We present a case of a 21-year-old male with a one-day history of right lower quadrant pain and CT scan findings suspicious for a perforated Meckel’s Diverticulum who underwent a robotic assisted small bowel resection with an intracorporeal anastomosis.
Milind D. Kachare, M.D.
Nisha Dhir, M.D., FACS
University Medical Center of Princeton at Plainsboro, Rutgers – Robert Wood Johnson Medical School
After a diagnostic laparoscopy showed no evidence of purulent peritonitis or feculent contamination, the da Vinci XI robot was docked. The cecum and the appendix were initially visualized and noted to be unremarkable. Then proximally, a broad segment of bowel was identified and the omentum was gently unroofed from this area, showing evidence of fibrinous exudate and minimal purulence. A perforation was seen at the base of the diverticulum. After this, the mesentery to the segment of bowel around the Meckel's diverticulum was divided using a vessel sealer. At this point the patient was administered ICG-9 and Firefly technology was used to ensure adequate perfusion at the site of resection. The proximal and distal bowels were then divided using a robotic stapler and the involved segment of bowel was completely resected. The two loops of small bowel were aligned and 2-0 silk sutures were used to approximate the anti-mesenteric sides. The distal suture was used to anchor the small bowel to the anterior abdominal wall. Then, using a hook cautery, enterotomies were made proximal to the staple line on both loops of bowel and an anastomosis was created with a robotic stapler. The common enterotomy was then closed using a 2-0 silk running suture and covered with 3-0 silk Lembert sutures. The mesenteric defect was reapproximated using a 2-0 Vicryl running suture. The specimen was placed in an EndoCatch bag and the abdomen was irrigated. An incision was then made in the periumbilical region and an Alexis wound retractor was placed, through which the specimen was delivered. The abdomen was again irrigated and hemostasis was ensured. The periumbilical incision was reapproximated using a 0 Ethibond running suture. The fascia of the 12 mm trocar site was reapproximated using a figure-of-eight 0 Vicryl suture. The skin incisions were then closed using 4-0 Monocryl subcuticular sutures followed by Dermabond.
The patient presented with acute abdominal pain, leukocytosis and a CT showing a perforation in his small bowel. The indication for a small bowel resection instead of a simple diverticulectomy in this particular case was due to the location of the perforation at the base of the diverticulum, as well as the involvement of the adjacent small bowel, which was edematous and had significant inflammatory changes.
As recent studies continue to question the relative contraindications to minimally invasive surgery, the majority of surgeons will still opt to perform an open operation vs. a minimally invasive approach in an unstable patient. This patient was hemodynamically stable and underwent a diagnostic laparoscopy prior to proceeding with a minimally invasive approach.
The patient was placed on the operating room table in supine position. Lower extremity compression stockings were placed. He received preoperative IV antibiotics. After the uneventful induction of general anesthesia and intubation, the patient had a Foley catheter and nasogastric tube inserted. The abdomen was prepped and draped. A local field block was placed at all trocar sites prior to making skin incision. An 8 mm incision was made in the left upper lateral abdomen and a Fios First Entry 5 mm trocar was inserted. The abdomen was insufflated to 15 mmHg and then the remaining trocars were placed under direct visualization. An 8 mm robotic trocar was placed in the left central lateral abdomen and an 8 mm robotic trocar in the left lower lateral abdomen. The 5 mm trocar was then exchanged for an 8 mm robotic trocar and the da Vinci XI robot was brought in from the patient’s right side.
Preoperative evaluation began with a thorough history and physical once the patient presented to the emergency department. The patient underwent appropriate blood work and had a computed tomography (CT) scan, which suspected a perforated Meckel’s Diverticulum. Due to this the patient was scheduled for a diagnostic laparoscopy prior to the decision of an open vs. a minimally invasive approach.
Meckel’s Diverticulum is a true diverticulum, containing all layers of the small bowel wall. It represents a persistent remnant of the omphalomesenteric duct and is seen arising from the antimesenteric surface of the distal ileum, approximately 45cm to 60cm proximal to the ileocecal valve.
Risks of any surgical procedure include bleeding, infection, risk to nearby organs, possible cardiac event, and even death. With minimally invasive surgery, there are some additional risks including port site hernias, gas embolus, and decreased venous return causing cardiovascular collapse.
Thank you to Dr. Dhir for her help and guidance.
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