Single-incision laparoscopic appendectomy for treating appendicitis in a patient with gastrointestinal malrotation

INTRODUCTION

Intestinal malrotation is a rare congenital anomaly, and acute appendicitis associated with intestinal malrotation is extremely rare.PRESENTATION OF CASE We report a rare case of a 47-year-old Japanese woman diagnosed with barium-related perforated appendicitis associated with intestinal malrotation. We used a transumbilical single-incision laparoscopic approach to resect the appendix, and the procedure was completed successfully without perioperative complications.

DISCUSSION

To our knowledge, single-incision laparoscopic surgery for appendicitis associated with intestinal malrotation has not been reported yet. In cases with mobile cecum such as this one, mobilization from inflammatory adhesion of the surrounding structures is easy.

CONCLUSION

We conclude that transumbilical single-incision laparoscopic appendectomy is a simple and less invasive method for treating appendicitis associated with intestinal malrotation.     

Repair of Bochdalek hernia in an adult complicated by abdominal compartment syndrome,gastropleural fistula and pleural empyema: Report of a case

INTRODUCTION

Bochdalek''s diaphragmatic hernia (BDH) rarely developed symptomatic in adulthood but mostly required an operation. In adult BDH cases, long-term residing of the massive intraabdominal organs in the thoracic cavity passively causes loss of domain for abdominal organs (LOD).

PRESENTATION OF CASE

A 63-year-old man presented at our institution complaining of sudden left upper quadrant abdominal pain. Chest radiography showed a hyperdense lesion containing bowel gas in the left pleural space. Computed tomography revealed a dilated bowel above the diaphragm and intestinal obstruction suggestive of gangrenous changes. These findings were consistent with the diagnosis of incarcerated BDH and an emergency laparotomy was performed. Operative findings revealed the hypoplastic lung, lack of hernia sac, and location of the diaphragmatic defect, which indicated that his hernia was true congenital. Organs were reduced into the abdominal cavity, and large defect of the diaphragm was repaired with combination of direct vascular closure and intraperitoneal onlay mesh reinforcement using with expanded polytetrafluoroethylene (ePTFE) mesh. On the postoperative day 1, the patient fell into the shock and was diagnosed to have abdominal compartment syndrome (ACS). Conservative therapies were administered, but resulted in gastropleural fistula and pleural empyema, which required an emergency surgery. Mesh extraction and fistulectomy were performed.

DISCUSSION

A PubMed search for the case of ACS after repair of the adult BDH revealed only three cases, making this very rare condition.

CONCLUSION

In dealing with adult BDH, possible post-repair ACS should be considered.     

A De Garengeot Hernia masquerading as a strangulated femoral hernia

INTRODUCTION

De Garengeot hernia is a rare occurrence whereby an appendix is found in a femoral hernia sac. It is rarer still to find an acutely inflamed appendix manifesting itself as a strangulated femoral hernia. This case is important to report as it highlights the diagnostic difficulty this particular condition presents to an emergency surgeon.

PRESENTATION OF CASE

We report the case of an 86 year old female who was found to have a De Garengeot hernia containing a necrotic appendix. A retrograde appendicectomy was performed to prevent peritoneal contamination. The hernia defect was repaired using a standard repair with non-absorbable suture.

DISCUSSION

De Garengeot''s hernia is a rare occurrence, is often unexpected and tends to be diagnosed intra-operatively. Pre-operative diagnosis remains difficult and it will often masquerade as a strangulated femoral hernia. In stable patients, where there is a diagnostic uncertainty CT scanning is a useful adjunct and may allow a laparoscopic approach to be undertaken in the absence of appendicitis.

CONCLUSION

A De Garengeot''s hernia should be considered as a differential diagnosis in patients presenting with clinical signs of a strangulated femoral hernia. It is often an incidental finding during an emergency operation. Although mesh repairs in the presence of appendicitis have been reported, the safest approach remains a primary suture repair.     

Meckel's diverticulum with small bowel obstruction presenting as appendicitis in a pediatric patient

Background:

Meckel''s diverticulum is a congenital anomaly resulting from incomplete obliteration of the omphalomesenteric duct. The incidence ranges from 0.3% to 2.5% with most patients being asymptomatic. In some cases, complications involving a Meckel''s diverticulum may mimic other disease processes and obscure the clinical picture.

Methods:

This case presents an 8-year-old male with abdominal pain, nausea, and vomiting and an examination resembling appendicitis.

Results:

A CT scan revealed findings consistent with appendicitis with dilated loops of small bowel. During laparoscopic appendectomy, the appendix appeared unimpressive, and an inflamed Meckel''s diverticulum was found with an adhesive band creating an internal hernia with small bowel obstruction. The diverticulum was resected after the appendix was removed.

Conclusion:

The incidence of an internal hernia with a Meckel''s diverticulum is rare. A diseased Meckel''s diverticulum can be overlooked in many cases, especially in those resembling appendicitis. It is recommended that the small bowel be assessed in all appendectomy cases for a pathological Meckel''s diverticulum.     

Symptomatic Bochdalek Hernia in an Adult

Background and Objectives:

Bochdalek hernias are congenital diaphragmatic defects resulting from the failure of posterolateral diaphragmatic foramina to fuse in utero. Symptomatic Bochdalek hernias in adults are infrequent and may lead to gastrointestinal dysfunction or severe pulmonary disease. We describe our experience with this rare entity.

Methods:

A retrospective chart review was performed on a single patient for data collection purposes.

Results:

The patient is a morbidly obese 53-year-old female who presented with epigastric pain and diffuse abdominal tenderness. Computed tomography scans of the chest and abdomen revealed a small posterior diaphragmatic defect containing gastric fundal diverticulum. Laboratory work and imaging revealed no other findings. Laparoscopic repair of the Bochdalek hernia was done via an abdominal approach and utilized primary closure with an AlloDerm patch apposed to the defect. The patient has had significant clinical improvement and continues to do well at 9 months postoperatively.

Conclusion:

Laparoscopic repair of symptomatic adult Bochdalek hernias can be performed successfully and may result in significant clinical improvement.     

De Garengeot Hernia

Background and Objectives:

We report a case of appendicitis presenting in an incarcerated femoral hernia, otherwise known as de Garengeot hernia. This rare hernia usually presents with both diagnostic and therapeutic dilemmas. We wish to underline the usefulness of laparoscopy in both the diagnosis and treatment of de Garengeot hernias.

Methods:

A diagnostic laparoscopy was performed initially. The appendix was seen to disappear into the hernia sac. A laparoscopic appendectomy was then performed prior to open exploration of the groin.

Results:

We were able to obtain a correct diagnosis and perform an appendectomy prior to making a groin incision. Operative findings included an incarcerated, inflamed appendix within a femoral hernia.

Conclusions:

Diagnostic laparoscopy could be a valuable tool in the correct diagnosis and management of unusual presentations of incarcerated groin hernias.     

Symptomatic Right-Sided Diaphragmatic Hernia in the Third Trimester of Pregnancy

Background:

Laparoscopic repair of incarcerated diaphragmatic hernias is widely recognized as both safe and effective. However, symptomatic diaphragmatic hernias encountered in the setting of pregnancy, while rare, present a significant surgical challenge. Furthermore, right-sided diaphragmatic hernias account for only 13% of cases. Here, we present a case in which a symptomatic, posterior right-sided diaphragmatic hernia, presenting in the later stages of pregnancy, was successfully repaired using a laparoscopic approach.

Methods:

Our patient is a 42-y-old gravid woman who, at 27 wk gestation, was admitted to the gynecology service with a 2-d history of right upper quadrant abdominal pain, right shoulder pain, abdominal distension, and obstipation.

Results:

Computed tomography of the chest demonstrated an incarcerated right diaphragmatic hernia. Surgical consultation was obtained, and the patient was taken to the operating room urgently for repair. Intraoperatively, the cecum was reduced and the diaphragm repaired primarily using a laparoscopic approach. The patient recovered well and was discharged home on postoperative day 8 with no complications to the patient or the pregnancy.

Conclusion:

Laparoscopic reduction and repair of symptomatic incarcerated diaphragmatic hernia can be safely performed in the third trimester of pregnancy.     

Chilaiditi's syndrome associated with colonic volvulus and intestinal malrotation—A rare case

INTRODUCTION

Chilaiditi''s syndrome (symptomatic hepatodiaphragmatic interposition of the colon) is an exceptionally rare cause of bowel obstruction and may present difficulty in diagnosis and management. This is the first reported case of colonic volvulus occurring in Chilaiditi''s syndrome in association with intestinal malrotation and this case study describes its successful management.

PRESENTATION OF CASE

An 18 year old male presented as an emergency with vague abdominal pain and a past history of gastroschisis repair with intestinal malrotation. CT scanning showed a closed loop obstruction due to a volvulus of the colon herniating under the falciform ligament. The patient was successfully treated by surgical reduction of the hernia, anatomical correction of the malrotation and caecopexy with a tube caecostomy. At six month follow up the patient was well and asymptomatic.

DISCUSSION

In nine of the previously reported cases of Chilaiditi''s syndrome with colonic volvulus, treatment was by partial colonic resection of which a third underwent stoma formation. One patient died as a consequence of anastomotic leak following primary anastomosis. We therefore suggest an alternative approach to management.

CONCLUSION

Chilaiditi''s syndrome with colonic volvulus in association with intestinal malrotation has not previously been described. As there is no consensus in the literature as to how to manage such a case we suggest that reduction of the volvulus, anatomical correction of the malrotation and fixation of the caecum by tube caecostomy results in a successful outcome. This approach avoids the need for colonic resection and possible stoma formation.     

Laparoscopic appendectomy for torsed appendix presenting as an acute abdomen in an infant female

Background:

Torsion of an otherwise normal appendix vermiformis is exceedingly rare and usually presents with symptoms consistent with acute appendicitis. We present the unusual case of an infant girl who was admitted with right lower quadrant pain and focal peritonitis who was found to have appendiceal torsion on laparoscopy.

Case Report:

An 11-week-old girl was brought to the emergency department with a 48-hour history of abdominal pain, emesis, low-grade fever, and focal right lower quadrant tenderness. Sonography found a noncompressible distended appendix in the right lower quadrant. Upon laparoscopy, a torsed, necrotic appendix vermiformis was found. Appendectomy was performed, and the patient recovered uneventfully.

Conclusion:

In an infant girl with lower abdominal pain, the differential diagnosis should include torsed appendix besides more common causes, such as torsed ovary, intussusception, or small bowel volvulus. Ultrasound is useful for planning the operative approach.     

Epigastirc hernia presenting as a giant abdominal interparietal hernia

INTRODUCTION

Epigastric hernia is a rare form of ventral abdominal hernia. When neglected it can attain an impressive size causing it un-aesthetic effect in addition to diagnostic difficulties.

PRESENTATION OF CASE

Presented is a 60-year-old female farmer with a 10-year history of a voluminous mass in the anterior abdominal wall.

DISCUSSION

Surgery revealed an epigastric hernia presenting as an interparietal hernia. The hernia was an omentocele with a grossly distended hernia sac filled with about 2.5 l of serous fluid. No similar case has been found in the medical literature.

CONCLUSION

Epigastric hernia can attain voluminous dimensions and present as a non-inguinal interparietal hernia.     

Swelling of the right thigh for over 30 years—The rare finding of a De Garengeot hernia

INTRODUCTION

Femoral hernias may – in some rare cases – contain the appendix, a phenomenon called de Garengeot hernia. It is usually an incidental finding in hernia repair. We found our case to be of interest because of the long standing femoral swelling before peracute appendicitis led to its removal.

PRESENTATION OF CASE

We present the case of a 71-year-old woman with a swelling of the right medial thigh for over more than 30 years. When the swelling suddenly grew in size and became tender, she was referred to our emergency department. Sonographically as well as clinically a femoral hernia was diagnosed. Intraoperatively, the appendix was found and open appendectomy as well as a hernioplasty was performed.

DISCUSSION

Open appendectomy is an elegant and safe procedure to repair a long standing de Garengeot hernia. Most case reports call for extensive diagnostics such as CT scan etc. We found a sonography of the femoral region to be conclusive.

CONCLUSION

Apart from the inherent risk of sudden incarceration in hernias, De Garengeot hernias can also develop peracute appendicitis years after their formation. This differential diagnosis needs to be taken into consideration in patients presenting with the clinical signs of a femoral hernia.     

Petersen's space hernia: A rare but expanding diagnosis

Background

Petersen''s space hernia is caused by the herniation of intestinal loops through the defect between the small bowel limbs, the transverse mesocolon and the retroperitoneum, after any type of gastrojejunostomy. The laparoscopic approach facilitates the occurrence of this type of hernia, due to the lack of post-operative adhesions which prevent bowel motility and hence, herniation.

Case report

We report the case of a 46 year-old male submitted to an open antrectomy and vagotomy with a Roux-en-Y reconstruction six-years before, for the treatment of bleeding gastric ulcer.He presented with epigastric abdominal pain radiating to the back and alimentary vomiting with a 3 days evolution, with an episode of hematemesis 2 h before admission. His abdomen was bloated and tender at the epigastric region. The laboratory exams revealed mild leucocytosis and CRP elevation with normal pancreatic tests. The abdominal CT scan revealed an intestinal occlusion. An exploratory laparotomy was performed, disclosing an incarcerated Petersen space hernia of the common limb, with obstruction and dilatation of the biliary limb.

Conclusion

The knowledge of this anatomic post-operative defect and a low threshold for diagnosis are crucial to its management, since its nonspecific clinical and laboratory findings. Early operative intervention is warranted in order to avoid the severe complications of bowel necrosis.     

Systematic review of blunt abdominal trauma as a cause of acute appendicitis

INTRODUCTION

Acute appendicitis commonly presents as an acute abdomen. Cases of acute appendicitis caused by blunt abdominal trauma are rare. We present a systematic review of appendicitis following blunt abdominal trauma. The aim of this review was to collate and report the clinical presentations and experience of such cases.

SUBJECTS AND METHODS

A literature review was performed using PubMed, Embase and Medline and the keywords ‘appendicitis’, ‘abdominal’ and ‘trauma’.

RESULTS

The initial search returned 381 papers, of which 17 articles were included. We found 28 cases of acute appendicitis secondary to blunt abdominal trauma reported in the literature between 1991 and 2009. Mechanisms of injury included road-traffic accidents, falls, assaults and accidents. Presenting symptoms invariably included abdominal pain, but also nausea, vomiting and anorexia. Only 12 patients had computed tomography scans and 10 patients had ultrasonography. All reported treatment was surgical and positive for appendicitis.

CONCLUSIONS

Although rare, the diagnosis of acute appendicitis must be considered following direct abdominal trauma especially if the patient complains of abdominal right lower quadrant pain, nausea and anorexia. Haemodynamically stable patients who present shortly after blunt abdominal trauma with right lower quadrant pain and tenderness should undergo urgent imaging with a plan to proceed to appendicectomy if the imaging suggested an inflammatory process within the right iliac fossa.     

Laparoscopic Repair of a Posttraumatic Left-Sided Diaphragmatic Hernia Complicated by Strangulation and Colon Obstruction

Background:

Posttraumatic diaphragmatic hernias (PDH) are serious complications of blunt and penetrating abdominal or thoracic trauma. Traditional thoracic or abdominal operations are usually performed in these cases.

Methods:

We present 2 cases of posttraumatic left-sided diaphragmatic hernia complicated by strangulation and colon obstruction. Both cases were successfully treated with laparoscopy.

Results:

We found that laparoscopy is a safe, successful, and gentle procedure not only for diagnosis but also for treatment of complicated PDH. Strangulation and colon obstruction were not contraindications to performing laparoscopic procedures. The postoperative course and long-term follow-up (range, 12 to 30 months) were uneventful and short. We expect the same good long-term results after laparoscopic repair as after open conventional surgery.

Conclusion:

We recommend the use a minimally invasive approach to treat posttraumatic diaphragmatic hernia complicated by strangulation and colon obstruction in hemodynamically stable patients.     

White Cell Count and C-Reactive Protein Measurement in Patients with Possible Appendicitis

INTRODUCTION

Clinical assessment outweighs the use of investigations in the diagnosis of acute appendicitis. Nevertheless, white cell count (WCC) and C-reactive protein (CRP) are regularly measured in patients with suspected appendicitis. The aim of this study was to assess the utility of these markers in patients presenting with acute lower abdominal pain.

PATIENTS AND METHODS

WCC and CRP were measured prospectively in 98 patients presenting with lower abdominal pain, and the results were correlated with each patient''s outcome.

RESULTS

No patients with WCC and CRP both in the normal range had acute appendicitis. Raised WCC and CRP were poor positive predictors of appendicitis, both alone and in combination, and correlated poorly with the development of complications.

CONCLUSIONS

This result may have important clinical and economic implications. We suggest that patients experiencing lower abdominal pain, with normal WCC and CRP values, are unlikely to have acute appendicitis and can be safely sent home.     

Small bowel volvulus with no malrotation after laparoscopic appendicectomy: Case report and literature review

INTRODUCTION

Small bowel volvulus, as a complication of laparoscopic surgery, is a rarely reported clinical entity. We present a case of a young female who developed small intestinal volvulus after laparoscopic appendicectomy. She had this complication in the absence of malrotation or other previous abdominal operations.

PRESENTATION OF CASE

A 17-year-old woman presented with acute appendicitis. After an uneventful laparoscopic appendicectomy, she developed acute small intestinal obstruction on the second post-operative day. A prompt laparotomy showed small bowel volvulus, which was reduced, with no evidence of malrotation. She had an uneventful recovery and was discharged within 3 days of the second operation, in a stable condition.

DISCUSSION

This article presents a review of the literature of this rare cause of small intestinal obstruction after laparoscopic surgery, stressing on the importance of early diagnosis and treatment. A discussion of the potential factors predisposing to this entity is presented, emphasising the need of a higher-evidence study as to its aetiology and prevalence.

CONCLUSION

Small bowel volvulus is a rare complication of laparoscopic surgery, but its early diagnosis and prompt treatment is essential to avoid morbid outcomes. Surgery is the therapeutic mainstay.     

Incarcerated spontaneous transdiaphragmatic intercostal hernia

Introduction

Prolapse of abdominal viscera into the thoracic subcutis through the chest wall is known as transdiaphragmatic intercostal hernia (TIH). Herein, we present the first case of spontaneous TIH presenting as a thoracoabdominal emergency.

Presentation of case

A 78-year-old male presented with acute left thoracoabdominal pain following a sudden bulge at the left posterolateral chest wall corresponding to a partially reducible soft tissue mass with ecchymosis at the overlying skin. Paroxysmal cough during the last four days was also reported along with a prolonged daily application of a special tight abdominal belt that used while milking sheep. CT-scan of the abdomen showed intrathoracic proptosis of the splenic flexure through a defect of the left hemidiaphragm and subcutaneous prolapse of the herniated colon through the 7th intercostal space. On laparotomy, the herniated colon showed signs of ischemic necrosis leading to segmental colectomy followed by repair of the diaphragmatic defect.

Discussion

The clinical diagnosis of spontaneous TIH demands very high index of suspicion and thorough patient''s history. In this case the daily elevation of the intraabdominal pressure due to an abdominal milking belt might have caused gradual slimming and loosening of the diaphragm and the intercostals muscles rendering them vulnerable to sudden increases of the thoracoabdominal pressure due to violent coughing. Such a hypothesis is reasonable in the absence of traumatic injury in this patient.

Conclusion

Spontaneous TIH should be suspected in patients presenting with a sudden palpable chest wall bulge and associated thoracoabdominal symptoms in the absence of preceding injury.     

Vanek's tumour mimicking an acute appendicitis

Introduction

Vanek''s tumour or Inflammatory Fibroid Polyp (IFP) are rare, benign localised lesions originating from the sub-mucosa of the gastrointestinal tract (GI) tract.¹ They have been widely reported as occurring within the stomach, Duodenum, Jejunum and Ileum, more rarely (<1%) in the caecum or appendix.

Presentation of case

We present a case of a 28-year-old lady who presented with a 2-day history of right iliac fossa pain, nausea and low-grade fever. Subsequent, ultrasonography (USS) of the abdomen demonstrated an inflamed tubular structure originating from caecum with fluid in the pelvis mimicking an acute appendicitis. Next to normal appendix an inflammatory polypoid mass was identified and on histological examination confirmed to be an IFP (Vanek''s tumour).

Discussion

Right Iliac Fossa (RIF) pain with suspected appendicitis is one of the most common presentations in any acute surgical unit. In young women of childbearing age, the differential diagnosis can be varied and vast. The surgical management of IFP (Vanek''s tumour) in such cases ranges from limited resection and caecectomy to limited right hemicolectomy.

Conclusion

To date, the exact histiogenesis of these tumours remains unclear and requires a high level of intra-operative suspicion. According to our search such presentation is not reported.     

Nematode infection: A rare mimic of acute appendicitis

INTRODUCTION

Acute appendicitis is a common condition seen in all surgical units. One rare condition that can mimic acute appendicitis is a nematode infection of the bowel. There have been few reported cases of nematode infection within the appendix and none that have been accompanied by intra-operative pictures.

PRESENTATION OF CASE

A 16-year-old female presented with a 12 h history of right iliac fossa pain and mild pyrexia. Bloods showed a neutrophilia and normal C-reactive protein. Laparoscopy was performed which revealed a non-inflamed appendix. The appendix was dissected and a live nematode was visualised exiting the base of the appendix. Anti-helminthics were given and the infection resolved.

DISCUSSION

Nematode infection is most commonly seen in Africa, Asia and South America. When seen within the United Kingdom (UK), it is seen most commonly within high-risk populations. Testing for these infections is not routine within the UK and when they are performed, the results take a considerable amount of time to return. These tests should be considered within high-risk populations so that unnecessary surgery can be avoided.

CONCLUSION

This case highlights the importance of considering rare causes of right iliac fossa pain including nematode infection in a young patient. The case highlights this by giving intra-operative pictures of live nematodes upon dissection of the appendix.