Management of Appendiceal Mucocele
Appendiceal mucocele requires careful surgical resection with meticulous technique to prevent rupture and pseudomyxoma peritonei, with the surgical approach ranging from simple appendectomy to right hemicolectomy depending on the size, base involvement, and histopathological findings.
Preoperative Diagnosis and Imaging
CT or ultrasound imaging is essential when mucocele is suspected, as accurate preoperative diagnosis fundamentally changes surgical planning and technique to avoid catastrophic complications 1, 2, 3.
Patients over 50 years presenting with right lower quadrant pain should undergo CT imaging rather than proceeding directly to surgery based on clinical suspicion alone 3.
Colonoscopy must be performed in all patients with appendiceal mucocele, as there is a significant association with synchronous colorectal malignancies 1.
Surgical Management Strategy
For Small, Simple Mucoceles (<2cm, no base involvement):
Laparoscopic appendectomy is acceptable if the mucocele is small, the base is not involved, and meticulous technique prevents rupture 4, 5.
The appendix must be removed intact without perforation, as spillage of mucin can lead to pseudomyxoma peritonei 5, 2.
For Large Mucoceles or Base Involvement:
Open surgery is strongly preferred over laparoscopy to minimize risk of intraoperative rupture 3.
Right hemicolectomy or ileocecal resection should be performed when the mucocele has a broad base involving the cecum, measures >2cm, or when malignancy cannot be excluded 1, 5, 3.
Laparoscopy-assisted partial cecum resection can be considered for intermediate cases where the base is minimally involved 4.
Critical Intraoperative Principles
Avoid any manipulation or compression of the mucocele that could cause rupture 5, 2.
If rupture occurs intraoperatively, immediate conversion to right hemicolectomy with copious peritoneal lavage is mandatory 5.
The entire peritoneal cavity must be inspected for mucin deposits if rupture is suspected 5.
Histopathological Considerations
The surgical adequacy depends on final histology 5:
- Simple mucocele or retention cyst: Appendectomy alone is sufficient
- Mucinous cystadenoma: Appendectomy with negative margins is adequate 1, 3
- Cystadenoma with uncertain malignant potential (UMP): Right hemicolectomy is recommended 5
- Mucinous cystadenocarcinoma: Right hemicolectomy with oncologic margins is mandatory 5
Postoperative Management
All patients require long-term surveillance for pseudomyxoma peritonei, even after apparently complete resection 5.
Repeat colonoscopy is essential given the association with colorectal malignancies 1.
Follow-up imaging (CT or ultrasound) should be performed at regular intervals to detect recurrence or peritoneal disease 5.
Common Pitfalls to Avoid
Never perform laparoscopic appendectomy without preoperative imaging when mucocele is suspected, as inadequate resection or rupture dramatically worsens prognosis 2, 3.
Do not assume a cystic appendiceal mass is benign—up to 20% may harbor malignancy requiring more extensive resection 5.
Failure to perform colonoscopy misses synchronous colorectal cancers present in a significant proportion of these patients 1.
Laparoscopic approach in elderly patients (>50 years) with appendiceal masses should be avoided in favor of open surgery with adequate exposure 3.