When a patient is taken to theatre for a laparotomy, surprises can still be found despite modern investigative techniques. We present the case of two rare abdominal pathologies (an appendicoileal fistula and an intra-abdominal testis adherent to the vermiform appendix) being found simultaneously and review the literature on these topics.
Case historyA 68-year-old man of Chinese origin presented to the emergency department with a 2-day history of abdominal pain. His past medical history was unremarkable, save for a previous history of intestinal Ascaris lumbricoides infestation treated in China with herbal medication many years previously. Clinical examination revealed generalised abdominal tenderness and plain abdominal radiography revealed dilated loops of small bowel, suggestive of small bowel obstruction. Laboratory investigations were borderline. Computed tomography (CT) of the abdomen showed a marked thickened small bowel wall, raising the possibility of mesenteric ischaemia (Fig 1). However, serum lactate concentration was normal. CT also raised the possibility of an obstructing lesion in the sigmoid colon. The decision was taken to optimise the patient physiologically before proceeding to an exploratory laparotomy.On opening the abdomen with a midline incision, a large amount of turbid fluid was encountered together with dense adhesions between much of the small bowel, which was significantly distended. Adhesions were divided with blunt and sharp dissection, and all bowel was viable. The sigmoid colon appeared unremarkable with no palpable mass. Further adhesions were found around the caecum and the terminal ileum, which were divided. Dissection revealed a side-toside anastomosis between the midportion of the vermiform appendix and a segment of terminal ileum approximately 15cm from the ileocaecal valve. The tip of the appendix appeared to consist of a solid mass (Fig 2).The appendix was ligated and removed, and 10cm of the terminal ileum containing the fistula was excised. A primary anastomosis formed between the segments, retaining the ileocaecal valve. The patient was transferred to the intensive care unit postoperatively for one day, before being discharged to a general surgical ward, where he made an uneventful recovery.