Retro-mesocolic Appendix: a Diagnostic Dilemma and Surgical
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A 30-year-old presented with right side severe abdominal pain for 2 days; his abdominal symptoms were much more severe than signs. He had tachycardia. Leucocyte count was 20,000/cmm; USG abdomen done elsewhere was equivocal. Urgent CECT scan of the abdomen was done in view of the diagnostic dilemma, which revealed retro-mesocolic severely inflamed appendix coursing behind the ileocaecal junction going upward medial to ascending colon and posterior to right mesocolon, and the tip of the appendix was behind the proximal transverse colon.

The retro-mesocolic appendix was responsible for lesser abdominal signs compared with symptoms. He underwent laparoscopic appendectomy, which required complete lateral to the medial mobilization of the right colon and hepatic flexure. Common positions of the vermiform appendix are retrocaecal, pelvis, subcaecal, pre- and post-ileal, and paracaecal. Various studies have reported different frequencies of these positions. During the pre-laparoscopic era, odd positions of the appendix may pose difficulty while doing appendectomy through McBurney’s incision, but in laparoscopic surgery, the majority of common positions can be dealt with easily.

There are few rare positions that have been reported in the literature, like the subhepatic appendix, lateral pouch appendix, or associated with malrotations. To the best knowledge, it is the first case to report a retro-mesocolic appendix which posed the diagnostic dilemma due to lesser abdominal signs compared with the symptoms. This position required complete mobilization of the right colon and hepatic flexure to perform an appendectomy which is not a part of the routine procedure. A surgeon who is not well versed with advanced laparoscopic surgery may need to open the abdomen.

Source: https://link.springer.com/article/10.1007/s12262-020-02595-z#citeas
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