Presentation
Day 2 post laparoscopic cholecystectomy. Drain in gallbladder bed, draining bile-stained fluid. Generalized abdominal pain. ?Collection ?Bowel injury.
Patient Data
Right-sided surgical drain with the tip in the subhepatic region. Minor postsurgical inflammatory change in the gallbladder fossa. No organized fluid collection.
The cecum is distended up to 10 cm in the craniocaudal dimension in the coronal plane. The ileocecal valve lies within the central abdomen and the cecum has flipped over. There is no evidence of a twist in the mesentery or mesenteric vascular compromise at the time of the scan. No features of small bowel obstruction.
Findings are in keeping with cecal volvulus (bascule type).
The patient had a diagnostic laparoscopy, which was converted to a midline laparotomy .
Intraoperative findings
The cecum had 180 degree twist so that the posterior wall of the cecum was lying anteriorly and in the midline. Multiple small mucosal gangrenous patches scattered in the anterior cecal wall. No perforation. Cecal mesentery was very redundant. Rest of bowel was grossly normal.
Histology findings
The cecal wall appears thin and dilated but it is viable, notably at the margins. Sections show viable small and large bowel wall.No evidence of dysplasia or invasive malignancy. The features are consistent with the clinical history of volvulus.
Normal position of cecum.
Case Discussion
Cecal bascule is a rare form of cecal volvulus, where the cecum folds anteriorly instead of twisting upon its axis 1.The development of a cecal bascule is dependent upon hypermobility of the cecum 2. This may be after a surgical procedure, such as laparoscopic cholecystectomy 1, or other surgical procedures. Another hypothesis states that changes in the patient position during surgery from reverse Tendelenburg to a horizontal plane may allow a hypermobile cecum to fold anteriorly and obstruct the large bowel causing cecal bascule 3.
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