Treatment of Appendiceal Mucocele
Surgical resection via appendectomy is the definitive treatment for appendiceal mucocele, with the critical imperative being intact removal to prevent pseudomyxoma peritonei—a potentially fatal complication that occurs when mucin-producing epithelial cells spread throughout the peritoneal cavity. 1, 2
Surgical Approach Selection
The choice between laparoscopic and open surgery depends primarily on surgeon expertise and mucocele characteristics, though minimally invasive techniques are increasingly supported when performed by experienced surgeons.
Laparoscopic Approach
- Laparoscopic resection is feasible and safe for appendiceal mucoceles when performed by surgeons with advanced laparoscopic expertise 1, 3
- A case series of 24 consecutive patients demonstrated no intraoperative mucin spillage with laparoscopic management, including simple appendectomy (4.2%), partial cecectomy (62.5%), and ileocecal resection (33.3%) 3
- Robotic-assisted and hand-assisted laparoscopic approaches have been successfully employed for intact mucocele removal 2
- Mean operative time ranges from 40-205 minutes, with minimal postoperative morbidity (4.2% wound infection rate) 3
Open Surgery Considerations
- Open surgery may be preferred when there is concern about potential rupture, when the mucocele is large, or when laparoscopic expertise is unavailable 1
- Traditionally recommended as the standard approach due to concerns about intraoperative rupture 2
Critical Intraoperative Principles
- The mucocele must remain intact during resection—any rupture can seed the peritoneum with epithelial cells, causing pseudomyxoma peritonei 2, 4
- Resection margins must be negative for tumor 3
- The extent of resection ranges from simple appendectomy to partial cecectomy or ileocecal resection, depending on tumor size and base involvement 3
Follow-Up and Surveillance
For patients ≥40 years old with appendiceal mucocele, both colonoscopy and interval full-dose contrast-enhanced CT scan are recommended due to the 3-17% incidence of appendicular neoplasms in this age group. 5, 1
Surveillance Protocol
- Colonoscopy screening is mandatory for patients ≥40 years old 1
- Interval contrast-enhanced CT scan should be performed 5, 1
- Long-term follow-up is warranted given the potential for delayed complications 3
Interval Appendectomy Considerations
- Routine interval appendectomy is NOT recommended after non-operative management in young adults (<40 years) and children 5, 1
- Interval appendectomy should only be performed for patients with recurrent symptoms 5, 1
Common Pitfalls to Avoid
- Failure to recognize the mucocele preoperatively leads to inappropriate surgical technique and increased rupture risk 6
- Attempting laparoscopic resection without adequate expertise increases the risk of intraoperative rupture 1, 2
- Inadequate follow-up in patients ≥40 years old misses underlying malignancy 1
- Treating appendiceal mucocele as routine acute appendicitis without special precautions for intact removal 6, 4