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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

APPENDICEAL MUCOCELE DIAGNOSED BY 3D-CT ANGIOGRAPHY


J Okuda, MD, PhD; SW Lee, MD; N Nishiguchi, MD, PhD; M Toyoda, MD, PhD; N Tanigawa, MD, PhD, Department of General and Gastroenterological Surgery, Osaka Medical College, Osaka, Japan

1. Summary


A mucocele of the appendix is uncommon and accurate diagnosis is rare preoperatively. Accurate pathological diagnosis is important because an appendiceal mucocele mandates a totally atraumatic resection to prevent rupture and potential development of pseudomyxoma peritonei. Recently, we experienced a case of an appendiceal mucocele accurately diagnosed by 3D-CT.

2. Keywords


Emergency, appendix, peritonitis, laparoscopy, mucocele

3. Patient


Female, 35-year-old

4. Past medical history


Right ovarian cyst

5. History of present illness


The patient was being evaluated for a presumed right ovarian cyst when a high level of carcinoembryonic antigen was noted. For this reason, a barium enema was performed which revealed a submucosal lesion in the cecum. The patient was subsequently transferred to our department for further evaluation and treatment

6. Barium enema


The barium enema showed a large, smooth filling defect in the cecum. The appendix was not revealed.

7. Colonoscopy


Colonoscopy demonstrated a protuberant submucosal mass at the base of the cecum. It was soft and covered with normal mucosa.

8. Endoscopic ultrasonography


Endoscopic ultrasonography demonstrated a heterogeneous hypo-echoic mass.

9. CT scan


A CT scan of the abdomen showed a 10×5 cm cystic lesion located in the right lower abdomen and impinging on the cecum.

10. 3D-CT angiography


3D-CT angiography showed that the ileocolic artery provided blood supply to the appendiceal tumor.

11. Clinical progress


As a result, the tumor had been preoperatively diagnosed as an appendiceal mucocele.

12. Operation


Exploration was performed by laparoscopy: the appendix was swollen, its serosa looked smooth, its capillaries were slightly dilated and there were no adhesions to surrounding organs. The peritoneum was normal. At first, the right mesocolon was medially excised, followed by the division of the ileocolic artery and vein. Finally the ileocecal region was mobilized including the appendiceal tumor. Laparoscopic ileocecal resection was performed using the "no-touch isolation technique", paying careful attention to avoid direct manipulation of the mucocele. The operation was completed without any injury or rupture of the appendiceal mucocele.
The postoperative course was uneventful, and the patient was discharged 10 days after the operation.

13. Pathology


The appendix was extremely dilated and contained abundant mucin. It consisted of a cystic mass with semi-transparent yellowish mucus and fibrous thickening of the wall. The final pathological diagnosis was mucinous cystadenoma.

14. Discussion


A mucocele is a cystic dilatation of the vermiform appendix that contains mucous material. It may be caused by benign or malignant diseases. An appendiceal mucocele is a rare entity with a nonspecific preoperative presentation. It occurs in only 0.4% of all tumors of the appendix and is diagnosed intraoperatively in a majority of cases. Although their radiological-morphological pattern varies, a correct preoperative diagnosis is possible in most cases by using imaging methods and taking the pattern of clinical findings into consideration. An appendectomy is an adequate treatment for benign disease. If malignant disease is demonstrated, a right hemicolectomy should be performed.
We experienced a case of an appendiceal mucocele accurately diagnosed by 3D-CT. This case demonstrates the utility and safety of laparoscopy in the treatment of appendiceal mucoceles. Ileocecal resection using proper laparoscopic techniques could be viewed as less invasive, barring unexpected complications or unusual recurrences.

15. References


  1. Gonzalez Moreno S, Shmookler BM, Sugarbaker PH. Appendiceal mucocele. Contraindication to laparoscopic appendectomy. Surg Endosc 1998;12:1177-9.
  2. Isaacs KL, Warshauer DM. Mucocele of the appendix: computed tomographic, endoscopic, and pathologic correlation. Am J Gastroenterol 1992;87:787-9.
  3. Koga H, Aoyagi K, Honda H, Fujishima M. Appendiceal mucocele: sonographic and MR imaging findings. AJR Am J Roentgenol 1995;165:1552.
  4. Miraliakbari R, Chapman WH 3rd. Laparoscopic treatment of an appendiceal mucocele. J Laparoendosc Adv Surg Tech 1999;9:159-63.