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Laparoscopic Cecal Wedge Resection Appendectomy

Marco Fisichella, MD, MBA, FACS
VA Boston Healthcare System; Ciro Andolfi, MD
University of Chicago Pritzker School of Medicine

Abstract

This is the case of a 66-year-old man with a history of colon polyps, who undergoes colonoscopy every 3 years for surveillance. During the last colonoscopy, he was found to have a polyp at the appendiceal orifice. The biopsy showed the presence of adenoma. Therefore, the patient underwent a laparoscopic appendectomy with wedge resection of the cecum. The operation went well and took less than an hour. We opened the specimen and found the adenoma within the lumen of the appendix, with at least 1.5 cm of clear margin. The patient was sent home the same day, and resumed regular diet and physical activities the following morning.

Case overview

Background

This is the case of a 66-year-old man with a history of colon polyps, who undergoes colonoscopy every 3 years for surveillance. During the last colonoscopy, he was found to have a polyp at the appendiceal orifice. The biopsy showed the presence of adenoma. Therefore, the patient underwent a laparoscopic appendectomy with partial resection of the cecum.

Focused history of patient

This is the case of a patient with an adenoma of the appendiceal orifice. This was discovered by routine colonoscopy. The adenoma was quite difficult to excise with endoscopy; therefore, the patient had the procedure performed laparoscopically, in the operating room.

Physical exam

Although the vast majority of patients with colon polyps have a normal physical exam and are diagnosed through colonoscopy, they may present with rectal bleeding, change in stool color and bowel habits, abdominal pain or iron deficiency anemia. Patients are regularly screened at the age of 50 or older. Patients with risk factors, such as family history of colon cancer, should begin screening at early ages.

Imaging

The adenoma was discovered by routine colonoscopy. Even if a CT colonography can be performed to diagnose colon polyps, it requires the same bowel preparation as for colonoscopy. Colonoscopy plays a key role in both diagnosis and treatment of colon polyps.1,2

Natural history

In case of an adenomatous polyp or a serrated polyp, there is an increased risk of colon cancer. The level of risk depends on size, number and characteristics of the polyps. A follow-up screening for polyps is needed every 5 years in case of 1 or 2 small adenomas, every 3 years in case of 3 or more adenomas measuring more than 0.4 inches, and in less than 3 years in case of more than 10 adenomas.3

Options for treatment

The gold standard is polyp resection.1 The available options for removal of colon polyps are the following:

  • Colonoscopy: removal with forceps or wire loop.
  • Minimally invasive surgery (laparoscopy or robot-assisted laparoscopy):
    • Selective resection: polyps that are too large or in unfavorable locations, such as the appendix, such that they cannot be removed endoscopically.
    • Total colectomy: for rare inherited syndromes, such as familial adenomatous polyposis (FAP).
Rationale for treatment

Some types of colon polyp are far likelier to become malignant than are others. However, all polyps need to be removed to analyze the histologic pattern.

Discussion

This is a case of a patient with an adenomatous polyp at the appendiceal orifice, discovered by routine colonoscopy. Due to the difficulty in excising the adenoma endoscopically, we decided to take the patient to the operating room and perform a laparoscopic resection. The challenge for us was to perform an appendectomy with partial resection of the cecum, respecting the oncological margins and being cautious not to resect too close to the ileocecal valve. We decided on a laparoscopic approach because the patient was relatively healthy, and never had any abdominal procedure before.

During the operation, we positioned the patient in a Trendelenburg position and on a left lateral decubitus, then we identified the colon and followed the teniae coli to reach the base of the appendix. The appendix was very densely adherent to the ileocecal valve, so we took the mesentery down from the ileocecal valve using the cautery. The appendiceal artery was taken down with the LigaSure. Then, we proceeded with cecal wedge resection appendectomy, in order to get the adenoma within the specimen.

The operation went well and took less than an hour. The staple line was free of bleeding and far away from the ileocecal valve. We opened the specimen and found the adenoma within the lumen of the appendix, with at least 1.5 cm of clear margin. The patient was sent home the same day, and resumed regular diet and physical activities the following morning.

Equipment

  • Minor surgical tray
  • Laparoscopic tray:
    • 5 or 10 mm 30° laparoscope
    • 5 and 12 mm trocars
    • Grasping instruments: atraumatic, fenestrated, Babcock-type, toothed, curved dissecting (Maryland), curved 45° and 90° forceps
    • Suction and irrigation kit
    • Dissecting scissors (Metzenbaum)
    • Needle holders
  • Other laparoscopic devices:
    • Hasson blunt port system
    • Electrosurgical instruments: monopolar (hook, EndoShears, etc.), ultrasonic device (LigaSure, Harmonic scalpel, UltraCision, etc.)
    • Eschelon stapler white/blue, with 45/60 reloads
    • Covidien Endo GIA universal stapler, with 30/45 reloads
    • Clip applier
    • Endoscopic Kittner
    • Tissue bag
    • Endoloops
    • Carter-Thomason laparoscopic port-site closure system

Disclosures

No disclosures.

Statement of consent

Informed consent has been obtained from the patient before video recording.

Citations

  1. Floyd TL, Orkin BA, Kowal-Vern A. Cecal wedge resection appendectomy for the management of appendiceal polyps. Tech Coloproctol. 2016;20(11):781-784. doi:10.1007/s10151-016-1529-0.
  2. Macht R, Sheldon HK, Fisichella PM. Giant colonic diverticulum: a rare diagnostic and therapeutic challenge of diverticular disease. J Gastrointest Surg. 2015;19(8):1559-1560. doi:10.1007/s11605-015-2773-8.
  3. Xue L, Williamson A, Gaines S, et al. An update on colorectal cancer. Curr Probl Surg. 2018;55(3):76-116. doi:10.1067/j.cpsurg.2018.02.003.