its incidence is usually quoted as approximately 2% of the population , but the prevalence can vary from 0.2% to 2% . it is a diverticular remnant of the omphalomesenteric duct located on the antimesenteric border of the ileum , a short distance from the cecum ( 60 cm proximal to the ileocecal valve ) . on average , although jejunal , colonic , rectal , pancreatic , duodenal , and endometrial tissues have all been found in the diverticulum , the heterotopic mucosa is likely to be gastric in origin in 80% of cases . as a result , diagnosis of a bleeding meckel 's diverticulum is established by technetium tc 99m - pertechnate scan (  meckel scan  ) . laparoscopic resection of perforated meckel 's diverticulum in a patient with clinical symptoms of acute appendicitis was first reported in 1992 by ng et al . here , we present our experiences with symptomatic meckel 's diverticulum in a series of adult and pediatric patients managed successfully by laparoscopy . physical examination showed an ill - defined mass in the right lower quadrant , in the vicinity of the umbilicus in 4 patients . a clinical diagnosis of meckel 's diverticulitis was made in these 4 patients , and for the other 8 patients a diagnosis of appendicitis was made . plain x - ray of the abdomen showed no evidence of air under the right diaphragm . in 8 patients , ultrasonogram ( usg ) and computerized tomography scan ( ct ) revealed an inflammatory mass in the area of the appendix , suggestive of a diagnosis of appendicular perforation . in the other 4 patients , because the normal appendix was visualized separately from the mass , the possibility of meckel 's diverticulitis was entertained . intravenous antibiotics ( cefotaxime 1000 mg and ornidazole 500 mg ) were administered 1 hour before surgery . the open hasson technique was used to establish pneumoperitoneum in all the patients , with the intra - abdominal pressure being maintained at 12 mm hg . a 10-mm trocar was inserted into the umbilicus ; a 5-mm trocar was introduced in the suprapubic area , and another 5-mm trocar in the right lower quadrant , under direct vision . a 10-mm ( 30 ) laparoscope was introduced into the 10-mm port for diagnostic laparoscopy . an inflammatory mass formed by the meckel 's diverticulitis was seen in 9 patients and perforated meckel 's diverticulum with localized peritonitis was seen in 3 patients ( figure 1 ) . the 10-mm laparoscope was removed from the umbilical port and replaced with a 5-mm ( 30 ) laparoscope introduced into the 5-mm suprapubic port . the umbilical port was used for the right - hand instrument , and the right lower quadrant port was used for the left - hand instrument . the bowels were gently separated by using the tip of a suction nozzle , which revealed a pocket of pus and the perforated meckel 's diverticulum . a thorough peritoneal washing was performed , and the decision to resect the diverticulum was made . an endostapler ( endopath ets - flex 45 endoscopic articulating linear cutter , ethicon , inc . cincinnati , oh ) was introduced into a 12-mm trocar , replacing the 10-mm umbilical trocar . it was applied to the base of the diverticulum , perpendicular to the base of the diverticulum but transverse to the longitudinal axis of the bowel ( figure 2 ) . the stapler was fired and the diverticulum was resected off the ileum ( figure 3 ) . small bleeding points at the edge of the staple line , if present , were sutured intracorporeally with 3 0 vicryl . all the specimens were delivered through an enlarged 12-mm umbilical port with the use of an endobag . a wedge resection was performed for 2 patients where the base of the diverticulum was inflamed . endostaplers were used for the excision , and bowel continuity was achieved by placing intracorporeal sutures with 20 vicryl . a drainage tube was kept only in the 3 patients with the perforated diverticula . a : terminal ileum ; b : inflamed meckel diverticulum ; c : proximal ileum . application of the endostapler . the open hasson technique was used to establish pneumoperitoneum in all the patients , with the intra - abdominal pressure being maintained at 12 mm hg . a 10-mm trocar was inserted into the umbilicus ; a 5-mm trocar was introduced in the suprapubic area , and another 5-mm trocar in the right lower quadrant , under direct vision . a 10-mm ( 30 ) laparoscope was introduced into the 10-mm port for diagnostic laparoscopy . an inflammatory mass formed by the meckel 's diverticulitis was seen in 9 patients and perforated meckel 's diverticulum with localized peritonitis was seen in 3 patients ( figure 1 ) . the 10-mm laparoscope was removed from the umbilical port and replaced with a 5-mm ( 30 ) laparoscope introduced into the 5-mm suprapubic port . the umbilical port was used for the right - hand instrument , and the right lower quadrant port was used for the left - hand instrument . the bowels were gently separated by using the tip of a suction nozzle , which revealed a pocket of pus and the perforated meckel 's diverticulum . a thorough peritoneal washing was performed , and the decision to resect the diverticulum was made . an endostapler ( endopath ets - flex 45 endoscopic articulating linear cutter , ethicon , inc . cincinnati , oh ) was introduced into a 12-mm trocar , replacing the 10-mm umbilical trocar . it was applied to the base of the diverticulum , perpendicular to the base of the diverticulum but transverse to the longitudinal axis of the bowel ( figure 2 ) . the stapler was fired and the diverticulum was resected off the ileum ( figure 3 ) . small bleeding points at the edge of the staple line , if present , were sutured intracorporeally with 3 0 vicryl . all the specimens were delivered through an enlarged 12-mm umbilical port with the use of an endobag . a wedge resection was performed for 2 patients where the base of the diverticulum was inflamed . endostaplers were used for the excision , and bowel continuity was achieved by placing intracorporeal sutures with 20 vicryl . a : terminal ileum ; b : inflamed meckel diverticulum ; c : proximal ileum . a total of 6700 appendectomies were done between 1994 and 2006 at our institution . out of this , 0.3% ( 20/6700 ) of patients had meckel 's diverticulum and 0.17% ( 12/6700 ) were symptomatic . the age range was 6 years to 43 years ; there were 3 adults and 9 children , 8 males and 4 females . perforation of meckel 's diverticulum was present in 3 patients and inflammation in 9 patients . the patient was allowed liquids orally between the third and fifth postoperative day ( pod ) and a soft diet thereafter . the day of discharge was in the range of the fourth through the seventh pod . there were no port - site hernias , intestinal obstruction , or leaks in any patient . one patient had infection of the umbilical wound , which was treated with the appropriate antibiotics . one patient had postoperative pneumonitis , treated with intravenous piperacillin / tazobactam for 5 days . histopathology of the diverticulum showed heterotopic gastric mucosa in 11 ( 73% ) patients , pancreatic tissue in 1 ( 27% ) patient , evidence of acute inflammation in 9 patients , and perforation in 3 patients . eight patients were followed up for 24 months , and 4 patients reported for follow - up after 45 months and were found to be symptom free . meckel 's diverticulum is the most common form of congenital abnormality of the small intestine , resulting from an incomplete obliteration of the vitelline duct . although originally described by fabricius hildanus in 1598 , it is named after johann friedrich meckel , who established its embryonic origin between 1808 and 1820 . the tip of the diverticulum is free in 75% of cases , and in 25% the tip is attached to another organ or structure by means of a band . most patients are asymptomatic , and it is usually an incidental finding when a barium study or laparotomy is performed for other abdominal conditions . in our series of 6700 laparoscopic appendectomies , there were 20 cases of meckel 's diverticula , out of which 12 were symptomatic . complications include bowel obstruction ( 35% ) , hemorrhage ( 32% ) , diverticulitis ( 22% ) , umbilical fistula ( 10% ) , perforation ( 5% ) , other umbilical lesions ( 1% ) , and intussusception . meckel 's diverticulitis may mimic appendicitis , and the correct diagnosis is usually established at the time of laparotomy or laparoscopy . none of the clinical features are pathognomonic , and the diagnosis is rarely made preoperatively . routine laboratory studies , such as leukocyte and erythrocyte counts , serum electrolytes , blood glucose , and urea serum creatinine , and coagulation screen were helpful in the general workup . ct and usg have been used to diagnose meckel 's diverticulum , but despite the availability of modern imaging techniques , the diagnosis is still challenging . so far , only case reports have been appearing in the literature regarding laparoscopic surgery for symptomatic meckel 's diverticula . laparoscopy is especially more useful in this situation as it is clinically difficult to distinguish between diverticulitis and appendicitis . definitive treatment of a complication , such as a bleeding , is the excision of the diverticulum . successful resection of a meckel 's diverticulum can also be accomplished through laparoscopy , using endostapling devices . the advantages and benefits of minimal access surgery can be truly appreciated in children with symptomatic meckel 's diverticulum . excision is mandatory for all symptomatic diverticula . with the advent of gastrointestinal stapling devices , another advantage of stapling is that it closes the bowel lumen as it cuts , thereby completely reducing the chance of peritoneal contamination . the contraindications for stapler excision is a very broad - based diverticulum or too short a diverticulum where a stapled excision can not be technically performed . in case the diverticulum is too short , there is a danger of including too much of the ileum during stapling or leaving behind part of the diverticulum . another way to accomplish excision is to exteriorize the diverticulum via a minilaparotomy incision , stapler - resection and suturing closed the ( common opening ) enterotomy . in 2 patients , the base of the diverticulum was also inflamed ; so a wedge resection including part of the normal ileum had to be performed . provided the base of the diverticulum is not involved , it is our contention that tangential resection of the lesion alone will suffice . it is vital that the direction of the staple line lie perpendicular to the ileum and not on the longitudinal axis . this way , the ileal lumen will not be compromised while the stapler is being fixed at the base of the diverticulum . the reticulating head of the stapler is invaluable in these situations because it can be maneuvered precisely on the base of the diverticulum . management of meckel 's diverticulum in asymptomatic patients is controversial because only about 4% develop complications . the only indications for excision of asymptomatic diverticula are size more than 5 cm or presence of an omphalomesenteric band at the tip that has a risk of torsion . stapler resection of asymptomatic diverticulum during surgery for unrelated disease has been shown to produce no added morbidity . in our series , 2 patients with asymptomatic meckel 's diverticulum in whom we did not perform excision reported later with diverticulitis . tangential excision of a symptomatic meckel 's diverticulum using endostaplers is sufficient , provided the base is normal . otherwise , wedge resection or segmental bowel resection is recommended . laparoscopy seems to have a definite role in both adult and pediatric patients with symptomatic meckel 's diverticulum , especially when the diagnosis is in doubt . it is crucial that the division be made transverse to the longitudinal axis of the small bowel . laparoscopy also provides all the benefits of minimally invasive surgery like reduced morbidity , early discharge , and better cosmesis .
background : meckel 's diverticulum was first described about 400 years ago and continues to be a rare congenital disorder . 
 laparoscopic surgery for meckel 's diverticulum has been described in mostly case reports . 
 we present our series of patients with symptomatic meckel 's diverticulum.methods:we have treated 12 patients with symptomatic meckel 's diverticulum from 1994 through 2006 at our institution . 
 all the patients presented with features of either appendicitis or peritonitis , some with a vague abdominal mass . 
 clinical diagnosis of meckel 's diverticulum was made in only 4 patients . 
 diagnostic laparoscopy confirmed meckel 's diverticulitis in all patients . 
 laparoscopic stapler resection of the lesions was performed for all patients , tangential excision in 10 and wedge excision in 2.results:the incidence of meckel 's diverticulum at our institution is 0.3% . 
 the majority of patients were male children . 
 there were no staple - line leaks in any case . 
 all patients recovered well postoperatively , and the day of discharge was in the range of the fourth to the seventh pod . 
 heterotopic gastric mucosa was found in the majority of the diverticula . 
 eight patients were followed up for 24 months , and 4 patients reported for follow - up after 45 months and were found to be symptom-free.discussion:the diagnosis of meckel 's diverticulitis is rarely made preoperatively . 
 surgical resection is indicated only if the diverticulum is symptomatic or if the base is narrow . traditionally , open wedge resection ( including the anterior wall of the ileum ) of the diverticulum is the treatment . 
 we think that a simple tangential stapler resection can also be performed , with good outcome.conclusion:laparoscopy is useful in both diagnosis and treatment . 
 laparoscopic resection of meckel 's diverticulum is feasible and ideal , especially when performed in specialized centers .