Residual appendix producing small-bowel obstruction after laparoscopic appendectomy.

A 36-year-old woman was investigated at a local hospital for persistent, intense pain in her right lower abdomen. Diagnostic laparoscopy revealed minor intraabdominal adhesions. An EVS was used during the resultant appendectomy. Histopathologic examination revealed a normal appendix. Ten days after discharge, the patient came to the emergency room with feculent vomiting and cramping abdominal pain. Her abdomen was distended and diffusely tender, with no signs of peritonitis. Abdominal radiographs were consistent with an incomplete, distal SBO. Non-operative management failed, and she was transferred to our institution for further management. A computed tomographic assessment of the abdomen with oral and rectal contrast fluids showed dilation of the small bowel up to a point in the right lower quadrant marked by surgical staples. The patient was taken to the operating room and the subumbilical incision opened. Under direct vision we inserted a 10-mm cannula, established pneumoperitoneum and introduced a 10-mm 30° camera. We placed a 10-mm working port in her left-lower quadrant and another 5-mm port above the pubic bone. There was a moderate amount of serous ascites and distended small bowel. The patient was positioned in steep Trendelenberg position, rotated to the left. At the point of obstruction, we identified a length of residual appendix (Fig. 1); the tip was adherent to the mesentery of the terminal ileum, resulting in an internal hernia. Mobilization of the residual appendix released an incarcerated segment of small bowel. We dissected the base of the appendix completely, ligated the residual appendix with an Endoloop (Ethicon, Cincinnati, Ohio) and excised it. The patient was discharged from hospital on the third day after her operation. Her recovery was uneventful, and 7 months later she was well.