Surgical inversion of the appendix

Surgical Inversion

of the Appendix

CALVIN REED BROWN, M.D., Salt Lake City, Utah From the Department of Surgery, Salt Lake General Hospital, and tbe University of Utab, College of Medicine, Salt Lake City, I/tab.

HE

clinical confusion of a surgically inverted appendix with polyps in the cecum is a reIatively uncommon occurrence. Until such time as our clinical acumen will Iead to a correct preoperative diagnosis, individual case reports will be of vaIue. One method of treatment of acute appendicitis includes clamping of the appendix a centimeter or more from its base. This resuIting stump of the appendix is then inverted with a hemostat by tucking it back into the cecum through its own lumen. The resulting defect is then closed with a purse-string suture in the cecal serosa. The effect of this procedure is the protrusion of a polyp-like portion of the base of the appendix into the lumen of the cecum. The majority of these poIyp-like Iesions become atrophic and revert to scar tissue in the appendicea1 dimple, but a few are reported at autopsy to have retained their polypoid shape, and some have increased in length, possibIy due to the friction of fecal stream and the effect of continuous peristalsis. Since most surgeons now prefer the use of a shorter appendicea1 stump, this problem does not often present itself. With the increased efficiency of radioIogic technics such lesions, when present, can usuahy be demonstrated in the cecum, and their discovery leads to the necessity of differentiation of an inverted appendicea1 stump from a benign or malignant polyp of the cecum. The case presented herein is of added interest since the patient had compIained of vague lower abdominal pain, and the radioIogic Iocation of the Iesion corresponded with the area of persistent tenderness found on physica examination. While inversion of the appendix was suspected cIinicaIly, a benign or mabgnant polyp of the cecum couId not be ruled out without expIoratory laparotomy.

T

CASE REPORT E. E. (Hospital No. 15009), a twenty-seven year old woman, entered the Surgical Service of the Salt Lake Genera1 HospitaI on March 9, 1954, with the chief complaint of lower abdominaI pain of two months’ duration. On or about January 1st ‘ower abdomina1, sharp, cramping pain not associated with nausea or vomiting, dysuria or uterine bIeeding had developed. Gynecologic examination was essentially negative. The cramps resembled menstrual pain but recurred at frequent inter\-aIs. She had been sIightIy constipated but had passed no bIood with her stooIs. Gastrointestinal series and a smaI1 bowel series on February 17th were reported as normal, but a bar:um enema on February 26th showed a polypoid mass in the cecum. Her past historv indicated that she had had an appendectomy-in 1941, the exact technic of which was not known, and a uterine suspension in 1950. Physical examination reveaIed the temperature to be 98.6%., p&e 70, respiration 16, and bIood pressure 100/60. The patient was a we11 deveIopec1, we11 nourished white woman who was alert, cooperative and in no acute distress. examination was Eye, ear, nose and throat essentiahy negative. The neck reveaIed no masses, the breasts were normal, the lungs were clear, and the heart showed no abnormality. The abdomen was soft and reveaIed no palpable masses. The bowel sounds were active, and there was a slight tenderness to deep pressure in the right lower quadrant. Right Iower quadrant and lower midline incisional scars were noted. The extremities and neurologic examination were not remarkable. Rectovaginal examination was essentiahy normaI, except for tenderness in the right lower quadrant. Sigmoidoscopy to a depth of 25 cm. reveaIed a poIyp, 0.5 cm. in diameter, about IO cm. from the anal opening. Laboratory data incIuded the foIlowing: urinalysis, negative; hematocrit, 45; white

Brown placed on routine bowel preparation and taken to the operating room March 9, 1954 for exploratory Iaparotomy. With the patient under genera1 anesthesia, the abdomen was entered through a IO cm., mid-right rectus incision. Upon entering the peritoneum, adhesions were found between the omentum and the Iower midIine incision; extensive adhesions aIso invoIved the cecum and the omentum. Palpation of the cecum, after freeing of adhesions, reveaIed an intraIumena1 tumor mass, I cm. in diameter and approximately 2 cm. in length. This was Iocated at the end of tinea bands and was suggestive of an inverted appendicea1 stump. Prior to opening the bowe1, the entire coIon and upper rectum were carefuIIy palpated in an attempt to determine whether other such tumor masses were present. There were no other paIpabIe masses. The liver was smooth and normal in appearance. The stomach and duodenum revealed no abnormalities. The gaIIbIadder was thin-waIIed, partiaIIy fiIIed with bile, and emptied easiIy. FoIIowing expIoration, the cecum was packed off with moist packs, and a 6 cm. incision was made in the anterior waI1 of the cecum. The tumor mass couId then be visuaIized in a sIightIy more dista1 and posterior position. With the polyp thus exposed, it was excised with an eIIiptic portion of norma waI1 around the base, measuring 2.5 by 1.5 cm. This excision area was cIosed with two layers of inverting, interrupted Lambert sutures. A purse-string suture was then pIaced around the anterior opening, and a sigmoidoscope was introduced into the cecum in an attempt to visuaIize the remainder of the finding no further ascending coIon. Upon Iesions, the instrument was withdrawn and the incision was cIosed with a row of interrupted Lambert inverting sutures. AI1 sutures were of No. 40 cotton. The abdomen was cIosed. The postoperative condition was satisfactory. The surgica1 specimen consisted of a poIypoid mass of tissue, measuring 2.0 by 0.8 by 0.4 cm. and exhibiting a reddish gray, hemorrhagic, smooth, shiny surface. Microscopic sections showed a poIypoid mass Iined on the externa1 surface with colonic mucus-producing gIands. In the submucosa1 regions were seen many Iymphoid foIIicIes not normally seen in a poIyp of the cecum. The central portion of the polyp consisted of severa Iayers of smooth muscle and a fused fibrous core resembling peritoneum. The impression from this microscopic appear-

FIG. I. X-ray reveaIs a discrete, round, fiIIing defect in the medial aspect of the cecum corresponding to the position of the appendix.

blood count, 7,652; urine culture, no growth; stool guaiac, 2 +. FoIlow-up stool guaiacs were al1 reported negative. Intravenous pyeIogram was essentialIy negative. X-ray examination of the large bowel by means of barium enema achieved fiIling up to, and including, the termina1 ileum. A persistent polypoid fiIIing defect, 2 by 1.5 cm., was present in the cecum just above the ceca1 pouch. This area aroused suspicion at ffuoroscopy and was spotted during the full phase without concIusive result. FoIIowing evacuation of the enema, the patient was refIuoroscoped and the area spotted again. The poIypoid defect couId not be moved within the lumen of the bowe1. In retrospect, a similar but smaIIer defect was thought to be present on the examination at the same reIative position on March 26, 1931, but this was reported as negative at that time. Re-examination on February 26, 1954, revealed the same persistent, circuIar, fiIIing defect on the anteromedial wall of the cecum, just beneath the iIeoceca1 vaIve. The Iocation of the Iesion was identical with the persistent tenderness of which the patient compIained. The x-ray impression was cecal polyp. (Fig. I.) Biopsy of the polyp in the rectum was reported as polyp, hyperpIasia. Because of the impossibiIity of ruling out a simiIar or malignant poIyp of the cecum, the patient was I42

SurgicaI

FIG. 2. Low power follicIes.

magnification

FIG. 3. High power microscopy foIlicIes identifying the structure

reveals

Inversion

the inverted

reveals the detaited as inverted appendix.

of Appendix

appendix

with

junction

between

ante was that this was not an ordinary cecal polyp. The microscopic diagnosis was “inverted appendix.” (Figs. 2 and 3.) The patient’s course folIowing the operation was uneventful. She was discharged from the hospital on the twelfth postoperative da) without serious complaints.

its outer

covering

of mucosa

mucus-producing

gIands

and lymphoid and

Iymphoid

a shorter appendicea1 stump should be used in the process of inversion during appendectomy. A contributing factor in the formation of such lesions couId be the development of intramural infection at the inversion site with resuItant protrusion of inflamed, indurated ceca1 mucosa into the Iumen. Because the usual case of inverted appendicea1 stump is entireIy symptomIess, a patient is likely to go through Iife with the condition undiagnosed. OccasionaIIy, as in this case, mild, vague symptoms of Iower abdomina1 distress may be observed. The exact differentiation of this lesion from benign or maIignant poIyps of the cecum is usuaIIy impossibIe without microscopic examination; however, the history of previous appendectomy, especially in a patient of the age group corresponding to the time when this method of surgical treatment was most prevaIent, should tend to make one highIy suspicious of this type of lesion in this particular region of the cecum. The simpIest method of treatment is, as we have described, cecotomy and wedge excision of the poIyp, including a small portion of surrounding ceca1 mucosa.

COMMENTS

Although much has been written on the subject of intussusception of the appendix since the first report of this condition was made by McKiddl in 1858, only about IOO cases of intussusception have been reported in the literature, and far less cases of inverted appendicea1 stump have been reported. Of a total of eighty-two cases of intussusception of the appendix reviewed by Fraser,2 four were cases of intussusception of inverted appendicea1 stumps. Burghard” has reported a case of intussusception of the vermiform appendix in which the intussusception protruded from the anus and was thought to be a rectal polyp unti1 microscopic diagnosis was made. McSwain4 aIso reported a case of intussusception of the appendix. Zeiferb reported a case from the surgica1 case service of Dr. John H. Garlock. The etiology of this Iesion seems apparent. While complications resuIting from this protrusion are rare, the occasiona confusion, discomfort and unnecessary operation resuIting from the presence of such Iesions indicate that

SUMMARY

A case of inverted appendix associated with miId lower abdomina1 discomfort in a twentyseven year old woman is reported. The similarity of this lesion to benign and maIignant poIyps of the cecum on radioIogic examina‘43

Brown 2. FRASER, K. Intussusception of appendix. Brit. J. Surg., 31: 23, 1943. 3. BURGHARD, F. F. Intussusception of the vermiform _. . . _. ^ appendix, the mtussusceptron protrudmg from the anus. BriC. J. Surg., I: 721, 1913-1914. 4. MCSWAIN, B. Intussusception of appendix; review of the Iiterature and report of a case. Southern M. J., 34: 263, 1941. 5. ZEIFER, H. D. Intussusception of the appendix. J. Mt. Sinai Hosp., 18: 125, 1951.

for expIoration is noted, and the necessity tory Iaparotomy for definitive diagnosis is emphasized. Methods of prevention and surgical treatment,

and the reIevant

Iiterature

are reviewed.

REFERENCES I. MCKIDD, J. Case of invagination of the cecum and appendix. Edinburgh M. J., 4: 793, 1859.

We recommend: Beyond the Germ Theory. The Roles of Deprivation and Stress in HeaIth and Disease. Edited by Iago GaIdson, M.D. A New York Academy of Medicine Book, 182 pages, 4 iIIustrations. (“This book does not negate or deny the germ theory of disease. It goes beyond the germ theory and deals with factors other than germs that engender iIIness and poor health.” From the Foreword.) New York, 1954. Health Education CounciI (American Lecture Series). Price $4.00. Neck Dissections. By James Barrett Brown, M.D. and Frank McDoweII, M.D. 163 pages, 82 iIIustrations, I I in coIor. SpringfieId, III., 1954. CharIes C Thomas. Price $7.50.

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