A surgical operation called a "Ladd procedure" is performed to alleviate intestinal

malrotation. The procedure involves surgical division of Ladd's bands, widening of the
small intestine 's mesentery , performing an appendectomy and correctional
placement of the cecum and colon .
PE!A"#L#A
$ec%el's diverticulum is the most common congenital abnormality of the gastrointestinal
tract.&'( )t is a true diverticulum containing all layers of the intestinal wall.* This
embryonic remnant arises from the antimesenteric border of the ileum.* The diverticular
remnant of the omphalomesenteric or vitelline duct was described in detail by +ohann
$ec%el in &,-,.&,* As the embryonic yol% sac enlarges, it develops a connection to the
primitive gut via the vitelline duct. Typically this duct obliterates in the embryo by the
fifth to ninth wee% during the progression and rotation of the foregut and hindgut. As this
occurs, the yol% sac also begins to atrophy.. )n -./0 to 1.*0 of the population, this
vitelline duct persists to become a $ec%el's diverticulum.&,.,2 The yol% sac is supplied
by 1 vitelline arteries, one of which degenerates as the yol% sac atrophies, while the
remaining artery develops into the superior mesenteric artery.. 3hen one of the vitelline
arteries fails to degenerate, it develops into a peritoneum covered fibrous band, or a
mesodiverticular band.. )t is usually attached from the tip of the $ec%el's diverticulum to
the ileal mesentery and is often the cause of a small bowel obstruction, as is presented in
this case.
!iverticulum PE!A"#L#A$ec%el adalah %elainan bawaan yang paling umum dari
gastrointestinal tract.& 4 ( )ni adalah diverti%ulum benar berisi semua lapisan wall.* usus
sisa embrio ini muncul dari perbatasan antimesenteri% dari ileum.* 5isa diverti%ular dari
omphalomesenteric atau . vitelline saluran itu di6elas%an secara rinci oleh +ohann $ec%el
di &,-,.&,* 5ebagai embrio membesar yol% sac , ber%embang sambungan %e usus primitif
melalui saluran vitelline . 7iasanya saluran ini obliterates dalam embrio oleh %elima
untu% minggu %esembilan selama per%embangan dan rotasi foregut dan hindgut . 8arena
ini ter6adi , yol% sac 6uga mulai atrophy.. !alam -,/ 0 men6adi 1,* 0 dari populasi ,
vitelline saluran ini tetap men6adi sebuah diverticulum.& $ec%el , .,2 The yol% sac
disuplai oleh 1 vitelline arteri , salah satu . yang berdegenerasi sebagai yol% sac
atrophies , sedang%an arteri yang tersisa ber%embang men6adi mesenteri%a superior
artery.. 8eti%a salah satu arteri vitelline gagal merosot , ber%embang men6adi peritoneum
tertutup band yang berserat , atau band.. mesodiverticular "al ini biasanya terpasang dari
. u6ung diverti%ulum $ec%el yang %e mesenterium ileum dan sering men6adi penyebab
obstru%si usus %ecil , seperti yang disa6i%an dalam %asus ini .
!)59#55):
The lifetime ris% of complications of a $ec%el's diverticulum, including diverticulitis,
bleeding and obstruction, is appro;imately (0 to .0,1'(,,,< and (-0 of these occur in
children younger than age &-.< )t is difficult to diagnose preoperatively, because its
presentation commonly mimics such disorders as appendicitis, peptic ulcer disease, and
9rohn's4appendicitis being the most common preoperative diagnosis.&,&- Therefore, a
complicated $ec%el's diverticulum should be considered in any patient with une;plained
abdominal pain, particularly younger patients.
The most common complications of $ec%el's diverticulum are inflammation and
obstruction caused by an adhesive fibrous band or internal hernia.&'/,&& 5mall bowel
obstruction is associated with appro;imately /-0 of symptomatic diverticula,/,&1 and is
a common cause of small bowel obstruction in the virgin abdomen.&& )n a few reported
cases, small bowel obstruction was also caused by enterolithiasis and phytobe=oars.&1,&/
A retrospective study in &<<. of ,( patients with $ec%el's diverticula reported a &-0
incidence of symptomatic enterolithiasis.&/ A thic%ened portion of the diverticulum may
also suggest ectopic gastric or pancreatic tissue. Ectopic mucosa carries an incidence of
&-0 to 1-0 and re>uires resection of the involved segment of ileum to prevent further
complications such as bleeding.2 The average si=e is /cm, with <-0 between &cm and
&-cm. Larger diverticula are more susceptible to complications.&(
?arely has a $ec%el's diverticulum been %nown to result in intussusception. The first
such reported case to be treated laparoscopically in 1--/ involved an ileoileal
intussusception diagnosed by small bowel enteroclysis with a bird4bea% appearance at the
distal ileum. The intussusception was reduced laparoscopically followed by a segmental
ileal resection and e;tracorporeal anastomosis.&* 7leeding and intussusception tend to
occur more often under the age of 1, while obstruction and inflammation are more
common in adults./,(,2
Efficacy of diagnostic imaging varies with this disease process. Plain films are usually
nonspecific. ?adionuclide scintigraphy will detect ,*0 of $ec%el's cases if ectopic
gastric mucosa is present in the diverticulum. Enteroclysis may also detect a smaller
percentage of diverticula, ranging up to 2*0./,(Abdominal 9T may yield a high rate of
diagnosis when small bowel obstruction is present @,&0 to <.0A, but a $ec%el's etiology
is difficult to identify as a cause due to the inability to distinguish a diverticulum amongst
loops of small bowel./
)n a 1--* retrospective study, #eberruec% et al&. analy=ed the significance of $ec%el's
diverticulum in cases diagnosed as appendicitis. )n a 1.4year period, a total of
appro;imately &- --- appendectomies were performed. The bowel was e;plored to
search for a $ec%el's diverticulum in appro;imately ,-0 of these cases. The presence of
a $ec%el's was discovered in /0 of these cases, while <0 of these diverticula were found
to have pathology, including obstruction, diverticulitis, perforation, and intussusception.
This study concluded in establishing the importance of e;ploring the bowel in all
appendectomy cases.&.
After removal of a complicated $ec%el's, the postoperative morbidity has been reported
to be &10 while mortality is 10. )n incidentally removed diverticula, the rates are 10
and &0, respectively.&,(,&(,&2Although controversial, many surgeons recommend
removing incidentally discovered $ec%el's based on the low postoperative complication
rate. These rates were found in a definitive study at the $ayo 9linic in &<<(, supporting
the role of prophylactic diverticulectomy. The ris%s of complications of $ec%el's
diverticula remained constant over all age groups at ..(0, while the postoperative
morbidity and mortality rates were much more favorable in asymptomatic, incidental
diverticulectomies @Table &A.(,&(,&2
?isi%o seumur hidup dari %ompli%asi dari diverti%ulum $ec%el, termasu% diverticulitis ,
perdarahan dan obstru%si , adalah se%itar ( 0 sampai . 0 ,1 4 ( , ,,< dan (- 0 di
antaranya ter6adi pada ana%4ana% muda dari usia &-,< 5ulit untu% mendiagnosa sebelum
operasi . , %arena meniru gangguan seperti presentasi umum radang usus buntu, penya%it
ul%us pepti%um , dan 9rohn's 4 usus buntu men6adi diagnosis.& pra operasi yang paling
umum , &- :leh %arena itu , diverti%ulum $ec%el rumit yang harus dipertimbang%an
dalam setiap pasien dengan nyeri perut yang tida% dapat di6elas%an , terutama pasien yang
lebih muda .
8ompli%asi yang paling umum dari diverti%ulum $ec%el adalah peradangan dan
obstru%si yang disebab%an oleh band fibrosa pere%at maupun internal hernia.& 4 / , &&
obstru%si usus %ecil berhubungan dengan se%itar /- 0 dari diverti%ula ge6ala , /,&1 dan
merupa%an penyebab umum dari usus %ecil . obstru%si pada abdomen.&& perawan dalam
beberapa %asus yang dilapor%an , obstru%si usus halus 6uga disebab%an oleh
enterolithiasis dan phytobe=oars.&1 , &/ sebuah studi retrospe%tif pada tahun &<<. dari ,(
pasien dengan diverti%ula $ec%el melapor%an %e6adian &- 0 dari enterolithiasis.&/ ge6ala
A menebal . sebagian dari diverticulum 6uga mung%in menyaran%an lambung e%topi%
atau 6aringan pan%reas . $u%osa e%topi% membawa sebuah %e6adian &- 0 sampai 1- 0
dan membutuh%an rese%si segmen yang terlibat ileum untu% mencegah %ompli%asi lebih
lan6ut seperti bleeding.2 #%uran rata4rata adalah /cm , dengan <- 0 antara &cm dan
&-cm . !iverti%ula yang lebih besar lebih rentan terhadap complications.&( .
+arang telah diverti%ulum $ec%el telah di%enal untu% menghasil%an intususepsi . 8asus
pertama dilapor%an The tersebut harus diperla%u%an laparos%opi pada tahun 1--/
melibat%an intususepsi ileoileal didiagnosa oleh enteroclysis usus %ecil dengan
penampilan burung paruh di ileum distal . )ntususepsi ber%urang laparos%opi dii%uti oleh
rese%si ileum segmental dan e;tracorporeal anastomosis.&* Perdarahan dan intususepsi
cenderung ter6adi lebih sering di bawah usia 1 , sedang%an obstru%si dan peradangan
lebih sering ter6adi pada adults./ , (,2 .
8eberhasilan pencitraan diagnosti% bervariasi dengan proses penya%it ini . Bilm polos
biasanya tida% spesifi% . 5%intigrafi radionu%lida a%an mendete%si ,* 0 dari %asus
$ec%el 6i%a mu%osa lambung e%topi% hadir dalam diverti%ulum tersebut . Enteroclysis
6uga dapat mendete%si persentase yang lebih %ecil dari diverti%ula , ber%isar hingga 2*
0 ./,( Abdominal 9T dapat menghasil%an ting%at tinggi diagnosis %eti%a obstru%si usus
%ecil hadir @ ,& 0 sampai <. 0 A , tetapi etiologi sebuah $ec%el sulit untu%
mengidentifi%asi sebagai . penyebab %arena %etida%mampuan untu% membeda%an antara
diverti%ulum loop bowel./ %ecil .
!alam sebuah penelitian retrospe%tif tahun 1--*, #eberruec% et al&. menganalisis
pentingnya diverti%ulum $ec%el dalam %asus didiagnosis sebagai usus buntu . !alam
periode 1. tahun , total se%itar &- --- usus buntu dila%u%an . #sus ini die%splorasi untu%
mencari diverti%ulum $ec%el pada se%itar ,- 0 dari %asus4%asus ini . 8ehadiran $ec%el
ditemu%an pada / 0 dari %asus4%asus ini , sementara < 0 dari diverti%ula ini ditemu%an
memili%i patologi , termasu% obstru%si , diverti%ulitis , perforasi , dan intususepsi .
Penelitian ini menyimpul%an dalam membangun pentingnya men6ela6ahi usus dalam
semua usus buntu cases.&. .
5etelah penghapusan rumit $ec%el , morbiditas pasca operasi telah dilapor%an men6adi
&1 0 sedang%an %ematian adalah 1 0 . !alam %ebetulan dihapus diverti%ula , harga 1 0
dan & 0 , respectively.& , (,&(,&2 $es%ipun %ontroversial , banya% ahli bedah
mere%omendasi%an menghapus %ebetulan menemu%an $ec%el berdasar%an ting%at
%ompli%asi pasca operasi yang rendah . Ang%a ini ditemu%an dalam sebuah studi definitif
di $ayo 9linic pada tahun &<<( , yang mendu%ung peran diverticulectomy profila%sis .
?isi%o %ompli%asi diverti%ula $ec%el tetap %onstan selama semua %elompo% umur
sebesar .,( 0 , sedang%an ting%at morbiditas dan mortalitas pasca operasi 6auh lebih
menguntung%an dalam asimtomati% , diverticulectomies insidental @ Tabel & A .(,&(,&2 .
)ntestinal obstructionCeditD
5ymptomsE Fomiting, abdominal pain and severe or complete constipation.C11D
The vitelline vessels remnant that connects the diverticulum to the umbilicus may form a
fibrous or twisting band @volvulusA, trapping the small intestine and causing obstruction.
Localised periumbilical pain may be e;perienced in the right lower >uadrant @li%e
appendicitisA.C*D
")ncarceration"E when a $ec%elGs diverticulum is constricted in an inguinal hernia,
forming a LittrH hernia that obstructs the intestine.C1/D
9hronic diverticulitis causing stricture
5trangulation of the diverticulum in the obturator foramen.
Tumors e.g. carcinomaE direct spread of an adenocarcinoma arising in the diverticulum
may lead to obstruction
Lithiasis, stones that are formed in $ec%el's diverticulum canE
E;trude into the terminal ileum, leading to obstruction
)nduce local inflammation and intussusception.C*D
The diverticulum itself or tumour within it may cause intussusception. Bor e;ample, from
the ileum to the colon, causing obstruction. 5ymptoms of this include "currant 6elly"
stools and a palpable lump in the lower abdomen.C&*D This occurs when the diverticulum
inverts into the lumen of the ileum, due to eitherE
An active peristaltic mechanism of the diverticulum that attempts to remove irritating
factors
A passive process such as the transit of foodC&2D
9omplications of $ec%el's diverticula in adults
9omplications of $ec%el's diverticula in adults
Complications of Meckel's diverticula in adults
httpEIIwww.ncbi.nlm.nih.govIpmcIarticlesIP$9/1-2*,2I
9omplications of $ec%el's diverticula in adults
+aymi !umper, 5hawn $ac%en=ie, Philip $itchell, Brancis 5utherland, $ay Lynn Juan,
and !aphne $ew
$ec%el's diverticulum is a normal anatomic variant found in 10 of the population. )t is a
remnant of the vitelline duct, which is usually located on the antimesenteric border of the
ileum, within about .- cm of the terminal ileum. As a congenital variant, $ec%el's
diverticula are often found in children and less commonly present in the adult population.
The anatomic variant was initially identified by Babricus "ildanus in &*<,K however,
+ohann $ec%el was the first to publish a detailed description of this not uncommon
finding.&
Brom an embryological standpoint, a $ec%el's diverticulum originates when the vitelline
@or omphalomesentericA duct, which normally connects the primitive gut to the yol% sac,
fails to obliterate around the seventh or eighth wee% of gestation. This leads to several
possible anomalies, including an omphalomesenteric fistula, an enterocyst, a fibrous band
connecting the intestine to the umbilicus or a $ec%el's diverticulum with or without a
fibrous cord connecting to the umbilicus.1'(
Anatomically, the $ec%el's diverticulum is a true diverticulum containing all layers of the
small intestine, arising from the anti4mesenteric border of the ileum and receiving its
blood supply from a remnant of the vitelline artery, which emanates from the superior
mesenteric artery. A commonly >uoted Lrule of 1sM also appliesE @&A 10 of the population
have the anomaly, @1A it is appro;imately 1 inches in length, @/A it is usually found within
1 feet of the ileocecal valve, @(A it is often found in children under 1 years of age and @*A
it affects males twice as often as females.1'. Although these are good general guidelines,
they are not based on accurate data. )n an autopsy series, -.&(0'(.*0 of cadavers
contained a $ec%el's diverticulum.2'&& The average length of a $ec%el's diverticulum is
/ cm, with <-0 ranging between & cm and &- cm and the longest recorded being &--
cm.&&'&( The mean distance from the ileocecal valve seems to vary with age, as
Namaguchi and colleagues&( showed in their study of .-- patients, with an average
distance of /( cm for children under 1 years of age. )n people aged /'1& years, the
average distance of the $ec%el's diverticulum from the ileocecal valve is (. cm and for
adults is .2 cm. The $ec%el's diverticulum has actually been found to occur e>ually in
both se;es,.,&*'&, but it causes complications more fre>uently in males.&&,&*,&< A
good, up4to4date review of the history, embryology, anatomy, complications and
treatment of $ec%el's diverticulum can be found at
httpEIIwww.emedicine.comImedItopic12<2.htm, by 8uwa6erwala and colleagues.1
"ere we provide an illustrative presentation, outlining the common complications of
$ec%el's diverticulum in adults. 3e saw 1 of these cases within a 14wee% period and 1
additional cases in the preceding / years.
!iverti%ulum $ec%el adalah varian anatomi yang normal ditemu%an dalam 1 0 dari
populasi . )ni adalah sisa dari saluran vitelline , yang biasanya terleta% di perbatasan
antimesenteri% ileum , dalam wa%tu se%itar .- cm dari ileum terminal . 5ebagai varian
bawaan , diverti%ula $ec%el sering ditemu%an pada ana%4ana% dan 6arang hadir dalam
populasi orang dewasa . Farian anatomi awalnya diidentifi%asi oleh Babricus "ildanus
pada &*<, , namun , +ohann $ec%el adalah orang pertama yang mempubli%asi%an
pen6elasan rinci tentang finding.& tida% 6arang ini
!ari sudut pandang embriologi , diverti%ulum $ec%el berasal %eti%a vitelline @ atau
omphalomesenteric A saluran , yang biasanya menghubung%an usus primitif %e %antung
%uning telur , gagal untu% melenyap%an se%itar minggu %etu6uh atau %edelapan %ehamilan
. "al ini menyebab%an beberapa anomali mung%in, termasu% fistula omphalomesenteric ,
sebuah enterocyst , band i%at yang menghubung%an usus %e umbili%us atau diverti%ulum
$ec%el dengan atau tanpa %abel berserat menghubung%an %e umbilicus.1 4 (
5ecara anatomis , diverticulum yang $ec%el diverticulum adalah benar berisi semua
lapisan dari usus %ecil , yang timbul dari perbatasan anti 4 mesenteri%a ileum dan
menerima suplai darah dari sisa dari arteri vitelline , yang berasal dari arteri mesenteri%a
superior . A sering di%utip " rule of 1s " 6uga berla%u E @ & A 1 0 dari populasi memili%i
anomali , @ 1 A itu adalah se%itar 1 inci pan6ang , @ / A biasanya ditemu%an dalam 1 %a%i
dari %atup ileocecal , @ ( A sering ditemu%an pada ana% di bawah usia 1 tahun dan @ * A itu
mempengaruhi la%i4la%i dua %ali lebih sering females.1 4 . $es%ipun ini adalah pedoman
umum yang bai% , mere%a tida% didasar%an pada data yang a%urat . !alam seri otopsi ,
-,&( 0 4(.* 0 dari mayat berisi $ec%el diverticulum.2 4 && ?ata4rata lama diverti%ulum
$ec%el adalah / cm , dengan <- 0 ber%isar antara & cm dan &- cm dan terpan6ang yang
tercatat men6adi &-- cm.&& 4&( $ean 6ara% dari %atup ileocecal tampa%nya bervariasi
dengan usia , seperti Namaguchi dan colleagues&( menun6u%%an dalam penelitian mere%a
dari .-- pasien , dengan 6ara% rata4rata /( cm untu% ana% di bawah usia 1 tahun . Pada
orang berusia /41& tahun , rata4rata 6ara% diverti%ulum $ec%el yang dari %atup ileocecal
adalah (. cm dan untu% orang dewasa adalah .2 cm . !iverti%ulum $ec%el The
sebenarnya telah ditemu%an ter6adi sama pada %edua 6enis %elamin ,.,&* 4 &, tetapi hal itu
menyebab%an %ompli%asi lebih sering pada males.&& , &*,&< A yang bai% , review up4to
4date dari se6arah , embriologi , anatomi , %ompli%asi dan pengobatan diverti%ulum
$ec%el dapat ditemu%an di httpEIIwww.emedicine.comImedItopic12<2.htm , oleh
8uwa6erwala dan colleagues.1
7eri%ut %ami beri%an presentasi ilustratif , mengurai%an %ompli%asi umum dari
diverti%ulum $ec%el pada orang dewasa . 8ami melihat 1 %asus ini dalam 6ang%a wa%tu
1 minggu dan 1 %asus tambahan di sebelumnya / tahun .