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Retroperitoneal Appendicitis: A Surgical Dilemma

Article  in  Euroasian Journal of Hepato-Gastroenterology · January 2013

DOI: 10.5005/jp-journals-10018-1070

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10.5005/jp-journals-10018-1070
Retroperitoneal Appendicitis: A Surgical Dilemma
CASE REPORT

Retroperitoneal Appendicitis: A Surgical Dilemma

Basil George Verghese, Sanjana Kalvehalli Kashinath, R Ravikanth

ABSTRACT Despite this there was only a minimal reduction in the

Introduction: Acute appendicitis is frequently encountered in patient’s symptoms. A urine sample was sent for culture
both the surgical OPD and emergency room setting. But, a and sensitivity studies which subsequently reported no
retroperitoneal appendicitis is very rarely seen and the literature growth. The patient was posted for an open appendectomy
available on it is scarce.
for the following day.
Case report: We wish to present a case of a 26 years old female During surgery, minimal collection of fluid was noted
who presented to the emergency room with features of
appendicitis and on whom an appendectomy was done. But in the RIF, but the appendix was found missing (Fig. 1).
during the surgery, the appendix was found situated Consequently, the cecum was mobilized by opening the
retroperitoneally and had to be removed via a retrograde lateral peritoneal reflection (Fig. 2) which revealed the
approach. We followed it with a short discussion of
appendix situated retroperitoneally (Fig. 3).
retroperitoneal appendix, the presentation of retroperitoneal
appendicitis and its surgical management. There was edema present of the surrounding
Conclusion: Documented cases of retroperitoneal appendix retroperitoneal structures. The appendix was around 4 cm
are rare to the best of our knowledge and should be kept as a in length, inflamed but intact with no signs of rupture. The
differential when a patient presents with atypical features of base of the appendix was healthy. As the tip of the appendix
appendicitis.
was not visualized, a retrograde appendectomy was performed
Keywords: Retroperitoneal appendix, Retrograde appendectomy, and the appendix specimen was sent for a histopathological
Abnormal positions of the appendix.
study. The biopsy reported a congestion and presence of
How to cite this article: Verghese BG, Kashinath SK,
Ravikanth R. Retroperitoneal Appendicitis: A Surgical Dilemma. acute inflammatory cells in the walls of the appendix
Euroasian J Hepato-Gastroenterol 2013;3(1):83-84. consistent with an impression of acute appendicitis. No
Source of support: Nil abdominal drain was placed, patient was nil by mouth for
Conflict of interest: None the next 24 hours.

CASE REPORT
A 26-year-old female, married, having one child presented
to our hospital emergency room with an h/o low backache
since 3 days, pain in the right lower abdomen since 2 days
and a single episode of vomiting the previous day. She
revealed that she had similar episodes in the past which
subsided after taking over the counter analgesics.
On examination her temperature was 98.6°F, pulse was
86/min, blood pressure was 130/70 mm Hg. Her last
menstrual period was 14 days back, 5/28, regular with
normal flow. Per abdomen examination elicited tenderness
in the right iliac fossa (RIF). Psoas sign was positive. Rest Fig. 1: Appendix not found at the ileocecal junction, (A) distal
ileum, (B) confluence of tenia, (C) cecum
of the systemic examination was unremarkable.
Laboratory values revealed an Hb of 11.4 gm%, a total
count of 7,500 cells/cumm and a differential count of 51%
polymorphs and 49% lymphocytes. Urine microscopy
showed 3 to 5 pus cells/hpf. Rest of the laboratory values
were within their respective normal parameters. An
ultrasound of the abdomen showed no collection in the RIF
but the appendix was not visualized. Due to financial
constraints of the patient, we were unable to perform a
computed tomographic (CT) scan of the abdomen.
A provisional diagnosis of acute appendicitis was made
with urinary tract infection as the main differential. The
patient was admitted and managed conservatively on Fig. 2: Reflection of the peritoneum after mobilizing the cecum,
analgesics and intravenous antibiotics for 8 hours. (A) cecum, (B) peritoneal reflection, (C) distal ileum

Euroasian Journal of Hepato-Gastroenterology, January-June 2013;3(1):83-84 83

Basil George Verghese et al

Ultrasound with a sensitivity of 85% and a specificity

of >90% is the preferred imaging modality in children9 while
a CT scan is best in adults and in the elderly.10
It is hazardous to remove the appendix through the
normal incision used in appendicectomy because there is
high probability of rupturing the appendix.5 A laparoscopic
appendicectomy is not possible either as the tip of the
appendix is not visualized. In these cases, a retrograde
appendectomy is the surgery of choice where the appendix
is approached and isolated via a lateral peritoneal incision
after mobilizing the right colon.
Fig. 3: Appendix located retroperitoneally, (A) distal ileum, (B)
peritoneal reflection, (C) retroperitoneum, (D) base of appendix CONCLUSION
The postoperative recovery of the patient was uneventful. The presence of a retroperitoneal appendix should be on a
She was discharged after 3 days and reviewed in the surgical surgeons mind when dealing with a patient with abdominal
OPD 3 days later for suture removal. pain with atypical features of appendicitis and a retrograde
appendectomy is the surgery of choice for a retroperitoneal
DISCUSSION appendix.
It was Reginald Fritz who first coined the term appendicitis
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pain at McBurney’s point is modified or absent.6
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On physical examination the classical sign for a induced fatal cancer from pediatric CT. Am J Roentgenol
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patient has pain on the extension of the right hip. Other 10. Weltman DI, Yu J, Krumenacker J Jr, et al. Diagnosis of acute
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1. Dunphy’s sign: Pain on coughing.
2. Rovsing’s sign: Pain in RIF on palpation on the left iliac ABOUT THE AUTHORS
fossa. Basil George Verghese (Corresponding Author)
3. Obturator sign: Pain in the hypogastrium on internal Junior Resident, Department of Medicine, St. Johns Hospital
rotation and flexion of hip suggestive of a pelvic appendix. Kattappana, Idukki, Kerala, India, e-mail: drbasilgeorge@gmail.com
4. Pointing sign: Here, the patient is asked to show where
the pain first migrated and where it subsequently migrated. Sanjana Kalvehalli Kashinath
Junior Resident, Department of Pediatrics, CG Hospital, Davangere
The white cell count is elevated with a predominantly
Karnataka, India
neutrophilic picture. A completely normal count and
differential is seen in 10% of the cases.7 Minimal pyuria R Ravikanth
maybe present as the infected appendix may come in contact Consultant Surgeon, Department of Surgery, St. Johns Hospital
with the ureter and cause its inflammation.8 Kattappana, Idukki, Kerala, India

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