Small Bowel Obstruction Due to Appendix Adhesion to an Aortic Graft

Background: Small bowel obstruction (SBO) is a common cause of surgical consultation. Adhesion bands, internal hernias, tumors and many other causes need to be considered. If non-operative management fails, exploratory laparoscopy or laparotomy is indicated.

Case Report: A 63 year old male with multiple comorbidities had undergone open aortobifemoral bypass grafting for occlusive disease. The graft failed as the patient was non-compliant with medical management and he underwent right below knee amputation. During the following 3 months, he had multiple emergency room visits for recurrent abdominal pain and vomiting. He ultimately was admitted with complete SBO and CT-scan showed a transition point in the mid-ileum. A mass in the tail of the pancreas was also found. He initially responded to non-operative management, however, upon oral challenge SBO relapsed and decision for surgery was made. On laparoscopy, the transition point was identified and strangulation was found to be caused by the appendix, which crossed the midline. The appendix base at the cecum was identified but the tip could not be found. Therefore, the appendix base was stapled off and the vascular pedicle was secured. The small bowel could be freed and the appendix was followed and cut out of dense adhesions to the aortic graft; pathology indicated chronic appendicitis. The patient recovered without complications from this surgery.

Conclusions: This is a very unusual case of SBO caused by an appendix, which became adhered to an aortic graft. It remains unclear if this pathology was caused by post-operative inflammation or if the patient had appendicitis. Laparoscopic exploration is useful in the management of SBO that does not resolve with non-operative management.