Laparoscopic appendectomy When the unexpected unveils… Dr. Grace KY Hung Kwong Wah Hospital

Laparoscopic appendectomy

When the unexpected unveils…

Dr. Grace KY HungKwong Wah Hospital

Case scenario

• 60/M• Right lower quadrant pain and fever• Physical examination

– Stable vitals with temperature 38.5C

– Tenderness over right lower quadrant

Laparoscopic appendectomy offered…

Background

• Acute appendicitis– Lifetime risk ~ 7%1

– One of the most commonly encountered emergency surgical condition

– Peak incidence towards 30 years old

Background

• Pathology– Bacterial infection secondary to

blockage of the lumen– Could be due to faecolith, caecal

tumor, appendiceal tumor, enlargement of lymphoid aggregate, parasites

Background

• Clinical presentation– Typical presentation: fever, right

lower quadrant pain, leukocytosis

Scenarios

• Negative appendectomy• Appendiceal neoplasm (Intra-

operative/histopathological)

Negative appendectomy

• Negative appendectomy rate: – 15% - 25%2,3,4

• Female patient of reproductive age are at higher risk

Negative appendectomy• pic

Differential diagnosis• Gynecological problem• Colonic diverticulitis• Colitis, ileitis• Meckels diverticulitis• Inflammatory bowel disease• Neoplasm (colonic, appendiceal)• Perforated peptic ulcer• Acute cholecystitis• Mesenteric adenitis• Others

Can pre-operative imaging help to decrease negative appendectomy

rate?

Pre-operative CT scan

• Sensitivity 83-99%5

• Specificity 86-100%5

• Krajewski et al (Meta analysis)6

• NAR (CT): 8.7% NAR (no CT): 16.7%• Use of CT was associated with a delay in

time to surgery, yet the appendiceal perforation rates were unchanged

• Depends on– Availability– Expertise in interpretation

CT criteria for infalmmed appendix7

• Diameter greater than 6mm• Appendiceal wall thickness greater

than 1mm• Appendiceal gas• Periappendiceal fat stranding• Caecal arrow-head sign• Caecal bar sign

CT scan of patient with acute appendicitis

• Even with pre-operative CT scan the NAR is 8.7%

• Does pre-operative CT scan has a role?– Yes– Provides additional information for

planning subsequent management

Differential diagnosis• Gynecological problem• Colonic diverticulitis• Colitis, ileitis• Meckels diverticulitis• Inflammatory bowel disease• Neoplasm (colonic, appendiceal)• Perforated peptic ulcer• Acute cholecystitis• Mesenteric adenitis• Others

Differential diagnosis• Gynecological problem• Colonic diverticulitis• Colitis, ileitis• Meckels diverticulitis• Inflammatory bowel disease• Neoplasm (colonic, appendiceal)• Perforated peptic ulcer• Acute cholecystitis• Mesenteric adenitis• Others

• Periappendiceal abscess maybe drained percutaneously

Pre-operative USG

• Rander A et al8

• Mean sensitivity of USG: 78%• Diagnostic accuracy inferior to CT• Still plays a role in patients in whom

radiation exposure is a concern (e.g. pregnant patients)

Sonographic findings in USG

• Compressed diameter greater than 6mm

• Brightly echogenic periappendiceal fat• Periappendiceal fluid collection• Hypervascularity on color Doppler

Scenarios

• Negative appendectomy• Appendiceal neoplasm (Intra-

operative/histopathological)

Tumor recognized at

time of surgery

Tumor recognized at

time of surgery

Tumor <2cmTumor <2cm

Base and mesoappendix:

clear

Base and mesoappendix:

clear

Evidence of perforationEvidence of perforation

Evidence of mucinous ascites

Evidence of mucinous ascites

Right hemicolectomy

Right hemicolectomy

Appendectomy Appendectomy

Appendectomy or, if not possible, tissue biopsy,

cytology on mucusPeritoneal lavage

Analysis of tumor markers (CEA, CA-125, CA 19.9) and

CT abd + pelvisColonoscopy

Appendectomy or, if not possible, tissue biopsy,

cytology on mucusPeritoneal lavage

Analysis of tumor markers (CEA, CA-125, CA 19.9) and

CT abd + pelvisColonoscopy

YES

YES

YES

YES

YES

No

No

No

No

Appendiceal neoplasm

• Accounts for 1% of all GI malignancies9

• Usually present as acute appendicitis• Incidental finding at operation/ on

histopathological examination• Carcinoid tumors are most common10

Classification of appendiceal neoplasms9

Primary Secondary

EpithelialBenign

•Hyperplastic polyp and diffuse mucosal hyperplasia•Serrated adenoma•Colonic type adenoma

Malignant•Low-grade mucinous neoplasms•Adenocarcinoma/ High-grade mucinous neoplasms

Non-epithelialCarcinoid tumors

•Classical carcinoid•Globet cell carcinoids/adenocarcinoids

Mesenchymal tumors•Gastrointestinal stromal tumors•Neuroma•Leiomyoma/sarcoma•Kaposi’s sarcoma•Lymphoma

OvarianColonicMelanoma

Carcinoid tumors• Arise from neuroendocrine cells• Usually located at the tip or distal third of the

appendix• Adverse prognostic feature: size >2cm,

mesoappendiceal extension11

• Simple appendectomy for tumor less than 2cm and does not involve the resection margin or mesoappendix12

• Right hemicolectomy for tumor more than 2cm or when there is involvement of the base of the appendix or mesoappendix12

Malignant epithelial lesions• Range from low grade mucinous neoplasms to

adenocarcinomas• Prognosis depends on whether they have perforated

and whether mucin and epithelial cells are present outside the appendix13

• May spread to peritoneal cavity, giving rise to pseudomyxoma peritonei

• Treatment:– Not perforated tumor not involving the

mesoappendix/base: Appendectomy– Perforated tumor: complete cytoreduction with

intraperitoneal chemotherapy

Synchronous appendiceal and colonic neoplasm

• Associates with a significant incidence of both synchronous and metachronous colorectal neoplasms.14

• 10% of appendiceal carcinoid • 50% of appendiceal malignant

epithelial tumors • Screening and surveillance

colonoscopy should be advocated

Conclusion

• Laparoscopic appendectomy is one of the most commonly performed surgical procedure which carries a negative appendectomy rate of around 15%-25%

• Pre-operative CT scan could decrease the negative appendectomy rate and provide more information for better planning if available.

Conclusion

• Rarely, appendiceal neoplasms are found incidentally during operation/on histopathological examinations

• Tumor less than 2cm without involvement of the resection margin and mesoappendix can be treated by simple appendectomy

• Screening and surveillance colonoscopy should be performed for all patients with appendiceal neoplasm

Reference1. Korner, H., J. A. Soreide, E. J. Pedersen, T. Bru, K. Sondenaa, and L. Vatten. "Stability in

Incidence of Acute Appendicitis. A Population-Based Longitudinal Study." Dig Surg 18, no. 1 (2001): 61-6.

2. Flum, D. R., and T. Koepsell. "The Clinical and Economic Correlates of Misdiagnosed Appendicitis: Nationwide Analysis." Arch Surg 137, no. 7 (2002): 799-804; discussion 804.

3. Humes, D. J., and J. Simpson. "Acute Appendicitis." BMJ 333, no. 7567 (2006): 530-4.4. Humes, D. J., and J. Simpson. "Acute Appendicitis." BMJ 333, no. 7567 (2006): 530-4.5. Musunuru, S., H. Chen, L. F. Rikkers, and S. M. Weber. "Computed Tomography in the

Diagnosis of Acute Appendicitis: Definitive or Detrimental?" J Gastrointest Surg 11, no. 11 (2007): 1417-21

6. Susan Krajewski, Jacqueline Brown, P. Terry Phang, Manoj Raval, Carl J. Brown. "Impact of Computed Tomography of the Abdomen on Clinical Outcomes in Patients with Acute Right Lower Quadrant Pain: A Meta-Analysis." Can J Surg 54, no. 1 (2011): 43-53.

7. Joshua D. Hawkins, Richard C. Thirlby. "The Accuracy and Role of Cross Sectional Imaging in the Diagnosis of Acute Appendicitis." Advances in Surgery 43, (2009): 13-22.

8. van Randen A, Bipat S, Zwinderman A. "Acute Appendicitis: Meta-Analysis Od Diagnostic Performance of Ct and Graded Compression Us Related to Prevalence of Disease." Radiology 249, no. 1 (2008): 97-106.

9. Murphy, E. M., S. M. Farquharson, and B. J. Moran. "Management of an Unexpected Appendiceal Neoplasm." Br J Surg 93, no. 7 (2006): 783-92.

10.Connor, S. J., G. B. Hanna, and F. A. Frizelle. "Appendiceal Tumors: Retrospective Clinicopathologic Analysis of Appendiceal Tumors from 7,970 Appendectomies." Dis Colon Rectum 41, no. 1 (1998): 75-80.

Reference11. Connor, S. J., G. B. Hanna, and F. A. Frizelle. "Appendiceal Tumors: Retrospective

Clinicopathologic Analysis of Appendiceal Tumors from 7,970 Appendectomies." Dis Colon Rectum 41, no. 1 (1998): 75-80.

12.Goede, A. C., M. E. Caplin, and M. C. Winslet. "Carcinoid Tumor of the Appendix." Br J Surg 90, no. 11 (2003): 1317-22.

13.Misdraji, J., R. K. Yantiss, F. M. Graeme-Cook, U. J. Balis, and R. H. Young. "Appendiceal Mucinous Neoplasms: A Clinicopathologic Analysis of 107 Cases." Am J Surg Pathol 27, no. 8 (2003): 1089-103.

14.Fujiwara, T., A. Hizuta, H. Iwagaki, T. Matsuno, M. Hamada, N. Tanaka, and K. Orita. "Appendiceal Mucocele with Concomitant Colonic Cancer. Report of Two Cases." Dis Colon Rectum 39, no. 2 (1996): 232-6.

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