Federico L Gattorno, MD, MC, FACS1, Keisha Bonner, MD2, Antonio F Chua, MD1, Ricardo Siller, MD2. 1NYU School of Medicine-Woodhull Medical Center, 2Woodhull Medical Center
Acute appendicitis is one of the most common causes of the acute abdomen and one of the most common indications for an emergent abdominal surgical procedure worldwide. Ten percent of the adult population will have cholelithiasis, 1-4 % develops symptoms and 20% of those patients develop acute cholecystitis. Acute appendicitis and acute cholecystitis are among the most common pathologies seen on general surgery practice, however, they are seldom observed in a simultaneous or synchronous fashion. The coexistence of acute appendicitis and acute cholecystitis has been explained by few authors, with only few case literatures reported. Having awareness of the possibility of this double diagnosis will allow clinicians to entertain this differential in the patient with acute abdomen where the physical examination and the imaging present a mixed picture. We also aimed to describe the use of standard laparoscopic cholecystectomy port placements to achieve both cholecystectomy and appendectomy in a single setting.
A 41 year old man with significant past medical history of benign heart arrhythmia presented to the emergency department complaining of right upper abdominal pain of 10 days duration. This was associated with vomiting, fever and chills. On physical examination the abdomen was soft with mild tenderness to the right upper and lower quadrants, there was no rebound tenderness or guarding present. Blood Laboratory analysis revealed no leukocytosis. Abdominal CT scan revealed a fluid filled dilated appendix with mural enhancement concerning for acute appendicitis. Diffuse gallbladder wall edema was demonstrated as well on the CT scan with no biliary duct dilation but with periportal free fluid, this was confirmed with an abdomen ultrasound, concerning for possible acute cholecystitis. Patient underwent emergent laparoscopic cholecystectomy and appendectomy. This was approached by umbilical Hasson port insertion, and three 5mm port insertion in the epigastric region and right midclavicular and anterior axillary subcostal spaces as for standard laparoscopic cholecystectomy. The gallbladder was visualized and appeared acutely inflamed with marked distention and edematous wall, appendix was also visualized and appeared dilated and hyperemic. After the gallbladder was removed, the appendectomy was performed using the same cholecystectomy ports: the epigastric and midclavicular ports were used as working ports to remove the appendix. Patient tolerated the procedure well with no complications and was discharged on postoperative day 3. Pathological evaluation of the appendix revealed changes consistent with early acute appendicitis. The gallbladder pathology showed acute cholecystitis superimposed on chronic cholecystitis with focal gangrenous change.
This paper aims to shed light on the possibility of a dual diagnosis of acute appendicitis and acute cholecystitis and to bring it to the awareness of clinicians who frequently evaluate patients with acute abdomen. Also we describe for the first time in the literature simultaneous laparoscopic appendectomy and cholecystectomy through the same ports as used for standard cholecystectomy.