Meckel's Diverticulectomy
What the Examiner Expects
Resection of a Meckel's diverticulum, a true diverticulum (containing all bowel wall layers) representing a remnant of the omphalomesenteric (vitelline) duct, found on the antimesenteric border of the ileum approximately 2 feet proximal to the ileocecal valve. The examiner expects you to know the rule of 2s, that ectopic gastric mucosa is the most common heterotopic tissue (causing bleeding via acid secretion on adjacent ileal mucosa), and that diagnosis in children is with a Technetium-99m pertechnetate scan (Meckel's scan). For a narrow-based diverticulum, stapled diverticulectomy perpendicular to the long axis of the bowel is sufficient. If the base is wide or there is palpable ectopic tissue at the base, a segmental ileal resection with primary anastomosis is preferred.
Key Examiner Focus Points
- Rule of 2s: 2% of population, 2 feet from ileocecal valve, 2 inches long, 2 types of ectopic tissue (gastric/pancreatic)
- Technetium-99m pertechnetate scan detects ectopic gastric mucosa
- Diverticulectomy vs segmental ileal resection depends on base width
- If narrow base: stapled diverticulectomy perpendicular to bowel axis
- If wide base or palpable ectopic tissue at base: segmental ileal resection
Common Curveballs
Incidentally found during appendectomy in a 25-year-old — should you remove it?
Controversial. Current evidence supports removal of incidental Meckel's diverticula in young patients (< 50) if the diverticulum is > 2 cm, has a palpable abnormality, or the patient has a history of unexplained GI bleeding. Leave it alone in elderly patients or if removal would complicate the primary operation.
Meckel's scan is negative but clinical suspicion remains high in a child with recurrent painless GI bleeding
False-negative rate exists if there is insufficient gastric mucosa. Consider tagged RBC scan, CT angiography, or diagnostic laparoscopy. PPIs or H2 blockers before the Meckel's scan can increase uptake sensitivity (pentagastrin stimulation).
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