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Chapter 55
https://t.me/med1917
Case on Postoperative Shock After
Laparoscopic Appendicectomy
Joris J.G. Scheepers
Keywords Bleeding • Abdominal wall • Acute appendicitis • Laparoscopic
appendectomy • Epigastric arteries
Diagnosis and Indication for Surgery
A 36-year-old lady was admitted to the hospital because of acute appendicitis.
Clinically but also on the CT scan the diagnosis was clear (Fig. 55.1 ).
Operation
Patient underwent a laparoscopic exploration by means of a three-trocar approach,
one of 10 mm under the umbilicus, a second of 5 mm suprapubic, and the third of
10 mm localized between the umbilicus and the anterior superior left iliac spine.
The operation was converted to a MacBurney incision because of bleeding from the
appendicular artery, and that was diffi cult to fi x. The appendix was taken out and
bleeding fi xed with stitches. After closure, the patient went into shock and she did
not react on saline and colloids. The surgeon thought of the possibility of a
re- bleeding from the appendicular artery and decided to reoperate the patient immediately. During the exploration through the MacBurney incision, the patient went
deeply into shock and surgeon called upon a senior surgeon to assist him. It was
clear that the appendicular artery was not the cause for the bleeding, but the abdomen was fi lled with blood and clots. The surgeons decided to perform a median
J. J.G. Scheepers , M.D.
Department of Surgery , Ranier de Graaf Hospital , Delft , The Netherlands
e-mail: j.scheepers@rdgg.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_55,
© Springer International Publishing Switzerland 2014
293
294
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Fig. 55.1 CT scan with
diagnosis of acute
appendicitis
J.J.G. Scheepers
laparotomy and it became clear that the bleeding was not coming from the liver or
the spleen but from a lesion of the left inferior epigastric artery and vein right on the
place of the last trocar between the umbilicus and the spine. Bleeding was fi xed by
means of transfi xion stitches and clots removed. Patient recovered after transfusion
of 4 packed cell units.
Discussion
The lesson of this case is that every step during laparoscopy, including insertion of
trocars, is very important and will be safe. Especially, lateral of the midline introduced
trocars are at risk for lesions of the vessels of the abdominal wall. Saber et al. studied
by CT scan the at-risk zones for bleeding in the abdominal wall and determined that the
inferior epigastric vessels are usually located in the area between 4 and 8 cm from the
midline [ 1 ]. Avoiding this area will determine the safe zone of entry of the anterior
abdominal wall. But it is not always possible to obviate this zone and it is possible by
visualization to see the epigastric vessels during insertion of trocars and the corresponding bleeding [ 2 ]. Moreover, this is a complication not frequently described in the
literature, probably occurring more frequent than published [ 3 ]. The patient here pre-
sented summarizes all problems in relation with lesion of the epigastric vessels during
laparoscopy: bleeding during operation, patient in shock, and diffi cult differential
diagnosis. Take care during creation of insuffl ation and insertion of trocars !
References
1. Saber AA, Meslemani AM, Davis R, Pimentel R. Safety zones for anterior abdominal wall
entry during laparoscopy: a CT scan mapping of epigastric vessels. Ann Surg. 2004;239:
182–5.
2. Hurd WW, Amesse LS, Gruber JS, et al. Visualization of the epigastric vessels and bladder
before laparoscopic trocar placement. Fertil Steril. 2003;80:209–12.
3. Valera Sánchez Z, Morales Conde S, López Bernal F, Cadet Dussort H. A large hematoma in
the abdominal wall after trocar insertion. Rev Esp Enferm Dig. 2008;100:64–6.
Chapter 56
https://t.me/med1917
Case on Postoperative Abscess
After Appendicectomy
Suzanne S. Gisbertz
Keywords Acute appendicitis • Laparoscopic appendicectomy • Percuatneous
drainage • Abscess
Diagnosis and Operation Description
Six weeks before, this 58-year-old female manager had undergone a laparoscopic
appendectomy because of a phlegmonous-infl amed appendix (Fig. 56.1 ). Through
three trocars her appendix had been removed by using an endostapler white. The
appendix was deposited in an endobag and consequently exteriorized. Hemostasia
was good, and after closure of the trocar sites, the operation was completed.
Postoperative Course: Identifi cation and Treatment
of Complication
During the same hospital stay, her postoperative course was complicated by a small
bowel ileus and fever. On the CT scan, an abscess was seen in the right paracolic
area, being subsequently percutaneously drained (Fig. 56.2a, b ). Patient improved,
and once the drain was removed, she went home.
Presenting now some weeks later at the outpatient policlinic, she claimed not
feeling well, having a poor intake, and diarrhea. She was readmitted to the hospital,
now sick, with temperature 38.1 °C, heart rate 94 bpm, and on physical examination
having localized pain in the right lower abdomen. The CRP was 250, and
S. S. Gisbertz , M.D.
Department of Surgery , Academic Medical Centre , Amsterdam , The Netherlands
e-mail: s.gisbertz@antoniusziekenhuis.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_56,
© Springer International Publishing Switzerland 2014
295
296
https://t.me/med1917
Fig. 56.1 US diagnosis acute
appendicitis
ab
S.S. Gisbertz
Fig. 56.2 ( a ) CT scan showing an abscess around cecum. ( b ) CT scan, percutaneous drainage
abscess
Fig. 56.3 CT scan, new
abscess, 3 weeks after 1st
operation
leukocytosis of 12.5 × 10 9 /l. On the CT scan an abscess was found paracolic space
right, again being drained (Fig.
(AB). Nutrition and general condition improved, and after retiring the drain, she
could return home at the 10th day following readmission.
56.3 ) and treated by iv broad spectrum antibiotics
56 Case on Postoperative Abscess After Appendicectomy
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297
Discussion
The Cochrane reviews and meta-analysis comparing rates of open and laparoscopic
appendectomies of postoperative abscesses show rates slightly higher for the laparoscopic group [ 1 ].
Pertaining lesson of this case is perhaps that before the fi rst discharge following
the requirement for checking clinically and by imaging whether the abscess has
completely disappeared. Instead—after pressure by the patient to return home for
reinitiating her work—this control had been omitted.
Reference
1. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus open surgery for suspected
appendicitis. Cochrane Database Syst Rev. 2010;6(10).
Chapter 57
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Case on Carcinoid Discovered in the Appendix
Miguel A. Cuesta and Maria Conde Rodriguez
Keywords Appendix tumor • Appendix • Carcinoid tumor
First Patient
Diagnosis and Indication for Surgery
A 47-year-old male schoolteacher was admitted to the department because of
abdominal pain in the lower abdomen and vomiting. He had fever of 39.2 °C and
leukocytosis of 13,000 and a CRP of 61 mg/l. On physical examination the patient
was sick and had a clear peritonitis sign on the right lower abdomen. On the US, an
imaging was suspected for acute appendicitis and the patient was proposed for a
laparoscopic appendectomy (Fig. 57.1 ).
Operation
A perforated appendicitis was found with local pus in Douglas space—thereafter
being drained. Patient received a 5-day administration of iv antibiotics and recovered slowly. On pathological examination, a perforated acute appendicitis was seen
with a carcinoid tumor of 8 mm, radically resected.
M. A. Cuesta , M.D. ()
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M. C. Rodriguez
Department of Surgery , Hospital Clinico , Universidad de Madrid , Spain
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_57,
© Springer International Publishing Switzerland 2014
299
300
https://t.me/med1917
Fig. 57.1 US diagnosis of
acute appendicitis with
possible tumor
M.A. Cuesta and M.C. Rodriguez
The patient was told that no interventions were necessary, and he recovered.
Outpatient clinic control was ended after 1 year.
Second Patient
Diagnosis and Indication for Surgery
A 66-year-old retired man, known with Bechterew’s disease and diabetes mellitus
type II, was admitted to the hospital with a worsening of abdominal pain, and vomiting. Since a year he had complained of progressive abdominal distension, colic pain,
and change of defecation pattern. On the day of admission, physical examination
showed a moderately sick patient with 37.8 °C temperature, abdominal distension,
and intestinal obstruction type peristalsis. Laboratory tests included a leukocytosis
57 Case on Carcinoid Discovered in the Appendix
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Fig. 57.2 CT scan, intestinal
obstruction with an abscess
located on the right lower
abdomen possibly of
appendicular origin
of 15,000 with CRP of 75. On the plain X-ray of the abdomen, small bowel dilatation was observed. On the CT scan, a small bowel intestinal obstruction was found
with an abscess located on the right lower abdomen possibly of appendicular origin
(Fig. 57.2 ).
301
Operation
Because of the intestinal obstruction, the surgeon decided to operate on the patient
through a midline incision, and so a perforated appendicitis was found with an abscess
of 7 by 7 cm. This was the cause of the intestinal obstruction. After appendectomy
and abscess drainage, intestinal loops were freed and abdomen closed leaving a drain.
Postoperative Course
Antibiotics were given iv for 7 days, and TPN (parenteral nutrition) until recovery
of the intestinal transit. Patient recuperated. Histological examination showed a
goblet cell carcinoid, growing diffuse over a trajectory of 4 cm with ingrowth
through the muscularis propria. Serosa and mesoappendix were free of tumor.
Moreover, an acute appendicitis with perforation was found.
On the postoperative CT scan, there were no distance metastases and after recovery patient was proposed for colonoscopy and right hemicolectomy based on the
302
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M.A. Cuesta and M.C. Rodriguez
histological outcome. Six weeks later, a right hemicolectomy was performed with
no special postoperative events. No metastases and no lymph node involvement of
the central mesentery were observed. On histological examination no rest of the
carcinoid tumor was seen and all the lymph nodes (17) were negative.
After 6 years of follow-ups, with regularly held CT scans of abdomen and
controls of serotonin in platelets, the patient could be discharged.
Discussion
A lesson drawn from both cases is that a carcinoid in the appendix can present itself
as acute appendicitis. In the majority of cases, the pathologist will reveal the diagnosis and then a decision should be done what to do.
Questions do arise. First, what to do during operation if suspicion arises of the
presence of a (malignant) tumor of the appendix? Second, what to do once the
pathology report confi rms the type of tumor and staging?
Concerning the fi rst question, my answer would be: If the tumor is larger than
2 cm, one must resect the tumor by radical operation—in most of the cases by an
ileocecal or right hemicolectomy resection. If in doubt or in the case of a small
tumor, being less than 2 cm, one must wait for the pathological report of the appendix. If the location of the tumor is in the base of the appendix at the cecum, then one
must do an ileocecal resection (Figs. 57.3 and 57.4 , Illustration 57.1 ).
Concerning the second matter, the different histological types and subsequent
treatment and behavior of malignant tumors of the appendix, Turaga et al. studied
all patients ( n = 5,655) with appendiceal malignancies and found in the Surveillance,
Epidemiology, and End Results (SEER) database from 1973 to 2007 [ 1 ]. The
tumors were classifi ed as malignant carcinoid, goblet cell carcinoid, colonic type
adenocarcinoma, mucinous adenocarcinoma, and signet ring cell type. The 5-year
disease- specifi c survival rates were 93 % for malignant carcinoid, 81 % for goblet
cell carcinoid, 55 % for colonic type adenocarcinoma, 58 % for mucinous
Fig. 57.3 Globet cell
carcinoid of the appendix.
Open specimen of ileocecal
resection
57 Case on Carcinoid Discovered in the Appendix
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adenocarcinoma, and 27 % for signet ring cell type. Histologic subtype is an
important predictor of disease-specifi c survival and overall survival in patients
with appendiceal tumors. Moreover, prognosis depends on the radicality of the
appendectomy but also of the size of the tumor. Especially carcinoids smaller than
2 cm and radically operated do not require other complementary treatment,
whereas tumors > 2 cm or not radical will need a right hemicolectomy to assure the
completeness.
Fig. 57.4 Goblet cell
carcinoid located at the origin
of the appendix in the cecum,
1 cm. Radically resected, but
5 positive lymph nodes
303
Illustration 57.1 In case that a carcinoid is found in the appendicectomy specimen, and the tumor
is less than 2 cm and radically resected, no more surgical resection should be added. If the tumor
is >2 cm or not radically resected, a right hemicolectomy should be proposed
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