Laparoscopic retrieval of an unusual foreign body.

Ingestion of foreign body is a serious problem commonly encountered in our clinical practice. Most of them pass spontaneously, whereas in others endoscopic or surgical intervention is required because of complications or non-passage from the gastrointestinal tract. We present here a case of teaspoon ingestion, which did not pass spontaneously. Laparoscopic retrieval of teaspoon was done from mid jejunum after enterotomy and the patient recovered uneventfully. Right intervention at the right time is of paramount importance.

INTRODUCTION

Foreign body ingestion is a common cause of accidental death. Although approximately 90% of them pass spontaneously, they can result in perforation or obstruction in the gastrointestinal (GI) tract. Toddlers aged 2-3 years are most commonly affected; as children in this age group are ambulatory and more orally explorative.[1] Intestinal perforation by a foreign body is uncommon occurring in <1% of patients. It normally affects the ileocaecal and rectosigmoid regions. According to Goh et al., the most common site of intra-abdominal perforation as the terminal ileum (approximately 39%).[2]

We present a case of young female with ingestion of foreign body which was impacted in a small intestine.

CASE REPORT

A 23-year-old female presented to the emergency of the Max Super Speciality Hospital, Saket, New Delhi, India with a history of ingestion of teaspoon, while she was eating ice cream 1 day before. She complained of pain abdomen and nausea. Physical examination revealed soft abdomen with mild tenderness around umbilicus and no signs of peritonitis. A plain X-ray abdomen revealed presence of a radio-opaque foreign body (metallic teaspoon) in the stomach. Initially, we decided to observe and closely monitor the patient after admitting her and starting conservative expectant treatment. The next day she was not relived, and the abdominal pain continued. In view of that, we took the decision to proceed with diagnostic laparoscopy. Repeat X-ray abdomen was performed in erect and supine position to locate the position of the teaspoon [Figure 1].

Figure 1

Abdominal X-ray showing spoon in jejunum

Diagnostic laparoscopy was performed with one 10 mm and two 5 mm midline ports. On initial evaluation, the bowels looked normal. There were no bowel adhesions. On the exploration and careful examination of upper GI tract jejunum was found to be dilated. On tracing the loop of jejunum, the spoon was located at the mid jejunal level. Enterotomy was performed on the antimesenteric border, and tablespoon identified and was retrieved [Figures 2 and 3]. Enterotomy closed with Endo GI stapler.

Figure 2

Retrieving the spoon

Figure 3

The foreign body (spoon)

Patient had an uneventful post-operative recovery and was ultimately discharged on post-operative day 4.

DISCUSSION

The management of foreign bodies in GI tract is based on collective anecdotal experience of surgeons. Majority of foreign bodies passes through the GI tract without any adverse effects.[3] The highest incidence of swallowed foreign bodies occurs in children between 6 months and 3 years, and coins are the most commonly ingested foreign bodies. There is a definite predilection for swallowed foreign bodies to become impacted at the level of cricopharyngeus and just below it or at the oesophagogastric junction. In our patient, the spoon crossed the pylorus and was lodged in jejunum.

A large number of foreign bodies will pass through the entire GI tract once past the gastroesophageal junction; nevertheless it is preferable to observe them in the hospital for a possible need for immediate abdominal exploration should bleeding,[4] or features of perforation occurs.[5] During the observation period, a daily radiograph should be obtained, and patient should be checked for signs of peritonitis or GI bleeding. Stools should also be examined for the foreign body in the follow-up.

Sharp objects may get impacted in the bowel wall or even penetrate through it. All sharp foreign bodies should be removed before they pass from the stomach because 15-35% of these will cause intestinal perforation, usually in the area of the ileocecal valve.[6] If a sharp foreign body does not progress for three consecutive days surgical intervention should be considered, and if the patient becomes symptomatic, surgical intervention will be necessary. Intraluminal endoscopic techniques are limited by the length of the instrument and the curved path it takes. Laparoscopic removal of foreign bodies from the peritoneal cavity (translocated intrauterine contraceptive devices) and a needle from the pelvis have been reported previously.[7] Wichmann et al.[8] laparoscopically removed a toothpick causing small bowel perforation followed by lavage of the abdominal cavity and laparoscopic closure of the perforation including omentoplasty. Murshid and Khairy[9] removed a metallic pin from small intestine laparoscopically under fluoroscopic guidance. Accurate localisation of foreign body in the small bowel is the main challenge. In our case, smooth contours of spoon through the bowel wall helped us to retrieve it. For irregular objects such as a safety pin, the site requires localisation and then a small enterotomy. This obviates the need for a formal laparotomy.

Depending on the availability of skill and expertise, laparoscopic removal of the GI foreign bodies should be considered an option. It is less invasive, less painful and offers faster recovery.

CONCLUSION

Patients with a history of ingestion of GI foreign bodies should be diligently monitored. The most optional method of retrieval in the form of endoscopy or surgery should be contemplated at the earliest indication. Laparoscopic retrieval may be a better option in comparison with laparotomy where facility and proper expertise are available.