Laparoscopic removal of a needle from the pancreas.

Foreign bodies inside the pancreas are rare and usually occur after the ingestion of sharp objects like fish bone, sewing needle and toothpick. Most of the ingested foreign bodies pass spontaneously through the anus without being noticed but about 1% of them can perforate through the wall of stomach or duodenum to reach solid organs like pancreas or liver. Once inside the pancreas they can produce complications like abscess, pseudoaneurysm or pancreatits. Foreign bodies of pancreas should be removed by endoscopic or surgical methods. We hereby report our experience of successful removal one a sewing needle from pancreas.

INTRODUCTION

Sewing needle is an uncommonly ingested foreign body which may perforate though the stomach to reach pancreas and other surrounding organs. Once inside the pancreas, it has potential to create fatal complications like pancreatitis, pancreatic abscess and pseudo aneurysm, so it should be removed once detected.[1-5] Most of these cases were managed by open surgical method and till date only two cases have been managed laparoscopically.[67] We hereby report a young lady with sewing needle inside the pancreas which was removed laparoscopically.

CASE REPORT

A 28 -year-old lady presented with pain in the epigastric region for 3 months which was not associated with heartburn, vomiting, fever, jaundice, haematemesis, melena, etc. She had a caesarean delivery two years back. Her physical examination and routine blood tests including haemogram, renal function test, liver function test, serum amylase and lipase were normal. X-ray of the abdomen (AP view) revealed a linear radio-opaque shadow in across T11 and T12 vertebrae [Figure 1]. Her CECT abdomen showed a 3.8 cm sized linear metallic density object inside the head of pancreas [Figure 1]. Her endoscopic examination, with both end and side viewing scopes, failed to localise any object inside the stomach and duodenum. Patient was planned for laparoscopic removal of the foreign body, lesser sac was approached through the gastro colic ligament, stomach and first part of duodenum dissected away from the pancreas, after that tip of the object could be felt by the instrument. Careful dissection was done to visualise the object and once in sight, it was removed with the help of Maryland dissector under vision and bleeding was controlled by pressure with a gauge [Figure 2]. Post-operative period was uneventful and the patient was allowed orals after 6 hours and discharged on second post-operative day. She is doing well for 1 year after the surgery.

Figure 1

(a) Radiograph showing linear radio-opaque shadow against T12 Vertebra. (b) CT picture (Left) showing hyperdense body (arrow) in the pancreatoduodenal groove region. (Right) enlarged reconstructed image showing linear hyperdensity (arrow) traversing duoenopancreatic groove into the head of pancrease

Figure 2

Intra-operative picture with extracted needle shown in inset

DISCUSSION

Sharp foreign bodies like fish bone, chicken bone, tooth pick and sewing needle may be ingested accidentally or otherwise. Most of them pass unnoticed but about 1% may perforate through the intestinal wall.[12] The cricopharyngeal sphincter, pylorus, C-loop of duodenum, duodenojejunal junction and ileocaecal junction are common sites of perforation, ileocaecal region being the commonest. Occasionally, these objects can perforate through the wall of the stomach or duodenum and may reach surrounding solid organs like liver and pancreas.[23] Once inside the pancreatic or hepatic parenchyma, they can lead to development of abscess which can further lead to pseudo aneurysm formation; they can also produce direct injury to blood vessel (portal vein, splenic vein) and sometimes may mimic other diseases affecting these organs.[34] The diagnosis of this condition is not always easy as most of the patients (like in our case also) don′t remember the incident; history of surgical intervention in the past may raise the suspicion of iatrogenic cause and organic objects may produce picture mimicking carcinoma.[3-5]

The diagnosis of the foreign body inside the abdomen may be suspected on roentgenogram of abdomen but computed tomography is a must to know exact location of the foreign body and the presence of complications due to it. On the basis of findings on CT, endoscopic removal may be attempted which may be successful in cases where some part of needle can be seen inside the lumen of stomach or duodenum, but it is not the case usually. Most of the reported cases have been dealt surgically by open method (except two cases).[2-5] In the modern era of minimally invasive surgery, laparoscopic removal of these foreign bodies should be attempted in all such cases before opting for open method, because it avoids incision of exploratory laparotomy and offers advantage of surgery under magnification and other benefits of laparoscopic modality.[67] We could find two case reports regarding laparoscopic removal foreign bodies from pancreas and hereby presenting a third case.

CONCLUSION

Laparoscopic removal of pancreatic foreign bodies is possible and should be tried before open surgical removal.