Gustavo Fernandez Ranvier, MD, PhD, Aida Taye, MD, Naif AlEnazi, MD, Darshak Shah, MD, Anthony Vine, MD. Mount Sinai Hospital New York
Introduction: As the second most common place for diverticula after the colon, the prevalence of duodenal diverticulum is as high as 22% in autopsy series. Most occur along the pancreatic or mesenteric border in the second or third portions of the duodenum. Perforations of duodenal diverticula are rare and patients with this condition present with vague and nonspecific symptoms. Although some duodenal perforations can be managed conservatively, cases with large perforations and/or systemic compromise need emergent surgery.
Case Presentation: Our patient is a 60-year-old female with history of hypothyroidism and an endoscopic Zenker’s diverticulectomy in 2013. She presented with vague diffuse abdominal pain associated with nausea and emesis. On physical exam she had normal vital signs and a normal laboratory profile including a normal white blood cell count. A computed tomography (CT) of the abdomen and pelvis was performed with intravenous and oral contrast showing a large amount of free air tracking along the lateral and posterior margin of the liver, surrounding the second portion of a dilated duodenum. The patient had multiple colonic diverticula as well.
The patient is taken to the operating room for a diagnostic laparoscopy and placed in supine position. The abdomen was accessed using a Hasson port in the umbilicus and 3 additional ports were placed in the following configuration: two 5 mm trocars in the right upper quadrant, and a 12 mm trocar in the left upper quadrant. A Nathanson liver retractor was placed through an incision in the epigastric area. A significant amount of edema and inflammatory tissue was encountered around the second and third portion of the duodenum. A laparoscopic Kocher maneuver was performed and it was possible to perceive a duodenal diverticulum plastered to the second and third portion of the duodenum. The diverticulum was safely mobilized and resected with an endoscopic stapler. A Jackson-Pratt drain was left in the subhepatic space, adjacent to the area of stapled duodenum.
An upper gastrointestinal series and a CT scan, both with water-soluble contrast, were performed on post-operative day 3 and 5 respectively, confirming the absence of a leak. The patient was discharged home on post-operative day 6 after tolerating soft diet and on oral antibiotics.
Conclusion: As the application of laparoscopy extends to emergent surgeries, it can also be meticulously applied to excise perforated duodenal diverticulum.
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