Abdelrahman A Nimeri, MD FACS, Mohammed B Al Haddad, MD. SKMC/Cleveland Clinic Abu Dhabi. Surgery Institute, Division of General, Thoracic, and Vascular Surgery
Duodenal diverticula (DD) are fairly common anatomical entities present in 22 – 23 % of autopsy series. Diverticula of the duodenum & small intestine rarely cause clinical problems. Symptomatic DD present with pain, bleeding, obstruction, perforation, pancreatitis, or malignant transformation. Diagnosis is usually made by Upper GI barium studies or by CT scan or MRI. Elective surgical treatment of asymptomatic diverticulum is not justified. However, a small percentage can cause fatal problems. Only 1-5% of diagnosed DD will require surgery. Operative procedure for diverticula of second part of duodenum needs mobilization of duodenum by Kochar maneuver. Diverticulum is excised and opening of duodenum closed transversely to avoid narrowing the lumen. Early diagnosis is essential for successful treatment. To our knowledge, this is the first report of laparoscopic resection of a perforated duodenal diverticulum.
Methods and Results:
A fifty year old male previously healthy, presented with sudden severe epigastric pain of few hours duration. He had history of Helicobacter pylori three years prior to his presentation but he declined treatment and endoscopy. He was hemodynamically stable; he was tender in the epigastric area. His complete blood count was normal. Computed tomography showed free air with free fluid & a perforated duodenal diverticulum. He was given antibiotics, and taken to surgery.
Under general anesthesia & endotracheal intubation, diagnostic laparoscopy was performed using three ports. There was large amount of free turbid intraperitoneal fluid. The duodenum was Kocherized, the perforated duodenal diverticulum was dissected, and resected at the base with an Echelon stapler. A falciform modified Grahm’s patch was sutured on top of the staple line. The operatve time was 120 minutes. Histopathology showed that the diverticulum was 4×5 cm with perforation 0.7 cm in diameter. Patient did well & was discharged on the 6th post operative day.
Laparoscopic resection of a perforated DD is a safe and effective method to treat this rarely symptomatic clinical entity. Early recognition and prompt surgical treatment are essential to a successful outcome. This is the first reported case of laparoscopic resection of a perforated duodenal diverticulum.
Program Number: V068