LAUSR

A 21-year-old female was presented acutely with a 24-h history of central abdominal pain localizing to the right iliac fossa, associated with nausea and vomiting. She had no surgical history. On examination, she was tender over McBurney’s point. She was diagnosed clinically with acute appendicitis. An emergency laparoscopic appendicectomy was undertaken with a three-port technique. The appendix was skeletonized and found to be inflammed but not to have perforated. Congenital adhesions from the terminal ileum to the appendix and from the caecum to the lateral abdominal wall were identified. These were divided to allow sufficient mobilization of the appendix. The patient made a seemingly uneventful recovery and was discharged home the following day. Forty-eight hours later, the patient was presented to emergency with sudden onset generalized abdominal pain and associated distension. She was noted to be hypotensive with a systolic blood pressure of 85 mmHg and tachycardic with a heart rate of 130. She was febrile with a temperature of 38.5 C. The abdomen was markedly distended with clinical evidence of peritonism. Her total white cell count was 9.02 × 10/L, beta human chorionic gonadotropin was <1 and C-reactive protein was 79. A subsequent contrast-enhanced computed tomography (CT) scan was performed, demonstrating radiological abnormalities consistent with organo-axial caecal volvulus (Figs 1,2). The caecum was rotated and distended, measuring up to 89 mm in maximal diameter (Figs 1,2). A clear transition point was apparent. Multiple small locules of pneumoperitoneum and a small volume free fluid in the right paracolic gutter were seen consistent with contained perforation. The patient was urgently taken to the operating theatre. Intraoperatively, the diagnosis of organo-axial volvulus of the caecum was confirmed. There was evidence of perforation at the tenial confluence. There was no significant peritoneal contamination. A right hemicolectomy and primary ileocolic anastomosis was performed. Histopathology of the right colon revealed localized ischaemia and necrosis of the mucosa and colonic wall at the site of perforation. The colonic wall was thin, up to 2 mm with no other evidence of histological abnormalities. Post-operatively, the patient required