AJR 2005; 185:81-83
© American Roentgen Ray Society
CT-Guided Kopans Hookwire Placement for Preoperative Localization of an Appendicolith
Steven V. Lossef1
1 Department of Radiology, Children's National Medical Center, 111 Michigan
Ave., NW, Washington, DC 20010.
Received June 14, 2004;
accepted after revision September 16, 2004.
Address correspondence to S. V. Lossef.
Abstract
OBJECTIVE. Retained appendicoliths that have spilled into the
peritoneal cavity after appendectomy may act as a nidus for recurrent abscess.
Appendicoliths are often small and located in inaccessible recesses of the
peritoneum, making surgical localization and removal difficult. The objective
of the study was to facilitate surgical removal of an appendicolith using a
Kopans breast localization hookwire placed with CT guidance.
CONCLUSION. Preoperative CT-guided localization of small
inaccessible retained appendicoliths can be readily performed using a Kopans
hookwire.
Introduction
Appendicoliths (also known as fecaliths) are small calcified
aggregations of inspissated vegetable matter that become lodged within the
appendix, causing obstruction and inflammation
[1]. Retained appendicoliths
are uncommon but may occur after laparoscopic and open appendectomy. In one
study [2], appendicoliths were
initially overlooked and resulted in delayed abscesses in 0.72% of 554
patients who underwent surgery for perforated appendicitis. Although every
attempt is made to remove any appendicoliths along with the appendix at the
time of appendectomy, occasionally one may spill into the peritoneal cavity,
eluding the surgeon.
Current opinion is that all retained appendicoliths are potentially
infectious because they harbor bacteria and act as a nidus for recurrent
infection and abscess formation
[3]. Ideally, spilled
appendicoliths should be removed. Unfortunately, appendicoliths are usually
small, are often surrounded by a necrotic rind of tissue, and are sometimes
located in inaccessible recesses of the peritoneum, making surgical
localization and removal technically difficult. In this article, I describe
the use of a Kopans breast localization hookwire placed with CT guidance to
facilitate surgical identification and removal of an appendicolith along with
the surrounding necrotic tissue.
Materials and Methods
An 11-year-old girl underwent laparoscopic appendectomy to remove a
ruptured appendix at an outside hospital. During laparoscopy, the urinary
bladder was iatrogenically injured, requiring conversion to laparotomy for
repair of a bladder laceration. After being discharged from the hospital, the
patient experienced right upper quadrant pain and intermittent fevers over a
4-month period.
Abdominal CT was performed eventually and showed an 8-cm abscess in the
posterior subhepatic space (Morison's pouch) containing a 3- to 4-mm focal
calcification that was believed to be a retained appendicolith
(Fig. 1A). The patient was
transferred to our institution and underwent CT-guided insertion of a
10-French pigtail drainage catheter via the Seldinger technique using a right
posterior lower intercostal approach. Fifty milliliters of foul-smelling pus
was aspirated, and the catheter was connected to an external drainage bag. The
patient was discharged to a pediatric rehabilitation center. After the patient
had received IV antibiotics for 4 weeks, drainage from the catheter ceased and
the patient became afebrile.
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Fig. 1A —11-year-old girl with abscess in posterior subhepatic space
containing calcified appendicolith. CT scan shows 8-cm abscess in posterior
subhepatic space (Morison's pouch) containing 3- to 4-mm focal calcification,
believed to be retained appendicolith.
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A CT scan was then obtained with the catheter still in place. This showed
resolution of the abscess collection. No distinct calcified appendicolith
could be seen on the CT scan, and the catheter was removed. Another CT scan
was obtained after removal of the catheter because it seemed possible that the
radiodense drainage catheter might have obscured a small adjacent
calcification. This was indeed the case, and the follow-up CT scan of the
upper abdomen obtained after removal of the drainage catheter showed complete
resolution of the subhepatic abscess but persistence of a small calcification
between the liver and right kidney (Fig.
1B). A decision was made to surgically remove it to minimize the
risk for the development of a future abscess due to the retained
appendicolith. However, at this point, the drainage catheter was no longer in
place to help guide the surgeon to the appendicolith. Because of the small
size of the appendicolith, the likelihood of surrounding chronic inflammation,
and the location in the posterior subhepatic space, CT-guided needle
localization was performed.
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Fig. 1B —11-year-old girl with abscess in posterior subhepatic space
containing calcified appendicolith. CT scan shows that abscess has resolved
after percutaneous drainage but appendicolith persists.
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After administration of general anesthetic to the patient and placement of
the patient in the prone position, a 20-gauge needle (Kopans Breast Lesion
Localization needle, Cook) was advanced up to the appendicolith using axial CT
guidance via a lower right posterior intercostal approach
(Fig. 1C). A posterior right
intercostal approach was selected because it was the only way to avoid
transgressing the adjacent liver and right kidney with the needle. The
surgeons found this route to be acceptable for surgical removal of the
appendicolith. A 25-cm-long hookwire (Kopans modified hookwire, Cook) was then
inserted so that the barbed hook was deployed adjacent to the appendicolith
(Fig. 1D). The patient was
immediately transported to the operating room with the Kopans wire secured to
the skin and underwent surgical exploration through a small incision made
alongside the Kopans hookwire between the 10th and 11th ribs.
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Fig. 1C —11-year-old girl with abscess in posterior subhepatic space
containing calcified appendicolith. CT scan shows tip of 20-gauge needle has
been advanced up to appendicolith via lower right posterior intercostal
approach.
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Fig. 1D —11-year-old girl with abscess in posterior subhepatic space
containing calcified appendicolith. CT scan shows barbed hook of Kopans
modified hookwire (Cook) has been deployed adjacent to appendicolith.
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A thick fibrous cavity, located just above Gerota's fascia, that contained
the small appendicolith and surrounding necrotic fat was completely removed. A
follow-up abdominal CT scan obtained 2 months later because of vague abdominal
pain showed no evidence of abscess, active abdominal infection, or retained
appendicolith.
Discussion
Preoperative insertion of a modified hookwire using imaging guidance was
described by Kopans and DeLuca
[4] for localizing occult
breast lesions. Hookwires have also been used for preoperative localization of
small musculoskeletal lesions
[5] and small lung lesions
[6]. In addition to its use for
localizing musculoskeletal and lung lesions, the Kopans needle can also be
used for preoperative localization of small lymph nodes and soft-tissue
neoplasms [7]. This type of
hookwire is readily available to the radiologist and is well suited for
localizing a small appendicolith that is buried in fibrotic and necrotic
tissue and located in an inaccessible recess of the peritoneal cavity.
Preoperative localization allowed surgical extraction of the appendicolith
with all the surrounding inflammatory tissue using a small incision.
Injection of a dye, such as methylene blue, was not used for preoperative
localization in this case because the barb of the Kopans hookwire appeared to
be firmly embedded in relatively dense tissue immediately adjacent to the
calcification. Methylene blue could have been used in addition to the Kopans
hookwire if the calcification had been located in a less secure tissue, such
as adipose tissue.
The idea of percutaneous removal with a stone basket was briefly considered
but was rejected because fecaliths may be fragile and can break into small
irretrievable fragments once the basket is tightened around the stone.
In conclusion, preoperative CT-guided localization of small inaccessible
retained appendicoliths can be readily performed using a Kopans hookwire.
Precise hookwire localization facilitates surgical removal of the
appendicolith.
References
- Chapman P, Milner SM. Escaped faecolith after appendectomy.
Br J Surg 1986;73:1006[Medline]
- Horst M, Eich G, Sacher P. Postappendectomy abscess: the role of
fecaliths [in German]. Swiss Surg2001; 7:205
-208[CrossRef][Medline]
- Strathern DW, Jones BT. Retained fecalith after laparoscopic
appendectomy. Surg Endosc1999; 13:287
-289[CrossRef][Medline]
- Kopans DB, DeLuca S. A modified needle-hookwire technique to
simplify preoperative localization of occult breast lesions.
Radiology1980; 134:781[Abstract/Free Full Text]
- Morrison WB, Sanders TG, Parsons TW, Penrod BJ. Preoperative
CT-guided hookwire needle localization of musculoskeletal lesions.
AJR 2001;176:1531
-1533[Free Full Text]
- Shah RM, Spirn PW, Salazar AM, et al. Localization of peripheral
pulmonary nodules for thoracoscopic excision: value of CT-guided wire
placement. AJR1993; 161:279
-283[Abstract/Free Full Text]
- Finch IJ. Preoperative CT-guided percutaneous localization of small
masses with a Kopans needle. AJR1991; 157:179
-180[Free Full Text]
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Abstract
Introduction
