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  • 1. Introduction
  • 2. Incision and Access to the Abdomen
  • 3. Viewing of Abdominal Organs and Exposure of Appendix
  • 4. Resection of Appendix with Cecal Wedge
  • 5. Gross Examination of Specimen and Viewing of Polyp
  • 6. Hemostasis
  • 7. Closure
  • 8. Post-op Remarks
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Laparoscopic Cecal Wedge Resection Appendectomy

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Ciro Andolfi, MD1; Marco Fisichella, MD, MBA, FACS2
1University of Chicago Pritzker School of Medicine
2VA Boston Healthcare System

Main Text

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.

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.

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.

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.

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.12

In the 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

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: for 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).

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.

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 in 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.

  • 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

No disclosures.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

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.

Cite this article

Andolfi C, Fisichella M. Laparoscopic cecal wedge resection appendectomy. J Med Insight. 2023;2023(207). doi:10.24296/jomi/207.