Treatment of Appendiceal Mucocele
Surgical resection is the recommended treatment for mucocele of the appendix to prevent complications such as pseudomyxoma peritonei. 1
Surgical Approach Options
Laparoscopic Approach
- Laparoscopic surgery is feasible and safe for managing appendiceal mucocele due to mucinous cystadenoma when performed by surgeons with advanced laparoscopic expertise 2
- Careful handling of the specimen is critical to avoid rupture and spillage of mucin into the peritoneal cavity, which could lead to pseudomyxoma peritonei 2, 3
- Special safety measures should be implemented during laparoscopy to prevent iatrogenic perforation and peritoneal seeding 3
Open Surgical Approach
- Open surgery may be preferred in cases where there is concern about potential rupture or when laparoscopic expertise is not available 4
- The approach should be determined based on the size of the mucocele, surgeon's experience, and risk of rupture 1, 5
Extent of Surgical Resection
The extent of surgical resection depends on the size and characteristics of the mucocele:
- Simple appendectomy: Appropriate for small, benign-appearing mucoceles without involvement of the base of the appendix 2, 6
- Partial cecectomy: Recommended when the base of the appendix is involved but the cecum appears normal 2
- Ileocecal resection or right hemicolectomy: Indicated for larger mucoceles, suspected malignancy, or involvement of the cecum 2, 5
Important Considerations
- All mucoceles greater than 2 cm should be excised to remove potentially premalignant lesions 5
- Intraoperative spillage of mucin must be avoided as it can lead to pseudomyxoma peritonei 2, 3
- Negative resection margins should be confirmed to ensure complete removal 2
- For patients ≥40 years old with complicated appendicitis (including mucocele), both colonoscopy and interval full-dose contrast-enhanced CT scan are recommended for follow-up 4
Risk Factors for Malignancy
Certain clinical findings are associated with higher likelihood of malignancy in appendiceal mucoceles:
- Presence of symptoms, particularly abdominal pain and weight loss 5
- Presence of an abdominal mass on examination 5
- Evidence of mucocele extravasation 5
- Pseudomyxoma peritonei 5
Follow-up Recommendations
- Long-term follow-up is warranted after surgical treatment of appendiceal mucocele 2
- For patients ≥40 years old, colonoscopy screening is recommended due to the higher incidence of appendicular neoplasms (3-17%) in this age group 4
- Interval appendectomy is not routinely recommended after non-operative management for complicated appendicitis in young adults (<40 years old) and children, but should be performed for those with recurrent symptoms 4
Common Pitfalls to Avoid
- Misdiagnosis as acute appendicitis, which may lead to inappropriate surgical approach 1, 3
- Rupture of the mucocele during surgery, which can lead to pseudomyxoma peritonei 2, 3
- Inadequate resection margins, which may lead to recurrence 2
- Failure to follow up patients, especially those ≥40 years old who have higher risk of underlying malignancy 4