A 70-Year-Old Man With Deteriorating Mental Status and Pain

Gamal A. Bebars, MD, FRCS; Evelyn P. Bebars, MD, FPCR

Disclosures

October 23, 2018

The patient in this case underwent exploratory laparotomy using a long midline incision rather than a limited inguinal incision. This choice allowed for satisfactory exploration of the entire abdomen, incision and drainage of all the intraperitoneal and pelvic abscesses, and generous peritoneal lavage. Intraoperatively, the cecum was found firmly adherent to the anterior abdominal peritoneum in the right inguinal region. With gentle traction of the cecum, the appendix was extracted from the inguinal hernial sac through the internal ring; approximately 15 mL of greenish, fecal-smelling pus were extracted as well.

The appendix was severely inflamed, gangrenous, and perforated in many locations. Appendectomy was performed and the peritoneal cavity was irrigated with copious amounts of warm normal saline solution. Hernioplasty was not performed as the presence of pus or perforation of the appendix is an absolute contraindication to the placement of a mesh for hernia repair because this greatly increases the chances of postoperative surgical site infection.[7] A rectal tube was introduced at the conclusion of surgery to facilitate closure of the abdominal incision and was removed shortly after the patient's recovery from anesthesia.

The patient's postoperative course was without incident. Bowel movements were present starting on the second postoperative day and the patient gradually began tolerating oral feeding. Postoperative investigations revealed a consistent improvement of all major systems. The patient was discharged on the eighth postoperative day in good overall condition.

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