Meckel's diverticulum is a relatively common anomaly of the gastrointestinal tract, occurring in an estimated 2% of the population, but it is an uncommon cause of SBO. Bowel obstructions from Meckel's diverticula most commonly occur due to intussusception, volvulus around an associated omphalomesenteric band, or inflammatory adhesion, or incarceration of the diverticulum within a hernia.1
Phytobezoar impaction in a Meckel's diverticulum is more rare with only 9 reported cases in the English literature.2–8
None of these cases were treated laparoscopically. We did feel the need to extend one of our port sites to 3cm to allow the impacted vegetable matter to be completely expressed from either end of the transected bowel ()
, though the resection was performed intracorporeally.
Although the patient was accurately diagnosed with SBO and surgically explored on that basis, the precise diagnosis of phytobezoar impaction in a Meckel's diverticulum was not made preoperatively. Some authors have noted the utility of CT for making this diagnosis, while others have not found CT to be effective.2–4
This case shows that abdominal CT has the potential to identify phytobezoar impaction in Meckel's diverticulum, but that it may nonetheless be a difficult radiographic diagnosis. In this case, vegetable matter filled the diverticulum, a short segment of distal bowel, and a longer segment of proximal bowel, giving a Y-configuration. This configuration has been previously described, though it may have contributed to the difficulty of making a preoperative radiologic diagnosis, because the diverticulum was not located precisely at the most distal point of obstruction.5
In other cases, the bezoar has been entirely proximal to the origin of the Meckel's diverticulum.7
While other obstructing phytobezoars identified in a Meckel's diverticulum have been associated with high fiber or vegetarian diets, no such association was present in this case.4,7,8
None of the other commonly noted risk factors for bezoar formation, such as prior gastric surgery, gastrointestinal motility disorders, or poor dentition, were present.9
While a single case report cannot demonstrate that our patient's outcome was better than it would have been using the standard open approach that has previously been used to address this problem, this report at least demonstrates the technical feasibility of a laparoscopic approach. Potential advantages of laparoscopy include decreased postoperative pain, quicker return of bowel function compared to laparotomy, and less adhesion formation. One retrospective study10
has indicated that laparoscopy may be superior to laparotomy for surgical treatment of SBO caused by bezoar. Whether these potential advantages become manifest in the laparoscopic treatment of SBO in general must be evaluated in the context of randomized clinical trials.11
While this case report cannot demonstrate these advantages or allow wide generalization about the role of laparoscopy in the treatment of SBO, it nevertheless provides an example of the potential utility of laparoscopy as an approach to SBOs with unknown causes, and illustrates the flexibility of the technique in adapting to unusual findings.