Article, Surgery

Single-incision laparoscopic surgery for ingested foreign body removal

American Journal of Emergency Medicine 32 (2014) 290.e1-290.e3

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: locate/ ajem

Case Report

Single-incision laparoscopic surgery for ingested foreign body removal?

Abstract

This report presents a 16-year-old Adolescent boy with Intentional ingestion of a 6-cm-length iron nail in detention center 6 hours ago. There was no symptom and sign of acute abdominal pain. abdominal computed tomographic scan was performed, and an iron nail was found in the left upper quadrant abdomen. Considering the size, shape, and location of the foreign body, emergency surgery was performed using single-incision laparoscopic surgery approach. Multiple trocars in umbilical incision technique and conventional instruments were used. After identification of the foreign body in jejunum by alternative clamping of small bowel, enterostomy was made, and extracorporeal suturing was performed. The operation time was 1 hour without blood loss during the surgery. The patient left the bed 6 hours after the surgery. Bowel function recovered, and the gastric tube was removed on postoperative day 2. No painkiller was used after the surgery. The patient was discharged on postoperative day 3 without any complication. To our knowledge, it is the first report on removal of ingested foreign body located in jejunum using single-incision laparoscopic surgery technique.

Intentional ingestion of foreign body is not rare for prison inmates [1]. When the foreign body is large, sharp, and endoscopically unobtainable, surgical removal is necessary. Laparoscopic removal of foreign body has been reported [2] due to its advantages. Single- incision laparoscopic surgery (SILS) is an advanced laparoscopic technique with less invasiveness and better cosmesis. We performed a single-incision laparoscopic foreign body removal recently. To our knowledge, it is the first report to remove a foreign body in the small intestine using SILS approach.

A 16-year-old adolescent boy presented with intentional ingestion of a 6-cm-length iron nail in detention center 6 hours ago. There was no symptom and sign of acute abdominal pain. Abdominal computed tomographic scan was performed, and an iron nail was found in the left upper quadrant abdomen (Fig. 1). Considering the size and location of the foreign body, surgical removal was decided, and single- incision laparoscopic approach was performed.

The patient was placed in supine position under general anesthesia. The conventional laparoscopic instruments were used [3]. After pneumoperitoneum was established, a 10-mm trocar was placed in the umbilical incision for camera access. No remarkable fluid and adhesion were found through careful laparoscopic inspection. The umbilical incision was then enlarged to 2 cm without cutting the anterior sheath of Rectus abdominis. Two other 5-mm trocars were

? The article has never been presented on any meeting.

implanted in the same incision (Fig. 2). The ileocecal region was identified first. Then the small bowel was clamped gently to detect the foreign body using 2 aTraumatic forceps, which was 10 cm far from each other. The clamping sites were changed alternatively from the end of the ileum to the beginning of the jejunum. The foreign body was identified at the site 150 cm away from the end of the ileocecum. Afterwards, a 0.5-cm incision was made on the jejunal wall opposite to the mesentery. An iron nail was identified and removed from this incision. A 5-mm laparoscopy was shifted to monitor, and the nail was retrieved through 10-mm trocar. The enterostomy was clamped using an atraumatic forcep, and the tissue of abdominal wall between 2 trocars was divided to make a 2-cm incision. The enterostomy was extracted and closed by hand-sewn suturing. After the closing was completed, the jejunum was sent back to the abdominal cavity, and the umbilical incision was closed carefully using absorbable monofil- ament sutures.

The operation time was 1 hour, and there was no blood loss during the surgery. The patient left the bed 6 hours after the surgery. Bowel function recovered, and the gastric tube was removed on postoper- ative day (POD) 2. The patient was discharged on POD 3 without any complication. No painkiller was used after the surgery. The incision was illustrated in Fig. 3, and the patient was extremely satisfied with the results.

Intentional ingestion occurs occasionally in adults, particularly in prison inmates. Migration of a big and sharp foreign body in alimentary tract is dangerous due to the potential perforation and subsequent peritonitis. When the foreign body is endoscopically unobtainable, laparotomy or laparoscopy is necessary. Single-incision laparoscopic surgery has been applied in some surgical procedures such as cholecystectomy [4], appendectomy [5], gastrectomy [6], and others. Less invasiveness and better cosmesis are the major advantages.

In this case, we retrieved an iron nail from the jejunum using single-incision laparoscopic approach. Based on experience of other SILS procedures, it is not technique challenging as expected compared with conventional laparoscopy.

For laparoscopic foreign body removal, one problem is to identify the foreign body. It is difficult in laparoscopic surgery without the sense of touch as in open surgery. The big and hard foreign body like in this case is more suitable. We found the protrusion of the nail from the intestinal wall by alternative clamping using atraumatic forceps. Another issue worth concerning is the closing of the enterostomy. Although it can be closed using stapler under laparoscopy, it is expensive and not accepted by every patient. In addition, a 12-mm trocar for stapler has to be used to replace one of the 5-mm trocars, which therefore increases the invasiveness. It also can be closed by intracorporeal suturing. However, it is technique challenging to perform intracorporeal suturing through 1 incision. Nevertheless, it is easy to retrieve the small bowel out of the abdominal cavity through

0735-6757/$ – see front matter (C) 2014

290.e2 H. Yu et al. / American Journal of Emergency Medicine 32 (2014) 290.e1290.e3

Fig. 1. A and B, Computed tomographic scan showed a metal foreign body located in left upper quadrant abdomen. C, A 6-cm-length iron nail retrieved from jejunum.

the umbilical incision and perform the closing extracorporeally during SILS. We think extracorporeal suturing is an easy, safe, and time- saving approach compared to intracorporeal suturing. Rapid recovery and better cosmesis obtained in this case make this approach more appealing particularly in young patients.

Single-incision laparoscopic foreign body removal is feasible for big and sharp foreign body in small intestine with quick recovery and better cosmetic results. More investigations are needed to verify the advantages of this approach.

Hong Yu PhD, MD Shuodong Wu PhD, MD Xiaopeng Yu MD

Quan Zhang MD

Shengjing Hospital of China Medical University, Shenyang

Liaoning Province, China E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.10.007

Fig. 2. A, A 10-mm trocar (A) and two 5-mm trocars (B and C) were placed in the umbilical incision. When extracorporeal suturing was decided, the tissue between A and C was divided to make a 2-cm incision. B, The position of trocars.

H. Yu et al. / American Journal of Emergency Medicine 32 (2014) 290.e1290.e3 290.e3

Fig. 3. A, The umbilical incision on POD 2. B, The umbilical incision 2 months after the surgery. Almost no scar can be seen on abdominal wall.

References

  1. Dalal PP, Otey AJ, McGonagle EA, et al. Intentional foreign object ingestions: need for endoscopy and surgery. J Surg Res 2013;184(1):145-9.
  2. Dente M, Santi F, Solinas L, et al. Laparoscopic diagnosis and management of jejunal perforation resulting from accidental toothpick ingestion. Am Surg 2009;75(2):178-9.
  3. Wu SD, Han JY, Tian Y. Single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: a retrospective comparative study. J Laparoendosc Adv Surg Tech A 2011;21(1):25-8.
  4. Chow A, Purkayastha S, Aziz O, et al. Single-incision laparoscopic surgery for cholecystectomy: a retrospective comparison with 4-port laparoscopic cholecys- tectomy. Arch Surg 2010;145(12):1187-91.
  5. Chiu CG, Nguyen NH, Bloom SW. Single-incision laparoscopic appendectomy using conventional instruments: an initial experience using a novel technique. Surg Endosc 2011;25(4):1153-9.
  6. Omori T, Oyama T, Akamatsu H, et al. Transumbilical single-incision laparo- scopic distal gastrectomy for early gastric cancer. Surg Endosc 2011;25(7): 2400-4.