Abstract
Introduction
Acute appendicitis is a common surgical emergency, typically resulting from luminal obstruction and subsequent inflammation. However, appendicitis within a hernia sac is uncommon, with ventral and incisional hernia involvement only reported sporadically in the literature. We present a rare case of appendicitis associated with an incisional hernia from ventriculoperitoneal shunt (VPS) placement.
Case Info
A 16-year-old male with a complex medical history including prematurity, hydrocephalus with VPS placement, and spastic quadriplegic cerebral palsy with baclofen pump placement presented to the emergency department with right lower quadrant abdominal pain. The patient was evaluated the day prior for emesis, right lower extremity pain, anxiety, and agitation. Imaging of the right extremity was unremarkable, though labs were significant for leukocytosis (17x10^3/uL), and elevated ANC and CPK. Symptoms improved with pain management, but the patient subsequently returned with abdominal pain. Physical exam revealed right lower quadrant tenderness without peritoneal signs. Computed tomography (CT) demonstrated a dilated (1.2 cm) fluid-filled appendix extending through the abdominal wall musculature within 2 mm of the VPS catheter. The appendix demonstrated inflammatory change without evidence of gross perforation. Pediatric surgery was consulted for management of appendicitis. Given the proximity of the appendix to the VPS, neurosurgery was also consulted pre-operatively to externalize the shunt. The patient underwent emergent laparoscopic appendectomy with debridement of the abdominal wall incision and shunt externalization. Intraoperative findings included contained appendiceal rupture with purulence contacting the VPS. Cultures obtained from the VPS subsequently grew E. coli. The patient’s postoperative course included intensive care for hypoxia and fevers, and repair of a brief shunt disconnection. He was hospitalized for 18 days between shunt externalization and reinternalization.
Disc Clinical
Abdominal complications of VPS include pseudocysts, bowel-related complications, ascites, catheter migration, and hernias. Inguinal hernias occur in approximately 13% of pediatric VPS patients aged 0–5 years, with greatest risk within two years of placement. Incisional hernias, in contrast, are a recognized but poorly characterized complication, with fewer than 10 cases reported. Appendices within hernia sacs have been extensively described for inguinal (Amyand’s) and femoral (de Garengeot) hernias, a small percentage of which present with acute appendicitis. Appendicitis within an incisional hernia is uncommon, reported only sporadically in the literature. CT is crucial for diagnosis and preoperative planning, as presentation varies with the entrapped appendix’s location, as demonstrated by our patient. Management of concurrent hernia repair depends on contamination: using mesh repair for clean fields and tissue repair for contamination. VPS presence further complicated surgical decision making for our patient. Shunt externalization or removal must be considered in a patient with potential for VPS contamination. CT can help assess proximity of infection to a VPS, while intraoperative findings may further inform decision making.
Conclusion
Appendicitis within a VPS–associated incisional hernia is, to our knowledge, previously unreported. CT guided diagnosis and treatment, as incision debridement and management of VPS contamination were required in addition to appendectomy. Awareness of this case reinforces the importance of recognizing atypical variations of common disease presentations, and how recognition of imaging findings can facilitate coordination of multidisciplinary care.