Laparoscopic Management of Stump Appendicitis after Open Appendectomy

Appendicitis is a common disease with a highly standardised and simple treatment; however, in certain circumstances, its management may involve serious difficulties [1-3]. Stump appendicitis is a very rare complication of appendectomy that requires a reoperation and complete removal of the appendix [4,5]. We present a case of stump apendicitis after open appendectomy removed using a laparoscopic approach.


Introduction
Appendicitis is a common disease with a highly standardised and simple treatment; however, in certain circumstances, its management may involve serious difficulties [1][2][3]. Stump appendicitis is a very rare complication of appendectomy that requires a reoperation and complete removal of the appendix [4,5]. We present a case of stump apendicitis after open appendectomy removed using a laparoscopic approach.

Case Presentation
We report a 41 years old female patient with a history of open appendectomy performed 7 months ago. According to the information gathered from the patient and the available medical records, it was a difficult open appendectomy that lasted 2.5 hours, performed for a gangrenous appendicitis with localized peritonitis. The patient received intravenous antibiotics for 7 days, being discharged on postoperative day 8. She presented now with persistent typical signs of appendicitis, identical with those encountered before the open appendectomy. At local examination, a healed 7 cm length scar was noted in the right iliac fossa, corresponding to a typical McBurney incision ( Figure 1). Repeated US and CT scans were normal.
Due to the persistent complaints, a decision for exploratory laparoscopy was made ( Figure 1). During the dissection of the adhesions from the right iliac fossa we found a 20 mm length appendicular stump whose tip was adherent to the anterior abdominal wall in the area of the scar from previous surgery, corresponding to the preoperative location of the pain. The stump was dissected with a hook and monopolar cautery, ligated at the base and removed using a 3 trocars approach and standard laparoscopy instruments. A left 20 mm diameter ovarian cyst with hemorrhagic content was also discovered and removed (Figures 2  and 3). The duration of the procedure was 90 minutes.
The postoperative course was favorable, with regain of transit after 24 hours and discharge after 4 days. The pathologic examination showed the typical histologic structure of an inflamed appendix ( Figure 4). The complaints of the patient disappeared immediately after surgery, with no recurrence at a 3 years follow-up.

Discussions
The first case of stump appendicitis was published by Rose [6] in 1945, so at almost 50 years after this procedure has become widely accepted as the treatment of choice for acute appendicitis. The exact incidence of this complication is not known and many cases are probably not reported; however, in the published literature there are only case-reports and reviews. In a review of the English literature, Subramanian and Liang found only 61 cases, which demonstrates an obvious low incidence [7].
The main difficuly is the corect diagnosis [1,4,5]. Although many cases (including the one presented by us) may present with suggestive clinical signs, the diagnosis of appendicitis after appendectomy is difficult to accept by both the patient and the surgeon, which leads to a late diagnosis and an increased rate of complications [8]. As Volume 12 • Issue 1 • 8 demonstrated by our case, a high index of suspicion is the key to the early diagnosis of this entity [9]. In our patient, the exploratory laparoscopy proved to be a both diagnostic and therapeutic tool,    allowing an effective management before the ocurrence of other complications.
Based on some case-reports, some authors suggest that this complication occurs more often after laparoscopic appendectomy due to the absence of a three dimensional field and the absence of tactile perception [10,11]. Although a steady statistical analysis is difficult to perform due to the rarity of this complication, the published reviews showed that this complication occurs after both laparoscopic and open appendectomy [4,8,12]. In fact, the laparoscopic approach is associated with a better visualisation due to the magnification. The key for preventing this complication is a clear visualisation of the base of the appendix [13]. In our case, laparoscopy was used to diagnose and treat a complication of open appendectomy.

Conclusions
The case is interesting due to the rarity and the use of the laparoscopic approach for the diagnosis and removal of the remnant appendicular stump after an open appendectomy. Laparoscopy is useful in patients with persistent abdominal symptoms after appendectomy. If an appendicular stump is present, it allows both an early diagnosis before the occurrence of other complications and its safe removal.