mucoceles of the appendix are uncommon , accounting for only 0.2 to 0.3% of appendectomy specimens .
an appendiceal mucocele is a cystic dilatation of the appendiceal lumen by accumulation of mucus , and may include mucosal hyperplasia , a mucinous cystadenoma , or a mucinous cystadenocarcinoma . frequently , the diagnosis of an appendiceal mucocele is made post - operatively because the manifestations are similar to appendicitis .
laparoscopic appendectomy is widely used for the treatment of appendicitis , but laparoscopic resection of appendiceal mucoceles is not routine .
we recently managed two large appendiceal mucoceles by laparoscopic resection and report our technique herein .
a 44-year - old woman sought evaluation from a gynecologist for a palpable right lower quadrant mass .
the abdominal mass was found incidentally while bathing 2 months ago , and has persisted .
the blood chemistries and other laboratory findings were normal . a computed tomography ( ct ) scan and ultrasonography of the abdomen showed a 14  5  4.5 cm cystic mass arising from the cecum ( fig .
the patient was referred to the department of general surgery , where we discussed the surgical options and recommended a laparoscopic resection .
an 81-year - old man had a palpable right lower quadrant mass of 2 months duration and severe headaches .
brain and abdominal ct scans revealed a chronic subdural hematoma and a large , tubular , cystic appendiceal mucocele , 15  4.5  4 cm in size .
after evacuation of the subdural hematoma , a laparoscopic mucocelectomy was performed 1 month later .
because the laparoscopic procedure for cases 1 and 2 was similar , only case 1 is presented in detail . after the induction of general anesthesia
, a 10-mm trocar was placed through a supraumbilical incision using the open hasson technique because of the previous infraumbilical incision for the laparoscopic tubal ligation .
a pneumoperitoneum was made by insufflation of carbon dioxide through the supraumbilical trocar to a pressure of 13 mmhg .
one 12-mm trocar for the primary surgeon was inserted in the left lower quadrant of the abdomen . a freely - movable
a 10-mm suprapubic trocar was inserted for retraction of the mucocele during the dissection and for extraction of the specimen ( fig .
3 ) . to clear the small intestine from the surgical field , the patient was placed in the left decubitus and reverse trendelenberg position .
a laparoscopic bag was used for handling the mucocele because the surface of the mucocele was too slippery and tense to grasp .
the primary surgeon manipulated the mucocele with the use of gravity and the laparoscopic bag wrapping the body of the mucocele , thereby reducing the risk of perforation and possible intraperitoneal spillage of mucinous content ( fig .
4 ) . mobilization of the cecum from the lateral wall and division of the mesoappendix were performed using an ultrasurgical device ( harmonic scalpel , ethicon endo - surgery , cincinnati , oh , usa ) .
because there was no segment of normal appendix , the base of the cecum was resected with the mucocele .
another instrument was needed to retract the ascending colon and terminal ileum during this procedure , thus another trocar site was placed in the right upper quadrant .
the mucocele was moved to in the caudal direction by the laparoscopic bag , then an endoscopic stapling device ( multifire endo gia , 60 mm ; us surgical co. , norwalk , ct , usa ) was used to perform the partial resection of cecum . the specimen ( fig .
5 ) was extracted through the suprapubic incision extended from the suprapubic trocar site and sent to a histopathologist .
frozen and permanent histopathologic evaluations of the appendicial mucocele were reported as a mucinous cystadenoma .
a 44-year - old woman sought evaluation from a gynecologist for a palpable right lower quadrant mass .
the abdominal mass was found incidentally while bathing 2 months ago , and has persisted .
the blood chemistries and other laboratory findings were normal . a computed tomography ( ct ) scan and ultrasonography of the abdomen showed a 14  5  4.5 cm cystic mass arising from the cecum ( fig .
the patient was referred to the department of general surgery , where we discussed the surgical options and recommended a laparoscopic resection .
an 81-year - old man had a palpable right lower quadrant mass of 2 months duration and severe headaches .
brain and abdominal ct scans revealed a chronic subdural hematoma and a large , tubular , cystic appendiceal mucocele , 15  4.5  4 cm in size .
after evacuation of the subdural hematoma , a laparoscopic mucocelectomy was performed 1 month later .
because the laparoscopic procedure for cases 1 and 2 was similar , only case 1 is presented in detail . after the induction of general anesthesia
, a 10-mm trocar was placed through a supraumbilical incision using the open hasson technique because of the previous infraumbilical incision for the laparoscopic tubal ligation .
a pneumoperitoneum was made by insufflation of carbon dioxide through the supraumbilical trocar to a pressure of 13 mmhg .
one 12-mm trocar for the primary surgeon was inserted in the left lower quadrant of the abdomen . a freely - movable
a 10-mm suprapubic trocar was inserted for retraction of the mucocele during the dissection and for extraction of the specimen ( fig .
3 ) . to clear the small intestine from the surgical field , the patient was placed in the left decubitus and reverse trendelenberg position .
a laparoscopic bag was used for handling the mucocele because the surface of the mucocele was too slippery and tense to grasp .
the primary surgeon manipulated the mucocele with the use of gravity and the laparoscopic bag wrapping the body of the mucocele , thereby reducing the risk of perforation and possible intraperitoneal spillage of mucinous content ( fig .
4 ) . mobilization of the cecum from the lateral wall and division of the mesoappendix were performed using an ultrasurgical device ( harmonic scalpel , ethicon endo - surgery , cincinnati , oh , usa ) .
because there was no segment of normal appendix , the base of the cecum was resected with the mucocele .
another instrument was needed to retract the ascending colon and terminal ileum during this procedure , thus another trocar site was placed in the right upper quadrant .
the mucocele was moved to in the caudal direction by the laparoscopic bag , then an endoscopic stapling device ( multifire endo gia , 60 mm ; us surgical co. , norwalk , ct , usa ) was used to perform the partial resection of cecum . the specimen ( fig .
5 ) was extracted through the suprapubic incision extended from the suprapubic trocar site and sent to a histopathologist .
frozen and permanent histopathologic evaluations of the appendicial mucocele were reported as a mucinous cystadenoma .
the neoplastic variety of a mucocele occurs from distention of the appendiceal lumen by mucus secreted from proliferating tumor cells .
the benign form of a mucocele is a mucinous cystadenoma and the malignant form is a mucinous cystadenocarcinoma .
these lesions secrete an excess of mucus while blocking outflow into the cecum , thus creating a distended appendix .
the pre - operative diagnosis of an appendiceal mucocele is difficult due to the non - specific nature of the findings .
the classic clinical features of an obstructive appendiceal mucocele includes right lower quadrant discomfort , a palpable mass , and x - ray findings of a filling defect in the cecum with non - visualization of the appendix .
on ct and ultrasonography , a nodular , enhancing lesion in the wall of the mucocele is suggestive of malignant disease . sometimes , it is asymptomatic and discovered incidentally at surgery or during imaging evaluation for another disease . if a mucocele is found , therapy is surgical .
the appropriate type of surgical treatment is related to the dimensions and the histology of the mucocele .
an appendectomy is used for simple mucoceles or cystadenomas when the appendiceal base is intact .
cecal resection is indicated for cystadenomas with a large base , and a right hemicolectomy is recommended for cystadenocarcinomas . the 10-year survival of patients with mucinous cystadenocarcinomas is 65% among patients treated by hemicolectomy , but only 37% among patients treated by appendectomy alone . while several cases of laparoscopic treatment of appendiceal mucoceles have been reported [ 4 - 8 ]
, many authors suggest that the laparoscopic approach should be avoided because of the increased risk of rupture and subsequent pseudomyxoma peritonei .
pseudomyxoma peritonei is caused by spillage and implantation of mucin - secreting cells into the peritoneal cavity .
thus , we reasoned that the complication rate of pseudomyxoma peritonei during laparoscopic surgery would be the same as that of open surgery if a minimal - touch technique was utilized .
reported the laparoscopic resection of a 12 cm large mucocele using gravity and position during minimal manipulation of the lesion .
also reported successful laparoscopic resection of an appendiceal mucocele and suggested that conversion to a laparotomy should be considered if the lesion is grasped traumatically or if the tumor clearly extends beyond the appendix .
recently , chiu et al .   presented a case involving the successful laparoscopic resection of an 8 cm appendiceal mucinous cystadenoma .
gonzlez moreno et al .   reported a case of an appendiceal mucinous tumor resected by laparoscopy associated with subsequent diffuse peritoneal carcinomatosis .
they suggested that if distention of the appendiceal lumen is observed laparoscopically , suggesting a mucocele as a possible diagnosis , conversion to open appendectomy may be the most prudent surgical judgment .
we performed laparoscopic resections of two appendiceal mucoceles using a laparoscopic bag to retain and retract the mucocele , in addition to using gravity and position , therefore we avoided grasping the tumor directly .
the application of laparoscopic surgery has been more widely adopted in the treatment of gastrointestinal diseases , and in some cases laparoscopic surgery is currently the standard treatment . in the surgical treatment of appendiceal mucoceles , however , open surgery is currently the standard surgical treatment due to its well - known safety and easy accessibility .
the authors are also aware of the possibility of rupture during laparoscopic dissection , and the subsequent fatal complication of pseudomyxoma peritonei .
nevertheless , if we can handle the tissue with minimal manipulation , and can secure enough safety by using various laparoscopic instruments , laparoscopic resection of an appendiceal mucocele might be an alternative surgical option to open surgery .
 laparoscopic resection of appendiceal mucoceles has recently been described , but the safety and efficacy are controversial . 
 we present two cases of laparoscopic mucocelectomies involving 14 and 15 cm cystic masses originating from the appendix . 
 the laparoscopic mucocelectomies were performed using four ports . from the beginning of the procedure , 
 a laparoscopic bag was used to safely contain the mucocele , prevent rupture of the mucocele , and retract the mucocele . 
 an endoscopic stapling device was used to transect the base of the cecum . 
 minimal handling was achieved by gravity and with the use of laparoscopic instruments . 
 laparoscopic appendectomies are widely performed for acute appendicitis , but laparoscopic resection is not routinely performed for an appendiceal mucocele because of the risk of perforation and subsequent pseudomyxoma peritonei . 
 we report two cases of laparoscopic appendiceal mucocelectomies , which were performed safely with laparoscopic instruments and minimal manipulation . 