Keywords
cecum - cecectomy - appendicitis - appendiceal tumors - cecal diverticulum - cecal
polyp
Introduction
The large bowel consists of four anatomical parts which include the cecum, the colon,
the rectum, and the anus. The cecum is anatomically defined as the portion of the
large bowel confined to the area below a horizontal line drawn medially to laterally
from the antimesenteric border of the terminal ileum at the ligament of Treves to
the lateral line of Toldt at the ascending colon ([Fig. 1]). The appendix is considered an appendage of the cecum. The most common disorder
of the appendix is appendicitis. However, other benign and malignant conditions can
affect both the appendix and cecum. Such pathologic states can range from infectious,
inflammatory, congenital, to neoplastic conditions. A variety of disorders affecting
the appendix and cecum have been reported including bacterial, viral, fungal, and
parasitic infections, diverticulitis of the cecum, appendiceal duplication, appendiceal
mucocele, neural derived tumors like paraganglioma and schwannoma, neuroendocrine
tumors, polyps, and carcinoma.[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10] While most patients with benign disorders of the appendix are treated by appendectomy,
a subset of patients such as those with necrosis of the appendiceal base from gangrenous
appendicitis or benign tumors extending into the appendiceal orifice require more
than the conventional appendectomy. Furthermore, a subset of patients with cecal pathology
require complete cecal resection. While an uncommon scenario, some patients have undergone
ileocolic resection or segmental colectomy for benign disorders of the appendix and
cecum when a cecectomy alone would have been a sufficient treatment.[10]
Fig. 1 Anatomic definition of the cecum.
The purpose of this article was to report our experience with laparoscopic cecectomy
and to illustrate the technical steps of this operation with a video.
Materials and Methods
Institutional review board and administrative approval was obtained for the study.
A retrospective review was performed of all patients who underwent laparoscopic cecectomy
over a 16-year period. All operations were conducted by a single board-certified colon
and rectal surgeon [MAA]. Data abstracted included patients' demographics, intraoperative,
and postoperative data. Long-term follow-up was obtained from the chart review.
The indication for laparoscopic cecectomy was based on preoperative imaging (Computed
tomography of the abdomen and pelvis or ultrasound) ([Fig. 2]) and/or colonoscopy ([Fig. 3]).
Fig. 2 Computer tomography axial and coronal views of abnormally dilated appendix [arrow].
Fig. 3 Colonoscopy view of an abnormal cecum due to extrinsic compression by an appendiceal
tumor.
The operation was performed in the supine position under general endotracheal anesthesia.
All patients received intravenous antibiotics within 1 hour prior to incision (cephalosporins
with metronidazole and for patients with severe penicillin allergy ciprofloxacin with
metronidazole). Additional doses of antibiotics were administered selectively in patients
with appendicitis. No oral mechanical bowel preparation was given.
The surgeon stood at the left side of the operating table along with the assistant
camera holder. The monitor and insufflating device were positioned next to the patient
right shoulder. All operations were performed laparoscopically using a 3-trocar technique:
5 mm trocars in the left lower quadrant and the lower midline, in addition to a 12 mm
supraumbilical trocar ([Fig. 4]). After establishing a pneumoperitoneum to 15 mm Hg, the patient was placed in the
Trendelenburg position with the left side down in order to keep the small bowel out
of the way. The ligament of Treves along with the mesoappendix were divided using
the Ligasure™ device (Medtronic, Minneapolis, Minnesota, USA). The ascending colon
was partially mobilized to its mid portion from a lateral to medial approach in order
to free it from its lateral and retroperitoneal attachments. This maneuver ensured
full mobility of the cecum for safe and complete transection. The cecum was transected
with 1 to 2 firings of the 60 mm purple load linear stapler (Medtronic, Minneapolis,
Minnesota, USA). The stapler was oriented horizontally along the antimesenteric border
of the terminal ileum for complete excision of the cecum while preserving the ileocecal
valve to avoid any stricture [see
[Supplementary Material Video 1]] ([Fig. 5]). Stapler line should be checked for integrity after the resection to avoid any
post operative leak ([Fig. 6]). The specimen was retrieved with an endocatch bag through the supraumbilical trocar
site which was slightly enlarged depending on the specimen bulk (Medtronic, Minneapolis,
Minnesota, USA). The supraumbilical trocar site was closed with several single interrupted
sutures using Vicryl 2.0 and the skin was approximated with Vicryl 2.0 subcuticular
stitch (Ethicon, Somerville, Massachusetts, USA).
Fig. 4 Trocars placement for laparoscopic cecectomy.
Fig. 5 Stapler position before resection. See the direction of the stapler marked with yellow
line preserving of the ileocecal valve by limiting the resection to the cecum to minimize
any potential negative functional impact
Fig. 6 Stapler line after resection.
Supplementary Material Video 1
Most patients were admitted for overnight observation. Full liquid diet was administered
within 4 hours of operation and advanced to a regular diet within 24 to 48 hours of
operation.
Results
During the study period, 19 patients (12 females, 63.2%) underwent laparoscopic cecectomy.
Median age was 42 years (range 16-84 years). [Table 1] represents the intraoperative and postoperative outcomes. Median estimated blood
loss was minimal (25 milliliters). No patient required blood transfusion. There were
no intraoperative or postoperative complications. No patient was converted to open
surgery. Median length of stay was 1 day and only 1 patient required hospitalization
for 6 days for psychiatric reasons. Appendiceal pathology was more common than cecal
pathology (12 patients, 63.2%). Appendicitis with necrosis and/or involvement of the
base was the most common reason for laparoscopic cecectomy, followed by benign appendiceal
tumors and cecal polyps (2 tubular adenoma and 2 tubulovillous adenoma). Interval
cecectomy for prior localized perforation of the appendix revealed fibrosis and scarring
without evidence of neoplasm in 2 patients. In the patients with polyps or neoplastic
lesions, none had a positive margin. During a median follow-up of 16 months (range
4-53), no patients required segmental colectomy.
Table 1
Intraoperative and postoperative outcome of 19 patients who underwent laparoscopic
cecectomy
|
|
|
N = 19
|
|
Intraoperative
|
|
|
|
|
|
Median estimated blood loss (range) in milliliters
|
25 (0-150)
|
|
|
Conversion to open
|
0%
|
|
|
Complications
|
0%
|
|
Postoperative
|
|
|
|
|
|
Complications
|
0%
|
|
|
Median length of stay (range) in days
|
1 (0-6)
|
|
|
Readmission
|
0%
|
|
|
Long-term need for re-operation
|
0%
|
|
Final pathology
|
|
|
|
|
Appendix
|
|
12 (63.2%)
|
|
|
Appendicitis [acute or chronic]
|
5 (26.3%)
|
|
|
Mucinous cystadenoma
|
4 (21%)
|
|
|
Fibrous obliteration
|
2 (10.5%)
|
|
|
Carcinoid
|
1 (5.3%)
|
|
Cecum
|
|
7 (36.8%)
|
|
|
Adenoma
|
4 (21%)
|
|
|
Intramucosal carcinoma
|
1 (5.3%)
|
|
|
Diverticulitis
|
1 (5.3%)
|
|
|
Submucosal lipoma
|
1 (5.3%)
|
Discussion
This retrospective study reported a surgeon's experience with laparoscopic cecectomy
and highlighted the technical steps of the operation. With proper selection of patients
with benign pathology of the appendix and cecum, the outcome of laparoscopic cecectomy
was very favorable with minimal morbidity while properly addressing the underlying
pathology.
The interest in publishing this study stems from the senior author's own encounters
with patients who underwent ileocolic resection or segmental colectomy by surgical
colleagues for benign disorders of the appendix and cecum. While such resections are
indicated in select cases, in most excising more than the cecum is a surgical overtreatment.
This more aggressive stance is probably due to a combination of factors, including
the uncertainty of diagnosis preoperatively in some patients, an overestimation of
the impact of some benign pathology, the concerns about a potential need to reoperate
and remove the right colon if unfavorable pathology, and an incomplete understanding
of the large bowel anatomy. While most surgeons in practice receive proper anatomical
education in their formative years, it is the senior's author observation that there
is at times confusion between the definition of the large bowel and the colon. The
large bowel as stated earlier has 4 parts: the cecum, the colon, the rectum, and the
anus. Similarly, the colon has 4 parts: the ascending, the transverse, the descending,
and the sigmoid. A clear understanding of the difference between these 2 definitions
and an appreciation for the cecal anatomy as a separate part of the large bowel provides
the surgeon with clarity and the ability to tailor an operation to the patient's need.
When indicated, a laparoscopic cecectomy carries several advantages compared to colectomy
including shorter operative time, less blood loss, less risk for intraabdominal sepsis,
and less risk for small bowel obstruction. Furthermore, the functional outcome following
colonic resection can vary from no change in bowel habits to frequent bowel movements
and diarrhea in a minority of patients due to the loss of the ileocecal valve. While
the function of the appendix and cecum remains poorly understood, a role in regulating
the human microbiome has been proposed.[11] Further investigation remains essential to understanding the role played by the
appendix and cecum. Preservation of the ileocecal valve by limiting the resection
to the cecum when clinically indicated can minimize any potential negative functional
impact.[12]
[13] Avoidance of ileocolic resection or segmental right hemicolectomy, when possible,
can hopefully decrease the small, albeit significant risk of diarrhea and its impact
on quality of life.[13]
[14] Cecectomy has been previously established as a viable alterative to appendectomy
in severe cases of appendicitis when a surgeon is concerned at the quality of the
tissue at the base of the appendix.[15] This role has expanded beyond appendicitis to include benign neoplastic conditions.
When properly selected, laparoscopic cecectomy can be curative in many patients with
benign conditions. However ileocolic resection or right hemicolectomy should be considered
for cases where a negative cecal margins cannot be achieved [such as large polyps
involving the ileocecal valve] or when there is a high index of suspicion for malignancy
based on endoscopic appearance of a cecal lesion or suspicious lymph nodes on cross
sectional imaging.
Conclusions
Laparoscopic cecectomy is a safe and effective procedure. Laparoscopic cecectomy should
be considered as an alternative to segmental bowel resection in select patients with
benign pathology of the appendix and cecum. A clear appreciation of large bowel and
cecal anatomy coupled with a good understanding of the various appendiceal and cecal
disorders can assist the surgeon in determining the ideal candidates for this operation.
