LAUSR

A 24-year-old man presented to the casualty with typical presentation of acute appenditis. On examination, there were generalized tenderness in the abdomen with guarding and rebound tenderness at right iliac fossa. The total white blood count was 17.2 × 10 μL with normal electrolytes levels. At that juncture, his surgical diagnosis was acute appendicitis and the decision for open appendicectomy was decided. Upon entry through a Lanz incision, there was a large gangrenous diverticulum measuring 20 × 5 cm identified (Figs 1,2). A wedge resection was done and primary closure was made. The normal appendix was resected to avoid confusion in the future. The abdomen was closed in layers. Postoperatively, the patient was recovered uneventfully and discharged home after 2 days. Histopathological examination was consistent with Meckel’s diverticulitis without presence of gastric heterotopia. Meckel’s diverticulum (MD) is a true diverticulum, develops after persistent vitellointestinal duct during embryonic life. It is well-known after the traditional ‘rule of 2s’. Commonly found in 2% of the population, it often presents before the age of 2, twice as likely to be symptomatic in boys compared to girls. The incidence is increasing up-to-date due to enhanced imaging modalities and widely used minimally invasive surgery. It is situated approximately 2 ft from the ileocaecal valve measuring 2 cm wide with 2 in. long. This rule however is frequently imprecise since certain literatures have described cases of giant MD. A diverticulum measuring more than 5 cm is considered as giant MD. Majority of MD usually are 1 to 10 cm in size with average of 3 cm. In our patient, we have discovered a gangrenous Meckel’s diverticulitis measuring 20 cm at longest axis during surgery (Fig. 2). As far as we concern, this case is among the longest and biggest ever reported case of MD in the literatures. The diagnosis of MD is always dubious as mostly asymptomatic. However, it is often discovered after investigation of obscure gastrointestinal bleeding, accidental findings of acute abdomen and during release of intestinal obstruction that puzzle the initial clinic presentations. According to Yamaguchi et al., in a series of 600 candidates looking at the aetiology of MD, 37% were due to obstruction, 10%–14% were after diverticulitis, perforation and bleeding while remaining were due to fistula and neoplasm. Among those who present with intestinal obstruction, they are mostly caused by intussusception. Usually, traditional intussusception happens after telescoping of thickened Peyer’s patches of the ileum. In contrast to intussusception secondary to MD, the diverticulum itself acts as an intussusceptum. Typical presentations include a colicky abdominal pain and vomiting, which then followed by a production of red currant jelly stool in severe form. This event happens in childhood most of the time but less in adulthood. Apart from intussusception, presence of mesodiverticular band can cause internal herniation which lead to intestinal obstruction. Patients may present with acute abdomen which include a migratory abdominal pain associated with low grade fever, nausea and anorexia. The pain is characterized by a periumbilical pain that shifts to the right iliac fossa. Since its nature as a diverticulum, it has a predilection to be inspissated by faeces and become inflamed which mimics acute appendicitis. It also has tendency for