Retro-mesocolic Appendix: a Diagnostic Dilemma and Surgical Difficulty
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IMAGES IN SURGERY
Retro-mesocolic Appendix: a Diagnostic Dilemma and Surgical Difficulty Jitendra Mistry 1
&
Sameer Mehta 2 & Vishal Shah 3
Received: 18 August 2020 / Accepted: 26 August 2020 # Association of Surgeons of India 2020
Abstract Common positions of the appendix are retrocaecal, pelvis, subcaecal, pre- and post-ileal, and paracaecal. Rare positions of the appendix may pose diagnostic dilemma and surgical difficulties. We report a case of retro-mesocolic position of appendix with appendicitis which posed diagnostic dilemma and required ascending colon and hepatic flexure mobilisation for laparoscopic appendectomy. To our best knowledge, we are the first to report this position. Keywords Positions of appendix . Retro-mesocolic appendix
Case Scenario and Discussion
McBurney’s incision, but in laparoscopic surgery, majority of common positions can be dealt easily.
A 30-year-old gentleman presented with right side severe abdominal pain for 2 days; his abdominal symptoms were much more severe than signs. He had tachycardia. Leucocyte count was 20,000/cmm; USG abdomen done elsewhere was equivocal. Urgent CECT scan of the abdomen was done in view of diagnostic dilemma, which revealed retro-mesocolic severely inflamed appendix coursing behind the ileocaecal junction going upward medial to ascending colon and posterior to right mesocolon, and the tip of the appendix was behind the proximal transverse colon (Fig. 1). Retro-mesocolic appendix was responsible with lesser abdominal signs compared with symptoms. He underwent laparoscopic appendectomy (Figs. 2, 3), which required complete lateral to medial mobilisation of right colon and hepatic flexure. Common positions of vermiform appendix are retrocaecal, pelvis, subcaecal, pre- and post-ileal, and paracaecal. Various studies have reported different frequencies of these positions [1]. During the pre-laparoscopic era, odd positions of appendix may pose a difficulty while doing appendectomy through * Jitendra Mistry [email protected] 1
Mission Gastrocare, an Institute of Gastroenterology, Liver – Pancreas & GI cancer sciences, 02/03 – Purv Prime, Near Natubhai Circle, Gotri road, Vadodara, Gujarat 390007, India
2
BAPS hospital, Vadodara, India
3
Sanya diagnostics, Vadodara, India
Fig. 1 Reconstructed image of CT scan abdomen showing thickened and inflamed retro-mesocolic appendix, running upward from ileocaecal region, medial to the ascending and behind the mesocolon with tip reaching behind the proximal transverse colon
Indian J Surg
Fig. 2 Operative picture while laparoscopy showing tip of the inflamed appendix (arrow) behind the proximal transverse colon (stars)
Fig. 3 Operative picture while laparoscopic appendectomy showing inflamed appendix (arrows) after complete lateral to medial mobilisation of ascending colon; stars are marking the white line of Toldt
There are few rare positions that have been reported in literature, like subhepatic appendix, lateral pouch appendix, or associated with malrotations [2]. To our best knowledge, we are the fir
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