these tumors are rarely associated with clinical manifestations ; therefore , they are usually discovered incidentally at the time of surgery , frequently in association with acute appendicitis .
its clinical significance lies in the possible rupture and consequent spillage of mucin into the peritoneal cavity , leading to pseudomyxoma peritonei . even if laparoscopy has been successfully used to perform appendectomy
, some concerns exist regarding its use in dealing with mucinous secreting lesions because of possible spillage of mucin during surgery .
the role of laparoscopic resection in the management of appendix tumors is not well defined in the literature .
we report the case of a large ( 10 cm  6 cm ) low - grade appendiceal mucinous neoplasm , for which a formal right hemicolectomy was successfully performed using a laparoscopic approach .
the patient was a 60-year - old doctor who was recently diagnosed with an appendicular tumor while being investigated for vague abdominal pain .
pneumoperitoneum was achieved via a veress needle and intraabdominal pressure maintained at 12 mm hg .
the patient was placed in the trendelenburg position with a left lateral tilt to facilitate the bowels to fall away from the right abdomen .
five ports were placed in the upper abdomen : ( 1 ) 10-mm port 2 cm above the umbilicus ;
( 2 ) 5-mm port ( right working hand ) in the left midclavicular line ; ( 3 ) 5-mm port ( left working hand ) in the right iliac fossa ; ( 4 ) 10-mm port ( for bowl retraction ) in the epigastrium ; ( 5 ) 10-mm port in the hypogastrium .
initially , with the telescope in the umbilical port , the lesion was identified as a large spherical tumor ( figure 1 ) .
the telescope was now moved to the hypogastric port , a 5-mm harmonic shears was placed in the umbilical port , and an atraumatic grasper was placed in the right iliac fossa port . the grasper was used to gently probe the tumor , taking care not to grasp it or handle it .
so the decision to perform a formal right hemicolectomy was made , and dissection was commenced by incising the visceral peritoneum adjacent to the ileocecal junction ( figure 2 ) .
the dissection was now continued in the avascular facial plane of toldt ( figure 3 ) , visualizing and preserving the right ureter and gonadal vessels .
the ileocolic , right colic , and right branch of the middle colic vessels were ligated with the ligasure ( valleylab , usa ) sealing device ( figure 4 ) .
a 5-cm incision was made by enlarging the umbilical port and a wound protector applied to it .
end - to - end ileocolic anastomosis was performed extracorporeally with 00 pds sutures in a single - layer fashion .
orally , liquids were allowed on the second postoperative day ( pod ) and semisolids the next day .
the drain tube was removed on the fourth pod , and the patient was discharged on the fifth pod .
histopathology report was consistent with low - grade appendiceal mucinous neoplasm characterized by herniation of mucin into the muscularis propria , forming a  diverticulum . 
the lesion was seen involving the base of the appendix , with no evidence of malignant cells or infiltrating pattern ( figure 5 ) .
the patient was followed up for 24 months and has had no recurrence so far .
histopathology : herniation of mucin into the muscularis propria , with no evidence of malignant cells or infiltrative pattern  possibility of  low - grade appendiceal neoplasm . 
they are found in less than 2% of appendectomies and are associated with appendiceal perforation in 20% of cases . quite often ,
other neoplasia like adenocarcinoma of the colon and ovaries coexist , so an intraoperative exploration of the whole abdomen and colonoscopy , especially in patients over 60 years of age , is desirable .
the 5-year survival rate is 100% in cases of benign mucocele and about 45% in malignant cases .
the existing terminology on appendiceal tumors do not provide an accurate description , underplaying the considerably high mortality and morbidity associated with these lesions .
so the term  low - grade appendiceal mucinous neoplasm  was coined by misdraji et al at harvard medical school to provide a more realistic perspective .
however , a right hemicolectomy should be considered for patients with malignant mucinous lesions or if a benign tumor involves the base of the appendix .
the latter was the case in our patient making it impossible to achieve a tumor - free margin at surgery , so we proceeded with a formal laparoscopic right hemicolectomy . also , if a mucocele is more than 2 cm in size , it is more likely to be neoplastic . in our patient ,
the indications for the laparoscopic approach to the resection of these tumors have not yet been established definitively .
some investigators have argued that laparos - copy does not increase the risk of local recurrence or metastasis after tumor resection over that associated with open surgery .
as evidence of the benefits associated with laparoscopic appendectomy accumulates , an increasing number of resections for appendiceal tumors are being performed via laparoscopy . despite growing evidence favoring the laparoscopic approach ,
gonzales et al reported a case of laparoscopic mucocele resection that was followed by early peritoneal progression , forcing them to conclude that this entity was a contraindication to laparoscopic resection .
we have published our series of 8 patients with appendiceal mucocele who successfully underwent laparoscopic resection at our institute .
data indicate that whether the resection of appendiceal carcinoids is accomplished via laparoscopy or the open approach , long - term results are similar .
however , only a few cases of appendiceal tumors not of the carcinoid type have been resected thus far by the laparoscopic approach .
even though our patient had no recurrence or spillage , experience with the laparoscopic resection of appendiceal neoplasms is still not sufficient , and therefore it may be wise to use the open approach in centers with little laparoscopic experience . as the technique of laparoscopic appendectomy evolves , the feasibility of resecting appendiceal neoplasms via this approach should also be assessed .
data from some studies indicate that laparoscopic appendectomy for the management of appendix neoplasms is associated with long - term results comparable to those obtained with open appendectomy .
our case report adds to the existing data regarding the safety of laparoscopy for cases of appendiceal neoplasm .
the wound protector that we applied will prevent port - site seeding . currently , opinion among surgeons regarding the laparoscopic treatment of appendiceal tumors stands divided .
we are of the opinion that laparoscopic surgery can be used for appendiceal tumors as well , provided certain precautions are taken .
we believe that the laparoscopic approach is safe if performed by an experienced surgeon . also , the benefits of minimally invasive surgery like reduced hospital stay , less pain , better cosmesis , and early return to work can also be utilized .
conversion to laparotomy should be considered only if the lesion is traumatically grasped and ruptures in the peritoneal cavity .
 tumors of the appendix are rare entities causing mucoceles . 
 the majority of them are discovered incidentally during investigation for other conditions . 
 laparoscopic surgery for appendiceal tumors is still controversial , as inadvertent rupture of the lesion due to improper handling will cause pseudomyxoma peritonei . 
 the patient was incidentally discovered to have an appendiceal tumor and referred to us for laparoscopy . because the tumor involved the entire appendix , a laparoscopic right hemicolectomy 
 was performed without directly handling the tumor . 
 postoperative recovery was uneventful . 
 pathological diagnosis was low - grade appendiceal mucinous neoplasm . 
 the safety of laparoscopic appendectomy for the management of incidentally discovered appendiceal tumors has not yet been established . 
 several reports in the literature support both laparoscopic and open surgery . 
 the main concerns to be addressed are the adequacy of resection and intraperitoneal rupture of the tumor . 
 our patient successfully underwent laparoscopic surgery without any complications . 
 a formal right hemicolectomy was performed because the tumor involved the entire appendix . 
 we now think laparoscopic surgery for appendiceal tumors is safe , feasible , and even may be beneficial . 
INTRODUCTION
CASE REPORT
RESULTS
DISCUSSION
CONCLUSION