REMOVAL OF A MESOAPPENDIX DURING A ROUTINE APPENDECTOMY IN A CASE OF APPENDICITIS

Appendectomies are one of the most common emergent surgical procedures performed around the world. Although typically a straight forward operation, it is still important to verify the pathology of the resected tissue and to ensure patient health improvement to confirm a successful surgery. This case report describes a patient who presented to the emergency department with an acute onset of fever and lower abdominal pain, and subsequently underwent two exploratory appendectomies. The surgery team removed the supposed “appendix” along with fecalith, which turned out to be mesoappendix on the pathology report. The patient’s symptoms improved initially, but he developed another fever, at which time he underwent a second exploratory appendectomy. This time, the appendix was removed successfully, which was confirmed by the pathology report, and the patient underwent a full recovery without further complications. Purpose (a): The purpose of this case report was to discuss the importance of pseudoduplication and duplication of the appendix while performing an appendectomy. Methods (b): The patient was a 58-year-old Caucasian male, with an unremarkable past medical and surgical history, who presented to the emergency department with an abrupt onset of fever and chills in the morning and mild burning periumbilical abdominal pain, which was temporarily relieved by an antacid tablet. Physical examination was within normal limits, and the patient was admitted to the hospital and placed on Vancomycin and Zosyn. Overnight, the patient developed right lower quadrant abdominal pain. Blood work confirmed an elevated WBC count and CT scan showed findings that were consistent with acute appendicitis. After consents were signed, the patient was taken to the operating room the following morning for a laparoscopic appendectomy. Results (c): The patient underwent an unsuccessful laparoscopic surgery since the base of the appendix could not be visualized. As a result, the procedure was converted to an open appendectomy; the appendix was resected and the sample was sent to pathology. Following the surgery, the patient was placed on Zosyn and Flagyl for 24 hours. The patient was progressing well until he developed a fever of 102° F, at which time the pathology report came back and revealed the removed tissue sample was an “abundant acute inflammation involving serosal surface of adipose tissue and sheet like portion of mesoappendix covered with fibromembranous tissue.” The patient consented to a re-exploration of his abdomen, and the surgeons took the patient back to the operating room, where they identified the inflamed appendix and the appendiceal artery. The specimen was removed and was confirmed by pathology as the appendix. The patient had an uneventful post-operative course with a full recovery and was subsequently discharged home. Conclusions (d): Surgeons need to be aware of pseudoduplication and the duplication of the appendix while performing an appendectomy. Although rare, it can become an unexpected complication and increase the morbidity and mortality in the patients. Therefore, it is recommended for physicians to perform a thorough assessment of the patient’s anatomy during the surgical procedure to reduce and eliminate future complications from duplicate or even triplicate appendices.