{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2024,9,21]],"date-time":"2024-09-21T12:40:24Z","timestamp":1726922424570},"reference-count":21,"publisher":"BMJ","issue":"1","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Trauma Surg Acute Care Open"],"accepted":{"date-parts":[[2018,12,18]]},"published-print":{"date-parts":[[2019,1]]},"abstract":"<jats:sec><jats:title\/><jats:sec><jats:title>Case summary<\/jats:title><jats:p>A 57-year-old woman with morbid obesity (body mass index [BMI] of 43), systemic lupus on steroids, type 2 insulin-dependent diabetes, peripheral vascular disease, unprovoked pulmonary embolism on rivaroxaban, and hypertension presented with 3 days of worsening abdominal pain and nausea. She had an extensive surgical history including a cesarean section, multiple laparotomies for small bowel obstructions (one complicated by bowel perforation requiring resection), and a double-barrelled ileostomy, which had been since reversed. As a result, she had a massive incisional hernia (figure 1). On presentation she was afebrile but tachycardic at 110 beats per minute. Physical examination revealed tenderness to deep palpation in the right upper and lower quadrants. CT demonstrated an 11 mm appendix with an appendicolith outside the hernia sac abutting the right kidney, discontinuity of the appendix tip, free fluid, and associated stranding in the subhepatic region (figure 2A). She was admitted to the surgical floor for a trial of conservative management with ancef and flagyl. On day 3, her pain worsened, her white cell count remained stable at 12 x10<jats:sup>9<\/jats:sup>\/L, her temperature was 37.8\u00b0C, she was not tachycardic, and a repeat CT showed a 15 mm perforated appendix with increased periappendiceal stranding and an associated small volume of free fluid. There was no phlegmon or organized abscess (figure 2B).<\/jats:p><jats:fig position=\"float\" id=\"F1\" orientation=\"portrait\"><jats:label>Figure 1<\/jats:label><jats:caption><jats:p>Patient\u2019s abdomen demonstrating midline laparotomy incisional scar, previous ileostomy scar, and massive ventral hernia.<\/jats:p><\/jats:caption><jats:graphic xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"tsaco-2018-000243f1\" position=\"float\" orientation=\"portrait\"\/><\/jats:fig><jats:fig position=\"float\" id=\"F2\" orientation=\"portrait\"><jats:label>Figure 2<\/jats:label><jats:caption><jats:p>Abdominal CT showing increased stranding centered around the appendix, with discontinuity of the wall of the appendix tip and free fluid within the abdomen and pelvis. (A) Admission CT. White arrow: appendix. (B) CT on postadmit day 3 as patient worsened clinically. Black arrow: fecalith.<\/jats:p><\/jats:caption><jats:graphic xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" xlink:href=\"tsaco-2018-000243f2\" position=\"float\" orientation=\"portrait\"\/><\/jats:fig><\/jats:sec><\/jats:sec><jats:sec><jats:title>What would you do?<\/jats:title><jats:list list-type=\"order\"><jats:list-item><jats:p>Continue non-operative management with broadened intravenous antibiotic coverage and bowel rest.<\/jats:p><\/jats:list-item><jats:list-item><jats:p>Laparoscopic \u00b1 open appendectomy without concomitant hernia repair.<\/jats:p><\/jats:list-item><jats:list-item><jats:p>Laparoscopic \u00b1 open appendectomy with abdominal wall reconstruction.<\/jats:p><\/jats:list-item><\/jats:list><\/jats:sec>","DOI":"10.1136\/tsaco-2018-000243","type":"journal-article","created":{"date-parts":[[2019,1,25]],"date-time":"2019-01-25T11:29:36Z","timestamp":1548415776000},"page":"e000243","update-policy":"http:\/\/dx.doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":4,"title":["Perforated appendicitis in the setting of a massive ventral hernia, morbid obesity, and multiple severe comorbidities: challenges in acute management"],"prefix":"10.1136","volume":"4","author":[{"given":"Graham","family":"Skelhorne-Gross","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David","family":"Gomez","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2019,1,24]]},"reference":[{"key":"2024092105050532000_4.1.e000243.1","doi-asserted-by":"publisher","DOI":"10.1097\/SLA.0b013e31811f3f9f"},{"key":"2024092105050532000_4.1.e000243.2","doi-asserted-by":"publisher","DOI":"10.1016\/j.surg.2009.11.013"},{"key":"2024092105050532000_4.1.e000243.3","first-page":"CD011670","article-title":"Early versus delayed appendicectomy for appendiceal phlegmon or abscess","volume":"6","author":"Cheng","year":"2017","journal-title":"Cochrane Database Syst Rev"},{"key":"2024092105050532000_4.1.e000243.4","doi-asserted-by":"crossref","first-page":"889","DOI":"10.1097\/SLA.0000000000002039","article-title":"Antibiotics versus surgical therapy for uncomplicated appendicitis: systematic review and meta-analysis of controlled trials (prospero 2015: CRD42015016882)","volume":"265","author":"Harnoss","year":"2017","journal-title":"Ann Surg"},{"key":"2024092105050532000_4.1.e000243.5","doi-asserted-by":"crossref","first-page":"1129","DOI":"10.1097\/TA.0000000000001450","article-title":"Operation versus antibiotics--The \"appendicitis conundrum\" continues: A meta-analysis","volume":"82","author":"Sakran","year":"2017","journal-title":"J Trauma Acute Care Surg"},{"key":"2024092105050532000_4.1.e000243.6","doi-asserted-by":"crossref","unstructured":"Podda M . 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