JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 18, Number 4, 2008

© Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2007.0190

Case Report

Laparoscopic Drainage of Postappendectomy-

Retained Fecalith and Intra-abdominal Abscess
in the Pediatric Population

Christopher J. Abularrage, MD,1 Sara Bloom, MD,1 David A. Bruno, MD,1 Anna Goldfarb, MD,1
Joseph J. Abularrage, MD, MPH,2 and A. Alfred Chahine, MD1,3

Abstract

Retained fecalith after an appendectomy is an uncommon complication frequently associated with intra-ab-
dominal abscess. Treatment options include percutaneous, open, or laparoscopic drainage of the abscess and
retrieval of the fecalith, as antibiotics and drainage alone are usually insufficient. Laparoscopy offers the ad-
vantages of enhanced visualization of the abdomen, improved cosmesis, and a quicker return to normal daily
activities. The principles of laparoscopic treatment include the careful identification of all anatomic landmarks,
as the abscesses are frequently adherent to intra-abdominal structures compromising the safety of the opera-
tion. In this paper, we present 2 cases of laparoscopic drainage of an intra-abdominal abscess with retrieval of
a fecalith in pediatric patients 1 and 6 weeks after an initial appendectomy and a review the literature.

Introduction pendicitis, for which he was treated with an open appen-

dectomy and intravenous (IV) antibiotics. At the time of sur-

A PPENDECTOMY REMAINS ONE OF the most common opera-

tions performed by pediatric surgeons. Approximately
300,000 patients underwent an appendectomy in the United
States in 2002, with 70,000 of those patients being less than
15 years of age.1 Since the first report in 1963, retained fe-
calith after appendectomy has been recognized as a cause of
postoperative intra-abdominal abscess.2 With the advent of
advanced laparoscopic techniques, treatment of this compli-
cation has become possible in a minimally invasive manner.
This is especially applicable to the pediatric population in
whom laparotomies, with their associated extensive dissec-
tions and considerable operative scars, lead to increased
morbidity and prolonged hospital stays.
Case 1
A healthy 10-year-old male presented to an outside hos-
pital with complaints of right lower quadrant pain. A com-
puted tomography (CT) scan showed acute perforated ap-
gery, the appendix was found to be necrotic and, by report,
fell apart upon dissection. He was discharged on postoper-
ative day 2 after an uncomplicated hospital course. He de-
veloped fevers, generalized abdominal pain, and bilious
emesis 1 week later. He had tenderness in the left lower
quadrant and a white blood cell count of 26,000. Repeat CT
scans showed two left lower quadrant intra-abdominal ab-
scesses and a retained fecalith (Fig. 1). He was transferred to
our institution, where he underwent a CT-guided percuta-
neous drainage of the abscesses with pigtail catheters and
treatment with IV antibiotics. After 7 days of drainage, an
ultrasound revealed a resolution of the abscesses, and a fis-
tulogram through the pigtail catheters ruled out communi-
cation with the intestines. The catheters were removed and
he was discharged home to complete a 3-week course of IV
antibiotics.
One week after the discontinuation of the antibiotics, the
patient presented to the emergency room with 24 hours of
recurrent fever to 39°C and generalized abdominal pain.

1Division
of Pediatric Surgery, Georgetown University Hospital, Washington, DC.
2Department of Pediatrics, New York Hospital Queens, Flushing, New York.
3Department of Surgery, Children’s National Medical Center, Washington, DC.

644
LAP DRAINAGE OF RETAINED FECALITH
FIG. 1. Abdominal computed tomography scan of Case 1
one week after an initial open appendectomy showing ini-
tial intra-abdominal abscess with retained fecalith (arrow).
Physical exam revealed a tender abdomen and palpable mass
with guarding in the left lower quadrant. A CT scan con-
firmed an intra-abdominal abscess around the retained fe-
calith (Fig. 2). The patient was brought to the operating room
for the laparoscopic drainage of the abscess and retrieval of
the fecalith. An incision was made in the prior appendec-
tomy site, and the abdomen was entered with a 12-mm tro-
car, using the Hasson technique. After insufflation, inspec-
tion of the abdomen revealed an abscess attached to the
anterior abdominal wall that was formed medially by loops
of small bowel and omentum, and inferolaterally by the rec-
tum and mesorectum. Two 5-mm trocars were placed under
direct vision in the right periumbilical region and right up-
per quadrant. Gentle blunt and hydrodissection were used
to free the omentum and small bowel from the abscess, and
the rectum from the anterior abdominal wall. The medial
wall of the abscess was clearly identified and entered. A
moderate amount of pus was drained and sent for culture.
Examination of the interior of the abscess cavity revealed a
mass that was suspicious for a retained portion of the ap-
pendix with appendicolith (Fig. 3).
The abscess was then carefully dissected free from the rec-
tum and mesorectum en bloc and placed in an endoscopic
retrieval bag. The abdomen was irrigated copiously, the
FIG. 2. Computed tomography scan of Case 1 (A) and ultrasound (B) of abdomen after percutaneous drainage showing
recurrent abscess and retained fecalith (arrow).
645
pneumoperitoneum was evacuated, and the skin and sub-
cutaneous tissues were closed in standard fashion. The pa-
tient was placed on broad-spectrum IV antibiotics for 5 days
and discharged home with oral antibiotics to complete a 2-
week course. Twelve months postoperatively, he is doing
well without abdominal pain and is tolerating a regular diet.
Case 2
A previously healthy 3-year-old female presented to our
emergency room with a 3-day history of right lower quad-
rant pain. On physical exam, she had tenderness in the right
lower quadrant with peritoneal signs. The white blood cell
count was 15,000. A CT scan showed a locally perforated ap-
pendicitis and a 5-mm focal calcification consistent with a fe-
calith (Fig. 4). The patient was brought to the operating room
for a laparoscopic appendectomy. Findings at the time of sur-
gery included a perforated, retrocecal appendix and dilated
loops of small bowel. The laparoscopic appendectomy was
performed without complication, although the fecalith could
not be identified due to obscuration by the bowel. The pa-
tient did well and was discharged on postoperative day 3.
Ten days later, the patient returned to the emergency room
with fevers and worsening abdominal pain. She had ten-
derness in the lower abdomen and a CT scan that showed
two abscesses and a retained fecalith (Fig. 5). She was placed
on IV antibiotics and underwent a transrectal drainage of the
fluid collection by interventional radiology. On hospital day
number 3 after discussion with the family, the patient was
brought back to the operating room for the drainage and re-
trieval of the fecalith secondary to the likelihood of repeated
intra-abdominal infectious complications.
The previous circumumbilical incision was reopened and
the abdomen was entered with a 12-mm trocar, using the
Hasson technique. After insufflation, inspection of the ab-
domen revealed adhesions to the previous suprapubic tro-
car site. Therefore, two 5-mm trocars were placed under di-
rect vision, one in the previous left lower quadrant incision
and one in the left upper quadrant. After an extensive ad-
hesiolysis, a confluence of the ileum, cecum, and rectum was
identified (Fig. 6). The space between this confluence was
dissected bluntly to reveal multiple small fecaliths within the
abscess cavity (Fig. 7). The fecaliths were removed with
cupped pituitary forceps, and the abscess cavity was irri-
646 ABULARRAGE ET AL.

FIG. 3. Intraoperative photographs of Case 1 showing (A) abscess cavity (large arrow) with retained appendix (small ar-
row) and (B) magnified view of retained appendix with fecalith (arrow).

FIG. 4. Initial computed tomography scan of Case 2 showing sagittal (A) and coronal views (B) of fecalith (arrow) and
surrounding inflammatory changes consistent with acute, perforated appendicitis.

FIG. 5. Computed tomography scan of Case 2 showing right lower quadrant and pelvic abscesses with retained fecalith
(arrow).
LAP DRAINAGE OF RETAINED FECALITH 647

scess. Prevention of leaving a fecalith is of paramount im-

portance to avoid infectious complications. Gentle handling
of the appendix and careful inspection of the abdominal cav-
ity after the completion of the procedure can be used to avoid
pulverization of the appendix and retention of a fecalith. Re-
trieval of the specimen with an endoscopic bag may help
prevent spilling the specimen and its contents into the ab-
domen.
Surgeons must have a high index of suspicion when pa-
tients present with an intra-abdominal abscess after appen-
dectomy. Diagnostic tests include roentgenography, ultra-
sound, and CT scan. Plain radiographs are economic but
have a poor negative predictive.18 Ultrasound is noninva-
sive, but technician dependent, and limited in its ability to
evaluate the entire abdomen in a time-efficient manner. The
CT scan is able to evaluate the entire abdomen, as well as
quickly assess for multiple fecaliths. Using bone-window set-
FIG. 6. Intraoperative photograph of Case 2 showing con- tings increases sensitivity from 31.3% to 62.5%, compared to
fluence of the ileum, cecum, and rectum surrounding the soft-tissue windows.8 CT scanning is further beneficial in its
fecalith. ability to determine whether the fecalith is free floating
within the abdominal cavity or contained within an abscess
cavity. It may also delineate the position of the fecalith in re-
gated copiously. The pneumoperitoneum was evacuated,
lation to other vital structures, which is an important aspect
and the skin and subcutaneous tissues were closed in stan-
of preoperative planning in the pediatric population due to
dard fashion. The patient had an uncomplicated postopera-
the limited amount of space in the abdominal cavity when
tive course. She completed a 7-day course of IV antibiotics
performing laparoscopy.
while in the hospital and was discharged on oral antibiotics
Extraction of a retained fecalith is mandatory, given the
for another 7 days. At the 6-month follow-up, she was with-
association with intra-abdominal abscess. This can be ac-
out abdominal pain and tolerating a regular diet.
complished by using percutaneous, open, or laparoscopic
approaches. Percutaneous extraction has been successfully
Discussion
employed once for retained fecalith after appendectomy.9
The presence of a fecalith in patients with right lower O’Shea et al. employed the tract formed by a percutaneous
quadrant pain has been the subject of much debate regard- drain used to treat an intra-abdominal abscess. The tract was
ing the proper diagnosis and treatment. Certain studies have dilated to 20 Fr, and balloon catheters were used extract the
shown that the presence of a fecalith provides no additional fecalith. The patient was readmitted 6 weeks later with re-
diagnostic value in the absence of inflammatory changes of current pain in the right lower quadrant and a retained cal-
the appendix and surrounding mesentery,3,4 whereas others culus, although she was discharged after appropriate anti-
have shown that it is a sensitive marker for distinguishing biotic therapy. The advantage of this technique is that it is
acute appendicitis from some other pathology.5,6 In one minimally invasive, and patients can be discharged the same
study, appendicoliths were identified in acute appendicitis
twice as often as in cases of a noninflamed appendix.7 Fur-
ther, the incidence of an appendicolith in a perforated ap-
pendicitis was significantly greater than in cases of uncom-
plicated acute appendicitis.
Including the current report, retained appendicolith lead-
ing to intra-abdominal abscess formation after the operative
management of acute appendicitis has been reported 27
times in the literature (Table 1). Eighteen cases were after an
open appendectomy, and 9 cases were after a laparoscopic
appendectomy. In pediatric patients, the median time to di-
agnosis of the retained fecalith was 1.5 weeks (average, 8).
Percutaneous drainage of the abscess was attempted in 5
cases and failed in all but 1. Laparoscopic drainage of the ab-
scess and retrieval of the fecalith has been performed five
times previously. To our knowledge, these are the first re-
ported cases of laparoscopic retrieval in the pediatric popu-
lation.
It is impossible to determine the true risk of abscess for-
mation after retained fecalith because of the lack of report-
ing of uncomplicated cases. Nevertheless, it seems impera-
tive to be aware of the presence and location of a fecalith at FIG. 7. Intraoperative photograph of Case 2 showing the
the time of the initial appendectomy or reexploration for ab- fecalith within the abscess cavity.
 TABLE 1. REPORTED CASES OF RETAINED FECALITHS AFTER APPENDECTOMY

Patient age at Abscess formation Previous

original Original after percutaneous
Author appendectomy appendectomy appendectomy Abscess location abscess drainage Fecalith retrieval

Current report case 1 10 years Open 1 week Periumbilical Yes Laparoscopic

Current report case 2 3 years Laparoscopic 10 days RLQ, Pelvic Yes Laparoscopic
Chapman et al.14 24 years Open 6 weeks Subhepatic No Open
Chapman et al.14 25 years Open 17 months Right Iliac Fossa No Open
Lossef et al.15 11 years Converted open 4 months Subhepatic No Open
Geoghegan et al.16 23 years Laparoscopic 10 days Pelvic Yes Open
Guillem et al.17 29 years Laparoscopic 3 weeks Pelvic No Open
Ng et al.10 22 years Laparoscopic 5 days RLQ No Laparoscopic
O’Shea et al.9 37 years Open 6 weeks Right Iliac Fossa No Percutaneous
Rahili et al.11 47 years Laparoscopic 1 year Subhepatic No Laparoscopic
Rahili et al.11 42 years Laparoscopic 2 years Subhepatic No Laparoscopic
Smith et al.12 28 years Laparoscopic 3 weeks Subhepatic Yes Laparoscopic
Horst et al.18 9 years Open 17 months RLQ No Open
Horst et al.18 8.5 years Open 6 weeks RLQ No Open
Horst et al.18 6 years Open 2 weeks RLQ No Open
Horst et al.18 12.5 years Open 2 weeks RLQ No Open
Strathern et al.19 54 years Laparoscopic 6 weeks Subhepatic Yes Open
O’Hanlon et al.20 37 years Open 9 months Right Psoas Muscle Yes Open
Cherniavskii et al.13 19 years Open 10 years RLQ No Laparoscopic
Coughlin et al.21 17 years Open 4 years RLQ No Open
Kozlenko et al.22 59 years Open 10 years RLQ No Open
Mulder23 22 years Open 7 years RLQ No Open
Sade24 19 years Open 10 years Subcutaneous No Open
Goldman et al.25 11 years Open 5 months RLQ No Open
Shaw26 Not reported Open “years” Subcutaneous No Spontaneous passage
Cossentino27 31 years Open 4 months Subcutaneous No Spontaneous passage
Monfore et al.2 22 years Open 2 months RLQ No Open

RLQ, right lower quadrant; RUQ, right upper quadrant.

LAP DRAINAGE OF RETAINED FECALITH
day. Disadvantages include the inability to visualize the en-
tire abdomen, difficulty in extracting larger fecaliths, and
pulverization of the fecalith, leading to further retained cal-
culi.
Open laparotomy is the traditional method for the explo-
ration of the abdomen, drainage of an abscess, and removal
of a fecalith. Advantages include being able to assess the en-
tire abdomen, and the ability to palpate the bowel and other
intra-abdominal structures in the setting of an inflammatory
response. Disadvantages include the need for a large inci-
sion in order to obtain adequate visualization, as well as in-
creased pain and hospital stay secondary to the procedure.
Laparoscopic drainage of a postappendectomy intra-ab-
dominal abscess and extraction of a retained fecalith has been
reported in the literature five times.10–13 In all cases, laparo-
scopic retrieval was successful and patients recovered with-
out complication. We believe that the laparoscopic approach
is best because it permits a thorough examination of the en-
tire abdomen, allowing the surgeon to assess for multiple ab-
scesses and fecaliths. This may be especially important with
the rise of the laparoscopic appendectomy. Placement of the
patient in the Trendelenburg position during the primary
procedure to enhance the visualization of the appendix and
cecum may lead to the migration of a fecalith to the right up-
per quadrant and subhepatic space.11 As in most laparo-
scopic procedures, theoretic advantages include smaller,
more cosmetic incisions, decreased pain, and shorter length
of stay; and perhaps most important in the pediatric popu-
lation, laparoscopy avoids the cumbersome nature of per-
cutaneous drains and secondary healing of fistulous tracts.
One major factor in determining whether to retrieve the
fecalith laparoscopically is the safety of the patient. As in
these cases, fecaliths are frequently surrounded by an ab-
scess with a dense inflammatory response and multiple ad-
hesions to local structures. Preoperative CT scanning may
aid in planning the trocar placement as well as the laparo-
scopic approach to retrieval. Surgeons must be aware of an-
atomic landmarks at every step of the procedure in order to
avoid iatrogenic injury to the bowel and other intra-abdom-
inal organs. When the safety of the patient is compromised,
the conversion to an open laparotomy is warranted.
Conclusions
In conclusion, retained fecalith after an appendectomy is an
uncommon complication frequently associated with intra-ab-
dominal abscess. Treatment includes drainage of the abscess
and retrieval of the fecalith. Laparoscopy offers the advantages
of enhanced visualization of the abdomen, improved cosme-
sis, and a quicker return to normal daily activities. Care must
be taken to clearly identify all anatomic landmarks, as the ab-
scesses are frequently adherent to intra-abdominal structures
compromising the safety of the operation.
Acknowledgments
The authors wish to thank E. Britton Chahine, MD, for her
help with the translation of foreign articles.
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