|Year : 2013 | Volume
| Issue : 3 | Page : 172-173
Low-grade mucinous neoplasm of the appendix managed with laparoscopic appendectomy
Jonas P DeMuro
Department of Surgery, Winthrop University Hospital, Mineola, NY 11501, USA
|Date of Web Publication||19-Oct-2013|
Jonas P DeMuro
Department of Surgery, Winthrop University Hospital, 259 First Street, Mineola, NY 11501
Source of Support: None, Conflict of Interest: None
Mucocele of the appendix is uncommon and caused by a variety of pathologies. While the gold standard approach to these lesions has historically been exploratory laparotomy and right hemicolectomy, there is increasing experience with a minimally invasive approach and the resection limited to an appendectomy. A case is presented of an appendiceal mucocele diagnosed preoperatively and managed with a laparoscopic appendectomy. The pathology showed a low-grade mucinous neoplasm, with no evidence of recurrence on 30 month follow-up.
Keywords: Appendix, laparoscopic appendectomy, malignancy, mucocele
|How to cite this article:|
DeMuro JP. Low-grade mucinous neoplasm of the appendix managed with laparoscopic appendectomy. J Sci Soc 2013;40:172-3
| Introduction|| |
Mucocele of the appendix is a dilation of the appendix, secondary to obstruction and mucous accumulation intraluminally. They are quite rare and only account for 0.2-0.3% of all appendectomy specimens.  The mucocele can develop from a variety of causes, including cystadenoma, mucosal hyperplasia, mucinous cystadenoma, retention cyst, endometriosis or carcinoid tumor. It is debated on the appropriate operation, namely to do an appendectomy or right hemicolectomy. There is also controversy on whether the approach should be through an exploratory laparotomy or whether laparoscopic. Experience with a case of a low-grade mucinous neoplasm of the appendix is presented.
| Case Report|| |
A 57-year-old female patient complained of back pain had a mucocele of the appendix found incidentally on imaging. The computed tomography (CT) of the abdomen and pelvis revealed an appendiceal mucocele that measured 3.3 cm × 2.5 cm [Figure 1].
|Figure 1: Computed tomography scan of the abdomen and pelvis with intravenous, but no oral contrast. The mucocele is designated by the black "X"|
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She had no other complaints and specifically denied nausea, vomiting, abdominal pain, weight loss or any change in bowel habits. She had a history of two lumbar spinal procedures within the last 5 years for chronic back pain, but no prior abdominal surgery. Her social history was positive for previous tobacco and current social alcohol use. There was no family history of malignancy in any relatives. On physical exam, the mucocele was not palpable, but there was a sense of fullness to the right lower quadrant of the abdomen, which was non-tender and free of peritoneal signs.
The mass was approached laparoscopically with patient in the supine position. Three port sites were used for the operation, a 12 mm, a 10 mm and a 5 mm. On diagnostic laparoscopy, the only pathology identified was the mucocele [Figure 2]. The dissection was carried out with the laparoscopic harmonic scalpel (including division of the mesentery of the appendix) and a laparoscopic endoGIA stapler was used to divide the appendix at the appendiceal-cecal junction. Care was taken to do the surgery atraumatically without grasping the mucocele at any time. The specimen was retrieved in a laparoscopic bag and not allowed to come into contact with the port site and handed off the field immediately. Patient was discharged home on the first post-operative day and made a full and complete recovery.
|Figure 2: Intraoperative image demonstrates the location of the mucocele of the appendix and that there was normal caliber appendix at the appendiceal cecal junction indicated by the black arrow. The two triangles indicate the mucocele and the cecum is indicated by a black "X"|
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Pathologic analysis revealed a low-grade mucinous neoplasm. There was no perforation of the appendix, but there was extensive subserosal mucin accumulation, with mucin focally present at the inked serosal surface. The surgical margin was negative for tumor.
Patient has been followed clinically as well as with serial imaging via CT and ultrasound for 30 months, with no evidence of any recurrence.
| Discussion|| |
A mucocele of the appendix typically presents as a pelvic mass. The mean age of diagnosis is 55 years, with a male to female preponderance of 4:1.  The most common presentation of an appendiceal mucocele is an asymptomatic mass found incidentally on imaging, although less commonly the symptoms can includes weight loss, nausea, vomiting, acute appendicitis, change in bowel habits or anemia. 
A mucocele of the appendix can be identified on a variety of imaging modalities. The test of choice is a CT scan as it has the advantage of better delineating the anatomic relationship to the right ovary than ultrasound and is superior than magnetic resonance imaging at finding mural calcifications. 
The choice of operation and its approach for an appendiceal mucocele remains a controversy, with options including open versus the laparoscopic approach and an appendectomy versus a right hemicolectomy. While the gold standard remains a right hemicolectomy for any appendiceal tumor with the high malignant potential, there are reports of the use of laparoscopic appendectomy for the benign and low malignant potential cases.  It is critically important that whatever approach is used that the surgery be performed atraumatically as pseudomyxoma peritonei can develop from any spillage in patients with mucinous cystadenocarcinoma.
| References|| |
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[Figure 1], [Figure 2]