Laparoscopic retrieval of unusual intra-abdominal foreign bodies in children.

Foreign body (FB) ingestion is a common problem among the pediatric population. On numerous occasions, the FB is left to pass out spontaneously without expecting any harm. There are instances when the FB is either to dangerous to be left alone, that is a button battery or a sharp object. There may be FB, which is either stuck in GIT or have migrated. The situation in these instances demand active intervention. The traditional option has been laparotomy and retrieval. We present here three cases where two needles and a belt buckle were removed by laparoscopy thus avoiding a laparotomy. These cases prove that laparoscopy should be the first choice for such kind of retrieval. These cases had a successful outcome with full recovery.

INTRODUCTION

Foreign body (FB) ingestion is a common problem in pediatric age group. Most ingested foreign bodies will pass the gastrointestinal tract without any harm but a small number of unusual foreign bodies get impacted in the gut. These unusual foreign bodies have to be surgically removed because either they are stuck or are dangerous, as in case of a pointed needles, fish bones, and button batteries that have been known to cause bowel perforation, infection, and even death.[12] Sometimes FB may migrate from their original entry point and pose a danger to major structures as a blood vessels or solid viscera. Removal is straight forward through open laparotomy after localization.[3] With the surge of laparoscopy, these unusual foreign bodies can be easily removed by minimal access surgery, avoiding a laparotomy scar and giving faster recovery to the child who is otherwise healthy. We describe three cases of unusual foreign bodies that were removed laparoscopically and highlight the advantages of laparoscopy for these instances.

CASE REPORTS

Case 1

An 8-year-old boy presented to our emergency with a history of diffuse nonspecific pain in the upper abdomen after accidentally swallowing a sewing needle 20 days back. Local treatment had advised soft diet and waiting for spontaneous expulsion with stools. When the parents failed to find it in the fecal matter for 20 days, and the child continued to have pain and persistence of needle in the stomach on serial X-rays, the patient was referred. Endoscopy confirmed the presence of needle, and it was decided not to attempt removal as the sharp tip may cause esophageal perforation during retrieval. The patient underwent laparoscopy, and the needle was made to pierce the stomach wall under the vision and extracted through one of the ports in a single short attempt[4] [Figure 1]. No ostomy was required, and a single suture repair was done at the site of piercing. The postoperative period was uneventful, and the patient was discharged in 2 days.

Figure 1

Sewing needle retrieval after piercing through stomach wall

Case 2

A 3-year-old boy presented to outpatient department with a history chronic abdominal pain after having swallowed a belt buckle about 18 months back. Serial X-rays done at a local hospital showed the persistence of FB in the lower abdomen with failure to pass spontaneously and to cause increasing anxiety for the parents. On laparoscopy, after a bowel walk the belt buckle was identified in the distal small bowel and extracted via an enterotomy that was closed after removal[5] [Figure 2]. The patient recovered uneventfully and was discharged on the 5th day.

Figure 2

Retrieval of belt buckle from small bowel

Case 3

An 8-year-old female child presented to our emergency with a history of continuous low-grade right flank pain after accidentally being pierced by a needle in the right flank 1-week back. There was a small bruise in the right flank at the entry site, but no part of the needle could be seen or palpated superficially. X-ray and computed tomography scan of the abdomen done at a local hospital showed the needle completely crossing the abdominal wall and stuck in the superficial part of the right lobe of the liver. The patient was referred to our hospital where laparoscopy revealed the needle partially embedded in the liver substance superficially with adhesion of this part of liver to the peritoneum at the site of entry. The needle was successfully removed via one of the ports without disturbing the liver adhesion for fear of causing bleeding.[6] The patient was observed for a day and then discharged.

DISCUSSION

FB ingestion is a common problem among pediatric populations. A variety of foreign bodies is ingested, ranging from coins, which are the most common, to toy parts, metal pieces, earth material. Most of the time these foreign bodies are innocuous and do not pose any danger and they can be allowed to pass through the gastrointestinal tract without any problem. In instances where the FB is sharp, it is advised to retrieve it as it may get stuck, perforate or migrate.[7] We have described three such cases where the FB was removed laparoscopically avoiding a laparotomy.

Fujiwara et al. classified the four routes of entry of a FB into the peritoneal cavity as percutaneous, penetration after swallowing, either by accident or intentionally, iatrogenic after surgery or examination, and via natural orifice. A variety of gastrointestinal symptoms such pain vomiting as well as respiratory symptoms such as coughing and stridor are associated with FB ingestion. The esophagus, in particular, the upper third, is the common site of FB obstruction. Objects in the stomach and intestine are spontaneously passed more frequently than at any other sites in the gastrointestinal system. Esophageal and gastric foreign bodies are often amenable to endoscopic removal whereas small bowel foreign bodies more often require surgical intervention in case they fail to pass spontaneously. Complications such as bowel perforations, infection, and death are sometimes the worst outcome with ingestion of objects such as batteries and sharp objects such as bones and needles.[1]

Surgery, though rarely required, is the only alternative when endoscopic extraction fails in case of esophageal or gastric foreign bodies and more distally impacted foreign bodies that fail to pass spontaneously or cause complications. There have been reports of laparotomy being done for such foreign bodies and some cases even requiring extreme measures like partial hepatectomy.[38] Laparoscopy is a much easier, quicker, safer, and cosmetically acceptable alternative. The three cases presented here emphasize the fact that laparoscopy should be the standard practice in such cases. Surgery may also be required for the rare cases with non-ingested intraperitoneal foreign bodies migrated from the surface either accidentally. Child abuse with needles has been described and so has been the need for laparotomy in such cases.[9] However, the case presented here (case 3) is only the second reported in the literature of a noningested intraperitoneal/visceral FB extracted with laparoscopy.[10] A timely laparoscopy in these cases should be the standard practice to avoid potentially fatal complications.

CONCLUSION

Laparoscopy is very effective in retrieving intraluminal and intraperitoneal foreign bodies, helping to avoid laparotomy. Laparoscopy should be the first-hand approach for these unusual situations prior to open exploration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.