Off Course: A Rare Ureteral Complication Following Laparoscopic Appendectomy

Document Type

Conference Proceeding

Publication Date

5-21-2025

Publication Title

Surg Endosc

Keywords

creatinine, abdominal pain, acute appendicitis, acute kidney failure, adult, appendectomy, attention deficit hyperactivity disorder, bipolar disorder, bipolar electrocautery, case report, cecum, clinical article, complication, computer assisted tomography, conference abstract, contrast medium extravasation, diagnosis, double J stent, emergency ward, exercise, flank pain, follow up, hematuria, human, iliac bone, laparoscopic appendectomy, leukocytosis, male, nausea and vomiting, open appendectomy, pelvic brim, pelvic cavity, percutaneous drainage, psoas muscle, surgery, surgical technique, suture, thermal injury, ureter, ureter injury, urinalysis

Abstract

Introduction: Appendectomy is the most common general surgical procedure performed worldwide, with iatrogenic ureteral injury being extremely rare. To date, only two cases of ureteral injury following open appendectomy have been reported in the literature. We present a unique case of distal right ureteral injury following laparoscopic appendectomy in a 26-year-old patient. Case Presentation: A 26-year-old male with a history of ADHD presented to the emergency department with a one-week history of abdominal pain, nausea, and vomiting. Computed tomography (CT) of the abdomen and pelvis showed uncomplicated acute appendicitis with appendicolith. The patient underwent laparoscopic appendectomy. Intraoperatively, the cecum was mobilized using a bipolar energy device. The appendix, found to be retrocecal, dilated, and inflamed, was non-perforated with dense inflammatory adhesions. The mesoappendix was dissected using bipolar cautery, and the appendix was doubly ligated with looped PDS sutures. The patient was discharged on postoperative day (POD) 0. He returned on POD 7 with right flank pain. Laboratory results revealed acute kidney injury (creatinine 1.13 mg/dL), leukocytosis (13.8 9 109/L), and hematuria on urinalysis. A follow-up CT showed a 3 cm fluid collection and contrast extravasation near the distal right ureter. Urological surgery was consulted, and a double J stent was placed, along with percutaneous drainage of the fluid collection. The patient was discharged on POD 11. Discussion: The right ureter typically follows a retroperitoneal course along the psoas muscle, crossing the iliac vessels into the pelvic cavity. A review of the initial CT imaging revealed the ureter to be within 1 cm of the appendix base at the pelvic brim. Given this proximity and the delayed presentation (POD 7), it is likely that the injury resulted from thermal damage caused by the bipolar energy device. Conclusion: Ureteral injury following appendectomy is exceedingly rare, with this being the first known case after laparoscopic appendectomy. Surgeons should carefully evaluate the ureter's proximity on preoperative imaging and exercise caution when using thermal devices to avoid this uncommon but severe complication.

Volume

31

First Page

S195

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