to look for a bleed, which was also negative. There was also no signs of any sort of a mass or intra-abdominal pathology. He then underwent a Meckel's scan, which was negative and underwent a video capsule endoscopy, which did show some specs of blood in the distal small bowel, but no masses were seen. He responded appropriately to blood products and was subsequently discharged home. He represented multiple times to the emergency department with the same thing, feeling lightheaded, dizzy, requiring blood transfusions 'cause he was found to be severely anemic even on iron transfusions as an outpatient. Multiple endoscopies were repeated, including a push enteroscopy and his video capsule endoscopy. Given that the video capsule endoscopy did see some specks of blood in the distal small bowel. The thought was that there was likely some sort of a small bowel pathology and the decision was made for myself and a gastroenterologist to proceed to the operating room for a diagnostic laparoscopy and a laparoscopic-assisted enteroscopy. So in the operating room, we did not do a bowel prep on the patient. We started laparoscopically and we placed four five-millimeter trocars to look at the small bowel and what you'll see is that we immediately are able to identify a Meckel's diverticulum approximately 120 centimeters proximal to the ileocecal valve. Given how large it is, you'll see that we decide to perform a small bowel resection that encases the diverticulum opposed to a simple diverticulectomy.
CHAPTER 2
We first entered the abdomen by inserting a Veress needle at Palmer's point. Once we reach adequate pneumoperitoneum, a five-millimeter trocar is placed. We then placed two additional five-millimeter trocars. For the positioning of this patient, we did tuck the left arm. And at this point, we are positioning the patient in Trendelenburg.
CHAPTER 3
Immediately we can see where the previously placed tattoo by the gastroenterologist is somewhere in the small bowel. Also unexpectedly, given that this patient has had no prior surgeries and is a virgin abdomen, we did see some of these adhesions of the mesentery to the small bowel to other portions of the small bowel as well. These adhesions were taken down with laparoscopic scissors, being careful not to injure any of the surrounding small bowel. Additionally, we did not use any cautery while lysing these adhesions. These adhesions did appear to be chronic and perhaps even congenital, and they were also primarily located within the right lower quadrant.
CHAPTER 4
Once the lysis of adhesion was performed, we were now able to mobilize the small bowel and then we immediately identified a Meckel's diverticulum. This was located just 10 centimeters proximal to the tattoo that had been placed by the gastroenterologist during their push enteroscopy. We continued to run the small bowel proximally to ensure that the small bowel itself was quite free. Here we can see that the Meckel's diverticulum is quite broad based and quite large, measuring to be approximately seven to eight centimeters. At this point, we were debating between either performing a diverticulectomy or a small bowel resection and doing a small bowel to small bowel anastomosis.
CHAPTER 5
Given how large the diverticulum is, we elected to perform a small bowel resection. We therefore place an additional five-millimeter trocar for an assist port and we also upsized one of our trocars to a 12-millimeter port in order to fit a stapler. We select points both proximal and distal to the diverticulum on the small bowel as our resection sites. We use the Maryland, the laparoscopic Maryland in order to create our window and then we elect to transect the small bowel, both proximal and distal to the diverticulectomy with an Endo-GIA 60 stapler using a white load. For the small bowel mesentery, this was transected using the laparoscopic Harmonic scalpel.
CHAPTER 6
For anastomosis, we elected to do a side-to-side functional end-to-end stapled anastomosis. We chose spots on the small bowel that was antimesenteric approximately one to two centimeters away from our staple line to create our enterotomies. We used the hot blade of the laparoscopic Harmonic scalpel to create our enterotomies and then used our laparoscopic Maryland forcep to widen the enterotomies to fit the Endo-GIA 60 stapler. We aligned the two limbs of the small bowel to ensure that there was no twisting of the mesentery as well. We used the Endo-GIA 60 stapler using a blue load to create our stapled anastomosis. We align the two limbs such that it was the antimesenteric side that would be used for the anastomosis as well. Once the stapler was fired, we looked on the inside to ensure that we had a wide open anastomosis and there was no bleeding at the staple line as well. For the common enterotomy, we elected to close this using a running 2-0 V-Loc suture in two layers. The next stitch that's placed is a 3-0 Vicryl as a crotch stitch to reduce the tension on the anastomosis. Laparoscopically, these sutures are cut to approximately six to seven inches.
CHAPTER 7
Here, we see that the mesentery is clearly not twisted. However, there is a mesenteric defect that needs to be closed to prevent any future internal hernias in this potential space. We closed the mesenteric defect with multiple figure-of-eight 2-0 Vicryl sutures. These mesenteric defects can be closed in multiple ways. Either interrupted figure-of-eight sutures such as this or a running 2-0 Vicryl would also be adequate, or also a purse-string would've worked as well.
CHAPTER 8
On final examination of our anastomosis, we see that it is clearly pink with no signs of ischemia. There is very minimal tension on the small bowel. The mesenteric defect is nice and closed, and the mesentery itself is not twisted. We then run the distal limb of the small bowel towards the terminal ileum and the ileocecal valve. We measure this to be approximately 90 to 100 centimeters to the ileocecal valve.
CHAPTER 9
Hemostasis is achieved, and we remove our specimen with a 10-millimeter Endo Catch Bag through the 12-millimeter trocar. This was sent off for final pathology. We close our 12-millimeter trocar with a 0 Vicryl using the suture passer. All trocars were then removed, and the abdomen was deflated. All skin incisions were then injected with local anesthetic, and closed with 4-0 Monocryl and then Dermabond. The patient tolerated the procedure well.
CHAPTER 10
[No Dialogue.]
CHAPTER 11
You saw in this case that this was a successful small bowel resection and we were able to identify the source of the bleed, which was a Meckel's diverticulum. In this case, I think, key points are that - first is identifying that a patient who has a persistent GI bleed, even though he went through exhaustive workup including multiple endoscopies, the suspicion was so high for some sort of a small bowel pathology as well as a Meckel's diverticulum, even though his Meckel's scan was negative, that we elected to proceed with a diagnostic laparoscopy, which I think is not very common but should be offered for these type of patients. In this case, also, having a combined effort with a gastroenterologist I think is the key, even though they were not needed since we found the obvious pathology right away. I think it's important to have that as a plan in case there is no obvious pathology right away. Postoperatively, the patient did great. He had return of bowel function after a few days and was subsequently discharged home on a regular diet and his repeat blood counts two months later were normal. Meckel's scan to look for a Meckel's diverticulum, its sensitivity is fairly high, but its specificity is fairly low. Meaning that if the test itself is negative, it doesn't necessarily mean there's absolutely no existence of that pathology. It is more sensitive in children compared to adults. Now he's 20 years old, so he's kind of on that cusp. So for a Meckel's diverticulum, it's well written in the literature that a simple diverticulectomy, so just transecting the diverticulum is sufficient. In this case, we did choose to do a small bowel resection because of the size of the diverticulum. We felt fairly strongly that if I resected just the diverticulum, that I would be narrowing the small bowel and that this would become a point of obstruction. And so I felt safer to perform a primary anastomosis even with the risk of an anastomosis would be more appropriate for this patient. I would say this case, I did choose to do a small bowel resection, and you'll see that the small bowel anastomosis that we do is intracorporeal. Now this is something that I prefer to do in the cases of decompressed small bowel where the pathology itself is quite small. If this was a point of obstruction where he had very dilated small bowel, I would err likely more towards doing an extracorporeal anastomosis and performing a mini-laparotomy. But I felt that given how decompressed the small bowel was that we could easily do this purely minimally invasive.