LETTER
Hippokratia 2015, 19(1):96
Spartalis E, Tsaparas P, Antoniou E
Second Department of Propedeutic Surgery, University of Athens, Medical School, “Laiko” General Hospital, Athens, Greece
Key words: Drain site, appendix, evisceration, appendectomy
Corresponding author: Eleftherios Spartalis, MD, MSc, PhD, Vasilissis Sofias 49, Kolonaki 106 76. Athens, Greece, tel. +306974714078, e-mail: eleftherios.spartalis@gmail.com
Dear Editor,
A 62-year-old female underwent low anterior resection for rectal cancer and during surgery a drain was placed into the pouch of Douglas. When the drain was removed, the vermiform appendix, being attached to the tube, was pulled out of the abdomen and was found to be slightly strangulated. Initially it was considered to proceed to appendectomy under general anaesthesia but due to shortage of immediately available operating room, we performed bedside resection of the appendix in a modified open fashion. Under sterile conditions, the appendix was brought out of the wound until its cecal base was identified and grasped. The initial drain site incision was not extended neither was anesthesia administered. Inversion of the appendiceal stump with a purse-string suture was not feasible. The patient experienced no pain during the procedure, had no further consequences, and the immediate postoperative course was uneventful.
Drain site evisceration of the appendix is a rare complication. In some reported cases, the drain is removed and the appendix is simply pushed back, while in others, appendectomy is performed in the operating theater under general anesthesia. In 1997 Duraker et al1 reported a similar rare case where the stab wound incision of the drain was extended and an appendectomy was performed under general anesthesia. This was the first reported case, where resection of the appendix was performed. In 2012 Yska and van Migem2 reported a similar case regarding a man, whose appendix had been pulled out attached to the drainage tube. In that case the drain was removed and the appendix was pushed back into the abdominal cavity. In the reported case herein, there was a need for urgent appendectomy, so we proceeded to bedside resection, implementing principles of well established techniques, similar to the extracorporeal single incision laparoscopic appendectomy introduced by Pelosi and Pelosi3 in 1992, and the innovative gasless “puppeteer” approach, presented by Roberts et al4 in 2009. According to these techniques, the thread is pulled by the surgeon extracorporeally and then removed in the manner of conventional surgery. In the reported case, however, this maneuver had already been done by the drainage tube itself, so there was no need for anesthesia and induction of pneumoperitoneum or other advanced operational features, thus simplifying the resection of the appendix.
The reported case demonstrates that urgent bedside appendectomy is feasible, painless and effective approach for drain site evisceration of the appendix and adds another option regarding appendiceal evisceration, which has never been reported before.
References
1. Duraker N, Büyükasik K, Helvacioglu Y. Drain site evisceration of the appendix: report of a case. 1997; 27: 651-652.
2. Yska M, van Migem P. [A man stuck to a drain]. Ned Tijdschr Geneeskd. 2012; 156: A3038
3. Pelosi MA, Pelosi MA 3rd. Laparoscopic appendectomy using a single umbilical puncture (minilaparoscopy). J Reprod Med 1992; 37: 588-5942.
4. Roberts KE. True single-port appendectomy: first experience with the “puppeteer technique”. Surg Endosc. 2009; 23: 1825-1830.