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Vermiform Appendix within a Left Extraumbilical Port-site Hernia: Appendiceal Port-site Evisceration

The increasing popularity of laparoscopic surgery is attributed, in part, to reductions in the length of hospital stay and postoperative recovery, but aside from these benefits, it will also expose patients to increased risks of “new” complications such as portsite metastasis and port-site hernia (PSH) formation. The presence of the vermiform appendix has been described in most of the anatomically recognized abdominal hernias, but has only been reported three times in a PSH since the advent of laparoscopy.13 We describe, the first to our knowledge, case of appendiceal entrapment in a left upper quadrant port site. A 63-year-old male presented to our department with a large swelling in the left upper abdomen, which developed after laparoscopic umbilical hernia repair done three years ago. He had noticed this swelling about two years after surgery, and his abdominal pain was of recent onset. Though reducible, standing the swelling was very prominent and caused local pain. He was diagnosed to have a 10-mm PSH, which was confirmed by ultrasonography. After meticulous evaluation of his records, we did not find history of situs in versus or any other comorbidities. Open surgery through a transverse incision made over the swelling was performed for this hernia was decided, and a large defect of about 15 cm was identified. The hernia sac could easily be identified, after splitting the external oblique muscle fibers. The sac was opened, and it contained cecum and vermiform appendix (Fig. 1). The neck of the sac was about 7 mm in diameter, which was widened more to push back the cecum into the abdominal cavity. The abdominal cavity was explored by inserting a finger through the hernia defect and no adhesions were found. The sac was excised, the defect closed with 1–0 polypropylene, and a polypropylene mesh was placed over the internal oblique muscle and fixed with 1–0 polypropylene sutures (Fig. 2). The external oblique muscle was approximated with 2–0 polyglactin sutures over the mesh. The skin and subcutaneous tissues were approximated with staples. The patient had uneventful recovery and remained asymptomatic without recurrence about six months after surgery. Incisional hernia is one of the complications after laparoscopy, with a reported incidence of between 0.14 and 22 per cent,4 but the actual incidence may be higher, because many patients remain asymptomatic or do not return to the primary surgeon. The contents of these trocar site herniae have been omentum, small bowel, caecum, ascending colon, and vermiform appendix.4 The early signs of a complicated trocar site hernia can be excessive pain, swelling at the site, and discoloration similar to hematoma. Intermittent or complete bowel obstruction may occur later. Clinical suspicion and liberal use of CT scanning can help the diagnosis in the early postoperative period,1 because CT can even indicate about the viability of the bowel.2 Ultrasound examination is useful in nonemergent situations. Surgery is the only option, which involves definition of the hernia sac, reduction of hernia contents by enlarging the defect whether needed, removal of excess sac whether necessary, followed by fascial defect closure and mesh enforcement. Bowel resection may be needed whether viability is compromised. Several factors contribute to the development of a PSH, like wound infection, obesity, and the diameter and the location of the port (common being the 10-mm port at the umbilicus, though some case reports of hernia at 5 and 3 mm trocar sites are available).3 Trocar DM and AAt designed the data extraction. DM, AAt, ES, AAn, PS, and EM performed the data analysis. TD reviewed the manuscript. DM wrote the paper. Address correspondence and reprint requests to Eleftherios Spartalis, M.D., M.Sc., Ph.D., 2nd Department of Propedeutic Surgery, University of Athens, Medical School, Vasilissis Sofias 49, Athens 106 76, Greece. E-mail: eleftherios.spartalis@gmail.com.