Unassisted single-channel transcolonic endoscopic appendectomy for an appendiceal neuroma

A 34-year-old man was admitted with recurrent abdominal pain over the preceding 2 years. A computed tomography (CT) scan revealed chronic appendicitis and an appendiceal fecal stone ([Fig. 1]). After a comprehensive preoperative assessment had been completed, transcolonic endoscopic appendectomy was chosen.

Fig. 1 Computed tomography scan of the pelvis showing an appendiceal fecal stone with evidence of chronic appendicitis.

First, saline with indigo rouge was injected into the submucosa at the opening of the annular appendix ([Fig. 2] a). A circumferential incision was then made around the appendiceal orifice as deep as the muscularis propria with a HookKnife ([Fig. 2] b). Incision into the serosal layer was performed with an IT knife to create active perforation and the endoscope was then advanced into the peritoneal cavity ([Fig. 2] c). The appendix was gradually separated along the meso-appendix and was resected with a snare ([Fig. 2] d). After hemostasis had been carefully achieved, the post-resection defect was closed with a purse-string suture ([Fig. 2] e). A drainage tube was placed at the wound area, transanally under direct vision, and fixed to the cecal mucosa. Another drainage tube was inserted transanally into the rectum for decompression. The total procedure duration was 130 minutes. The patient recovered uneventfully and was discharged on postoperative day 4. The entire procedure is shown in [Video 1].

Fig. 2 Images from the unassisted single-channel transcolonic endoscopic appendectomy of an appendiceal neuroma showing: a an indigo rouge and saline mixture being injected into the submucosa at the opening of the annular appendix; b a circumferential incision made with a HookKnife to the depth of the muscularis propria around the appendiceal orifice; c incision of the serosal layer made using an IT knife to create active perforation; d the appendix being gradually separated along the meso-appendix; e the defect completely closed by a purse-string suture; f the resected specimen.

Unassisted single-channel transcolonic endoscopic appendectomy is performed for an appendiceal neuroma.Video 1

The final pathologic diagnosis was an appendiceal neuroma. The hematoxylin and eosin (H&E)-stained sections showed a proliferation of spindle cells in the submucosa ([Fig. 3] a). Most of these cells were positive for S100 protein ([Fig. 3] b). Appendiceal neuroma is a rare benign lesion characterized by proliferation of neural tissue due to frequent inflammatory attacks [1] [2]. The traditional treatment is open or laparoscopic appendectomy. Transcolonic endoscopic appendectomy is a new endoscopic resection technique that has developed quickly in recent years. This is the first reported case of transcolonic endoscopic appendectomy for an appendiceal neuroma; the procedure was challenging, probably owing to fibrosis of the appendix.

Fig. 3 Microscopic images of the resected appendix showing: a on hematoxylin and eosin staining, a proliferation of spindle cells; b positivity for S-100.

Endoscopy_UCTN_Code_TTT_1AQ_2AD_3AF

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Al-Janabi MH, Hasan S, Issa R. Appendiceal neuroma presented as acute appendicitis: A rare case report from Syria. Int J Surg Case Rep 2022; 98: 107532
• 2 Molina GA, Torres MA, Montenegro MS. et al. Neuroma of the appendix, a rare cause of appendicitis and an important reason for close follow-up. J Surg Case Rep 2020; 2020: rjaa023

Publication History

Article published online:
02 October 2024