Intricacies in the surgical management of appendiceal mucinous cystadenoma: a case report and review of the literature

INTRODUCTION Mucinous cystadenoma is a type of mucocele of the appendix that is rarely encountered in clinical practice. Dogmatic consensus on the optimal surgical modus operandi of appendicular mucocele is lacking in the literature and this remains a subject of controversy. There is little agreement with regard to the best procedure (right hemicolectomy versus appendectomy) or the best surgical approach (laparoscopic versus laparotomy). CASE PRESENTATION We report the case of a 70-year-old Asian woman from Karachi who presented with pain in the right iliac fossa for 15 days. On physical examination, a mobile and firm mass was palpable in the right iliac fossa. A colonoscopy was performed which showed external compression of the cecum. A biopsy of the mucosa was normal. Computed tomography scan showed a mucocele of the appendix with minimal periappendiceal fat stranding. She underwent an initial diagnostic laparoscopy to evaluate any mucin spillage in the peritoneal cavity. Once no spillage was identified, an open appendectomy was then performed. Intra-operatively, a frozen section of the appendiceal sample was sent to ascertain the need for an extension of surgery to a right hemicolectomy. Absence of any malignancy on the frozen section obviated the need for a surgical extension. The final histopathological examination showed a mucinous cystadenoma of the appendix. The patient was symptom-free at one year after surgery. CONCLUSION It is important to distinguish between mucinous cystadenomas and mucinous cystadenocarcinomas. However, this distinction remains elusive in the pre-operative setting. A simple appendectomy using an intra-operative frozen section appears to be a reasonable surgical approach for selected cases with an intact mucocele of the appendix. However, long-term follow-up is warranted in such patients to evaluate the risks of using this approach.