Torsion of the vermiform appendix is a rare cause of appendicitis that is clinically indistinguishable from the classical presentation. In this paper, we present the first report in the literature of an appendicular torsion as- sociated with an undescended cecum. A 3-year-old male patient with persistent pain in the right hypochon- drium and peritoneal irritation underwent diagnostic laparoscopy, finding necrosis of the vermiform appen- dix caused by torsion of its base associated with an undescended cecum located in an indurated area of the subhepatic region. A video-assisted transumbilical appendectomy was performed

Abrego Moya, Valdemar

Montes Tapia, Fernando Félix

Quiroga Garza, Aquiles

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JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUESVolume 19, Number 6, 2009© Mary Ann Liebert, Inc.DOI: 10.1089/lap.2008.0300Primary Torsion of the Vermiform Appendix and Undescended Cecum Treated by Video-AssistedTransumbilical AppendectomyFernando Montes-Tapia, MD,1 Aquiles Quiroga-Garza, MD,2 and Valdemar Abrego-Moya, MD, PhD2AbstractTorsion of the vermiform appendix is a rare cause of appendicitis that is clinically indistinguishable from theclassical presentation. In this paper, we present the first report in the literature of an appendicular torsion as-sociated with an undescended cecum. A 3-year-old male patient with persistent pain in the right hypochon-drium and peritoneal irritation underwent diagnostic laparoscopy, finding necrosis of the vermiform appen-dix caused by torsion of its base associated with an undescended cecum located in an indurated area of thesubhepatic region. A video-assisted transumbilical appendectomy was performed.839IntroductionAppendicitis is the most common cause of abdominalsurgery in pediatric patients.1,2 Torsion of the vermi-form appendix is a rare cause that is clinically indistin-guishable from appendicitis.2–8 The first description of tor-sion of the vermiform appendix was made by Payne in 1918.3A lack of elongation of the colon during embryonic devel-opment causes the cecum to not descend to the right iliacfossa, which produces an undescended and mobile cecum.9Case ReportThe patient was a 3-year-old male with abdominal colic of18 hours located in the right flank with hyporexia and vom-iting of gastric contents. At the time of the initial evaluation,there were no signs of peritoneal irritation. An abdominalultrasound was performed without finding the appendix norsigns of inflammation in the right iliac fossa. The patient wasreassessed after 18 hours of observation, finding abdominaldistension, pain located in the right hypochondrium with apalpable mass, and signs of peritoneal irritation; an abdom-inal X-ray showed fluid levels. A complete blood countshowed leukocytosis (18,500 wbc/mm3 with 95% neu-trophils). A laparoscopic examination was decided becauseof clinical signs of an acute abdomen.Surgical techniqueWe started with two 5-mm ports, one in the umbilicalscar for 5 mm and 30-degree optics (Karl Storz GmbH &Co. KG, Tuttlingen, Germany) and another in the left iliacfossa. On abdominal examination, inflammatory liquidwas found in the pelvic cavity and an indurated area inthe right parietocolic and subhepatic spaces. We were un-successful in an attempt to separate the indurated area, sowe placed another 5-mm port in the right iliac fossa. Ly-sis of adhesions of the omentum, small intestine, and ce-cum was done. Once the indurated area was separated, wefound a necrotic subhepatic appendix, twisted three timescounterclockwise, adhered to the abdominal wall of theright parietocolic and subhepatic spaces (Figs. 1 and 2). Wealso observed that the appendix had a narrow appendicu-lar mesentery and a movable cecum without fixation. Avideo-assisted transumbilical appendectomy was per-formed, exteriorizing the appendix and the cecum throughthe umbilical scar (Fig. 3). The operative time was 55 min-utes. Feeding was started on postoperative day 1, and thepatient was discharged on the second day.DiscussionAlthough torsion of the vermiform appendix has been de-scribed for 90 years, it is rare in pediatric patients, with 15cases being reported previously.10,11 No specific age pre-dominates, but the range found in the literature varies from50 days5 to adults.12 Primary and secondary torsion of thevermiform appendix have been described. Among the pri-mary causes are abnormalities of the mesentery, such as anarrow base, as occurred in our case, the absence of azygoticfolds that normally laterally fix the appendix, and even1Department of Pediatric Surgery and 2Pediatric Department, Hospital Universitario “Dr. José E. González,” Universidad Autónoma deNuevo León, Monterrey, México. abnormal peristaltic movements.3,4,11 Still, its etiology is un-certain. Benign tumor pathology such as mucocele,13 malig-nant pathology such as cistadenoma,11 or after intestinal in-vagination10 or intestinal duplication14 have been associatedto secondary causes.Abdominal ultrasound has been used to find the vermi-form appendix, in the differential diagnosis of the most fre-quent causes of pain in the right iliac fossa,2,15 or to suggestthe diagnosis of appendicular torsion.16 In our case, the ap-pendix was not found by ultrasound because it was locatedin the subhepatic area. Computerized tomography has beenused for diagnosis in cases where the appendix was notfound.11An undescended cecum has been reported in 6% of thepopulation, predominantly in men.9 Cecal malpositionmakes the clinical diagnosis of appendicitis and appendic-ular torsion difficult, since abdominal pain is not located inthe right iliac fossa. The undescended cecum and its lackof fixation in this case contributed to the torsion of the ver-miform appendix and the lack of classical signs of appen-dicitis.Surgical treatment in pediatric patients is an appendec-tomy by the conventional approach or by laparoscopy.17,18A complete laparoscopic appendectomy can also be per-formed. Our usual approach is the transumbilical video-as-sisted appendectomy. Since we do not have optics with anoperating channel, we usually use two ports to perform atransumbilical video-assisted appendectomy. On this occa-sion, another port was necessary to separate the induratedarea where the necrotic appendix was located. The mobilececum made the transumbilical appendectomy easier.ConclusionIn our patient, laparoscopic exploration led to the diag-nosis of acute abdomen caused by appendicular torsion andan undescended mobile cecum. This case is the first reportin the literature of this type of association.AcknowledgementsThe authors thank Sergio Lozano-Rodriguez, MD, for hishelp in translating the manuscript.Disclosure StatementNo competing financial interests exist.References1. Anderson KD, Parry RL. Appendicitis. In: O’Neil JA, Jr, RoweMI, Grosfeld JL, Fonkalsrud EW, Coran AG, eds., PediatricSurgery, 5th ed. St. Louis, MO: Mosby, 1998;1369–1379.2. Rabah R. Pathology of the appendix in children: An institu-tional experience and review of the literature. Pediatr Ra-diol 2007;37:15–20.MONTES-TAPIA ET AL.840FIG. 1. Arrow at the base of the necrotic appendix indi-cating counterclockwise torsion. The diagram shows thethree turns.FIG. 2. Diagram of the three turns of appendicular torsion.The asterisk marks the liver, showing the subhepatic loca-tion of the appendix and the cecum.FIG. 3. Extraction of the appendix through the umbilicusfor video-assisted transumbilical appendectomy.3. Dewan PA, Woodward A. Torsion of the vermiform ap-pendix. J Pediatr Surg 1986;21:379.4. Lowry WL, Redman JF. Torsion of the vermiform appendix:Cause of acutely painful scrotum. Urology 1986;28:117–118.5. Yeung CK, Saing H. Primary torsion of the vermiform ap-pendix in a 50-day-old infant. Pediatr Surg Int 1991;6:223–224.6. Bowling B, Lipscomb G. Torsion of the appendix mimick-ing ovarian torsion. Obstet Gynecol 2006;107:466–467.7. Bestman TJR, van Cleemput M, Detournay G. Torsion of thevermiform appendix: A case report. Acta Chir Belg 2006;106:228–229.8. Sarin YK, Pathak D. Torsion of vermiform appendix. Ind Pe-diatr 2006;43:266–267.9. Skandalakis JE, Gray SW, Ricketts R, Richardson DD. Thesmall intestines. In: Skandalakis JE, Gray SW, eds. Embry-ology for Surgeons, 2nd ed. Baltimore, MD: William &Wilkins, 1994;184–241.10. Baeza-Herrera C, García-Cabello LM, León-Cruz A,Martínez-Rivera ML. Torsión del apéndice cecal asociada ainvaginación intestinal [Torsion of the cecal appendix asso-ciated with intestinal invagination]. Cir Ciruj 2006;74:369–371.11. Kitagawa M, Kotani T, Yamano T, Tsurudome H,Hatakeyama T, Kuriu Y, Nishi H, Yabea M. Secondary tor-sion of vermiform appendix with mucinous cystadenoma.Case Rep Gastroenterol 2007;1:32–37.12. Tzilinis A, Vahedi MH, Wittenborn WS. Appendiceal tor-sion in an adult: Case report and review of the literature.Curr Surg 2002;59:410–411.13. Udo R, Sandeep M. Volvulus of an appendiceal mucocele:Report of a case. Surg Today 2007;37:514–517.14. Oguzkurt P, Oguzkurt L, Kayaselcuk F, Oz S. An unusualcause of acute abdomen: Torsion of colonic duplicationover a duplicated appendix. Pediatr Surg Int 2004;20:722–723.15. Abu-Yousef MM. Ultrasonography of the right-lower quad-rant. Ultrasound Q 2001;17:211–225.16. Uroz-Tristan J, García-Urgelles X, Poenaru D, Avila-SuarezR, Valenciano-Fuentes B. Torsión of vermiform appendix:Value of ultrasonographic findings. Eur J Pediatr Surg1998;8:376–377.17. Gopal K, Kumar S, Grewal H. Torsion of the vermiform ap-pendix. J Pediatr Surg 2005;40:446–447.18. Koontz CS, Smith LA, Burkholder HC, Higdon K, AderholdR, Carr R. Video-assisted transumbilical appendectomy inchildren. J Pediatr Surg 2006;41:710–712.Address correspondence to:Fernando Montes-Tapia, MDDepartment of Pediatric SurgeryHospital Universitario “Dr. José E. González”Universidad Autónoma de Nuevo LeónMadero y Gonzalitos s/n, MonterreyNuevo León 64460MéxicoE-mail: ffmt@yahoo.comVERMIFORM APPENDIX TORSION AND UNDESCENDED CECUM 841

Primary torsion of the vermiform appendix and undescended cecum treated by video-assisted transumbilical appendectomy

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Primary torsion of the vermiform appendix and undescended cecum treated by video-assisted transumbilical appendectomy

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