Laparoscopic management of small bowel obstruction due to a mesodiverticular band of a Meckel's diverticulum: A case report.

A 15-year-old male presented with a three-day history of severe, colicky abdominal pain exacerbated by oral intake, accompanied by persistent non-bilious vomiting, nausea, and absolute constipation. On admission, he appeared acutely ill and dehydrated, with vital signs revealing a temperature of 38.3 °C, heart rate of 118 bpm, blood pressure of 100/65 mmHg, respiratory rate of 38 breaths per minute, and oxygen saturation of 92 % on room air. Physical examination demonstrated diffuse abdominal tenderness, guarding, rigidity, and rebound tenderness, consistent with generalized peritonitis. Laboratory investigations showed leukocytosis (WBC 15,000/μL) and elevated CRP (116 mg/L), suggestive of an ongoing inflammatory process. Abdominal ultrasonography revealed free fluid in the right paracolic gutter and pelvis, dilated small bowel loops, and increased intraluminal gas. Contrast-enhanced CT imaging ( Fig. 1 , Fig. 2 ) demonstrated a fluid collection with air bubbles in the pelvis, extensive inflammatory changes in the right iliac fossa, and a Meckel's diverticulum with an associated mesodiverticular band compressing the terminal ileum. Fig. 1 Axial CT view of the abdomen showing small bowel obstruction caused by Meckel Diverticulitis with an associated mesodiverticular band. Fig. 1 Fig. 2 Coronal CT view of the abdomen showing small bowel obstruction caused by Meckel Diverticulitis with an associated mesodiverticular band. Fig. 2 Axial CT view of the abdomen showing small bowel obstruction caused by Meckel Diverticulitis with an associated mesodiverticular band. Coronal CT view of the abdomen showing small bowel obstruction caused by Meckel Diverticulitis with an associated mesodiverticular band. Immediate broad-spectrum intravenous antibiotic therapy with piperacillin-tazobactam and metronidazole was initiated upon diagnosis. Under general anesthesia, three laparoscopic ports were placed: one 10-mm trocar at the umbilical region and two 5-mm trocars in the suprapubic region and the left lower quadrant. Laparoscopic exploration revealed diffuse suppurative peritonitis with purulent collections predominantly in the right iliac fossa and small pelvis. A fibrous mesodiverticular band ( Fig. 3 ), originating from a perforated and gangrenous Meckel's diverticulum (MD) ( Fig. 4 ), was found to be compressing the terminal ileum, resulting in moderate small bowel obstruction. The band was carefully divided using a harmonic scalpel, followed by gentle adhesiolysis. Given the extent of localized necrosis and the absence of visible ectopic tissue at the diverticular base on intraoperative assessment, the gangrenous MD was resected at its base using a 60-mm linear endoscopic stapler ( Fig. 5 ), ensuring safe margin control and complete removal of the diseased segment. The appendix appeared reactively inflamed and was removed concurrently via appendectomy. Evacuation of intraperitoneal abscesses and extensive abdominal lavage were performed, and a 16 Fr drain was placed in the small pelvis. The procedure was completed without intraoperative complications. Fig. 3 Intraoperative image demonstrating the mesodiverticular band causing small bowel obstruction. Fig. 3 Fig. 4 Intraoperative image showing the inflamed and gangrenous Meckel's diverticulum after Dissection from the adjacent small bowel loops. Fig. 4 Fig. 5 Intraoperative image showing resection of the gangrenous Meckel's diverticulum using an endostapler. Fig. 5 Intraoperative image demonstrating the mesodiverticular band causing small bowel obstruction. Intraoperative image showing the inflamed and gangrenous Meckel's diverticulum after Dissection from the adjacent small bowel loops. Intraoperative image showing resection of the gangrenous Meckel's diverticulum using an endostapler. Histopathological examination confirmed a gangrenous Meckel's diverticulum measuring 3 × 2 cm, with features of transmural necrosis, mucosal ulceration, and focal perforation. No ectopic gastric or pancreatic tissue was identified, and all surgical margins were free of necrotic changes or ectopic mucosa. There was no evidence of dysplasia or malignancy. The postoperative course was uneventful; the patient demonstrated progressive clinical improvement with successful reintroduction of enteral nutrition and full recovery of bowel function. He was discharged in stable condition on the third postoperative day. Postoperatively, the patient and his family expressed satisfaction with the received treatment and appreciated the timely intervention, particularly the use of a minimally invasive technique. Clinical follow-up was conducted for a duration of six months through scheduled outpatient visits. During this period, the patient remained asymptomatic, with no recurrence of abdominal pain, signs of bowel obstruction, bleeding or infectious complications. Although long-term surveillance beyond six months may provide additional reassurance, the absence of symptoms and normal physical examination findings throughout the follow-up interval suggest a complete and durable recovery.

The work has been reported in line with the SCARE criteria.

Dr. Wail Alqatta was responsible for the conception and design of the case report, surgical management of the patient, data collection, literature review, drafting and revising the manuscript, and final approval for publication.

The author provides consent for publication.

Ethical approval was not required for this case in accordance with the institutional guidelines.

The author received no financial support for the research, authorship, or publication of this case report.

Written informed consent was obtained from the patient's parents/legal guardian for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

This is not a First-in-Man case report. The intervention described has been previously reported in the literature.

Dr. Wail Alqatta accepts full responsibility for the work and the decision to publish this case report.

This case illustrates the diagnostic and therapeutic challenges of small bowel obstruction secondary to a mesodiverticular band of Meckel's diverticulum, a rare but important cause of small bowel obstruction, particularly in patients without prior abdominal surgery. Due to the nonspecific clinical presentation, a high index of suspicion is essential for early recognition. While imaging is useful in identifying obstruction, definitive diagnosis often requires surgical exploration. In this case, laparoscopy proved invaluable, offering both diagnostic clarity and therapeutic benefit. The minimally invasive approach enabled precise identification and resection of a gangrenous, perforated Meckel's diverticulitis with minimal operative trauma, facilitating a smooth recovery and reducing postoperative morbidity. This case underscores the importance of individualized surgical decision-making. Given the presence of gangrene and perforation, resection of the Meckel's diverticulum was imperative to control the source of infection and prevent further intra-abdominal complications. The use of a laparoscopic stapler ensured secure closure and preserved bowel continuity. In summary, early laparoscopic intervention is a safe and effective strategy for managing small bowel obstruction caused by mesodiverticular bands. Surgeons should consider Meckel's diverticulum in the differential diagnosis of unexplained small bowel obstruction, as prompt recognition and management are key to preventing severe complications and ensuring optimal outcomes.

Meckel's diverticulum may be asymptomatic throughout life, but 15 % to 25 % of patients develop complications and undergo surgery for an acute abdomen [ 14 ]. The most common complications are intestinal obstruction (35.1 %), ulcer bleeding (14.6 %), intestinal overload (14.5 %), diverticulitis (12.5 %), and perforation (7.5 %) [ 15 ]. Meckel's diverticulum is caused by malabsorption of the yolk intestine; however, if the right and left yolk arteries, which are the nutritive vessels, are retained, they form a mesodiverticular band, which reportedly causes intestinal obstruction in symptomatic Meckel's diverticulum [ 16 , 17 ]. Moreover, ectopic pancreatic tissue may be detected in Meckel's diverticulum, and cancerous lesions have been previously reported in the same area [ 18 ]. Therefore, it is extremely important to simultaneously resect Meckel's diverticulum for histopathological examination. If ectopic tissue is detected at the resection margin, the possibility of malignant transformation cannot be excluded, and strict outpatient follow-up or additional resection is necessary. Computed tomography (CT) has 90–94 % sensitivity and 96–100 % specificity for the diagnosis of small bowel obstruction and a 40–73 % positive predictive value for predicting the cause of the obstruction [ 19 , 20 ]. In cases of acute small bowel obstruction where a mesodiverticular band is suspected, multidetector CT (MDCT) with multiplanar reconstructions is essential. Key findings include a blind-ending fluid or gas-filled structure connected to the antimesenteric border of the distal ileum by a vascular band, causing a transition point and proximal dilation [ 21 ]. In these cases, early recognition of the clinical picture and scheduling surgery as a therapeutic option is of vital importance, since a delay in surgery of 36 h or more can triple the mortality rate from 8 to 25 % [ 22 ]. Surgery, in specific Meckel's diverticulectomy, remains the mainstay of treatment in such cases. The most common forms are diverticulectomy, wedge, or segmental resection, and the rationale for which procedure to form depends largely on the integrity of the diverticular base and proximal ileum and the location of ectopic tissue if any [ 23 ]. The type of procedure to be performed for resection of symptomatic MD depends on: (a) the integrity of diverticulum base and adjacent ileum; and (b) the presence and location of ectopic tissue. The presence of ectopic tissue cannot be accurately predicted intraoperatively by palpation and macroscopic appearance; however, when present its location can be predicted based on height-to-diameter ratio long diverticula (height-to-diameter ratio > 2) have ectopic tissue located at the body and tip, whereas short diverticula have wide distribution of ectopic tissue including the base [ 24 ]. Consequently, categorization of MD in long and short, based on height-to-diameter ratio, can aid in decision making. Based on the above, when the indication of surgery is: (1) simple diverticulitis of a long MD, diverticulectomy can be performed; (2) simple diverticulitis of a short MD, wedge resection should be performed; (3) complicated intestinal obstruction, complicated diverticulitis with inflamed or perforated base and tumor, wedge or segmental resection should be performed; (4) bleeding, wedge resection or segmental resection are the preferred methods for resection; however diverticulectomy can be performed for long diverticula [ [23] , [24] , [25] ]. When residual ectopic tissue is histologically confirmed after simple diverticulectomy for bleeding MD, reoperation for segmental resection is necessary only after bleeding remission as simple diverticulectomy does not increase the risk of postoperative bleeding [ 26 , 27 ]. Laparoscopic approach (diverticulectomy with endostaplers, wedge or segmental resection with extracorporeal or intracorporeal anastomosis) has equivalent outcomes to traditional laparotomy for symptomatic MD in both pediatric and adult patients [ 28 ]. Ezekian et al. in a retrospective study of 148 cases of MD, showed that postoperative complications, rate of reoperation and readmission were similar between laparoscopy and laparotomy patients. The authors reported a conversion rate of 27.4 % and suggested avoiding routine conversion for palpation of the MD or segmental small bowel resection in the absence of compelling intraoperative findings or operative complications [ 29 ]. In the present case, the decision to perform a diverticulectomy rather than a wedge resection was based on intraoperative findings. The diverticulum was gangrenous and perforated, but the inflammation and necrosis were confined to the body of the diverticulum without involvement of its base or the adjacent ileum. Additionally, there was no evidence of ectopic tissue at the base of the diverticulum on gross inspection. Furthermore, since there was no evidence of bleeding or ulceration in the adjacent ileum, a simple diverticulectomy was deemed sufficient. This approach minimizes the extent of bowel resection and preserves bowel length, which is particularly important in young patients. However, it is crucial to ensure that the resection margin is free of ectopic tissue, which was confirmed by histopathological examination in this case. The successful use of laparoscopy in this case highlights the importance of early intervention and the role of minimally invasive surgery in treating rare but significant causes of SBO, such as MD and mesodiverticular bands. In patients with a suspected obstruction but no history of prior surgery or other typical causes of SBO, clinicians should consider Meckel's diverticulum as a potential diagnosis, particularly in younger patients. This is crucial to avoid complications like bowel ischemia, necrosis, or perforation, which could occur if left untreated.

Small bowel obstruction (SBO) is a common and often urgent surgical condition, accounting for about 15 % of all surgical admissions related to acute abdominal pain [ 1 ]. The causes of SBO are diverse, with the most common being adhesions (60 %), hernias (15 %), and malignancies (10 %) [ 2 ]. However, there are fewer common causes that are often more difficult to diagnose, such as Meckel's diverticulum (MD) and its associated anomalies, including mesodiverticular bands. Meckel's diverticulum (MD), extensively described in 1809, by the German anatomist, Johann Friedrich Meckel the Younger [ 3 ]. It is present in approximately 2–3 % of the population and located on the antimesenteric border of the ileum, approximately 45–60 cm proximal to the ileocecal junction, and its length ranges from 3 to 5 cm in most of the patients [ 4 ]. It is a true diverticulum, i.e., the walls contain all the three layers of the intestinal wall, and it has its own blood supply arising from the superior mesenteric artery. The mucosa of the diverticulum may contain heterotopic gastric mucosa (50 %), pancreatic mucosa (5 %), and less commonly colonic mucosa, endometriosis, or hepatobiliary tissue. These types of mucosae make it vulnerable to other complications such as hemorrhage, chronic peptic ulceration, and perforation [ 5 ]. Complications typically occur before the age of 2-years old and a MD is generally recognized as an etiology of acute abdominal pain in children [ 6 ]. In adults, a MD may be incidentally encountered during surgery for other conditions or discovered due to complications, such as intestinal obstruction, hemorrhage, perforation, and diverticulitis, with a lifetime risk of complications ranging from 4.2 % to 9 % [ 4 , 7 ]. The symptoms can often mimic other, more common causes of SBO, which makes identification of the underlying issue more complex. Symptoms of SBO, including abdominal pain, vomiting, and distension, may be seen in the context of a wide range of pathologies, which means a high index of suspicion is needed when unusual causes, such as Meckel's diverticulum, are suspected. The radiological workup for small bowel obstruction due to a mesodiverticular band from a Meckel's diverticulum typically begins with abdominal radiographs, followed by computed tomography (CT) as the primary diagnostic modality, potentially supplemented by a technetium-99 m pertechnetate scan (Meckel's scan) if clinical suspicion remains high despite equivocal CT findings [ 8 ]. Computed tomography (CT) is the cornerstone for diagnosing small bowel obstruction and may reveal the Meckel's diverticulum itself, an associated inflammatory mass, or signs suggesting the presence of a mesodiverticular band as the cause of obstruction; however, definitive diagnosis is often made at laparoscopy or laparotomy [ 9 ]. Treatment typically involves surgical removal of the diverticulum, if the MD is symptomatic-in-nature or causes complications [ 10 ]. The mesodiverticular band (MDB), a remnant of the vitelline artery and vein, is commonly found adjacent to the MD. Moreover, approximately 8 % of cases of an MD are associated with an MDB [ 6 ]. Due to the rarity, nonspecific symptoms, and imaging variability thereof, diagnosing an MD in adults is challenging, frequently resulting in an exploratory laparotomy [ 11 ]. This condition is relatively rare, but it poses a diagnostic challenge. In case of incidentally found MD divericulectomy is recommended as studies have shown that incidence of complications from surgery is less than that from left alone MD [ 12 ]. In this case report, we discuss the laparoscopic management of SBO caused by a mesodiverticular band in a 15-year-old male. The patient presented with typical SBO symptoms, and imaging studies eventually revealed the presence of the MD and its band. This case provides a valuable opportunity to explore the challenges of diagnosing this rare cause of SBO and the role of laparoscopic surgery in its management. Through this case, we aim to emphasize the importance of considering Meckel's diverticulum and its associated anomalies in the differential diagnosis of SBO, particularly in patients who present with unexplained or atypical symptoms. Early recognition and prompt surgical intervention are key to ensuring favorable outcomes, especially when rare pathologies such as mesodiverticular bands are involved. This Report has been reported in line with the SCARE 2025 criteria [ 13 ].

The author declares that he has no competing interests.