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Internal hernia and small bowel obstruction caused by a linear cutter staple at appendiceal stump following laparoscopic appendectomy

Internal hernia and small bowel obstruction caused by a linear cutter staple at appendiceal stump... JSCR 2014; 1 (2 pages) doi:10.1093/jscr/rjt114 Case Report Internal hernia and small bowel obstruction caused by a linear cutter staple at appendiceal stump following laparoscopic appendectomy 1 1 2,* 3 Lindsay F. Petersen , Mary C. Nally , Andrew Agos and Kyle Petty 1 2 Department of General Surgery, Rush University Medical Center, Chicago, IL, USA, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA and NorthShore Center for Simulation and Innovation, NorthShore University HealthSystem, Evanston, IL, USA *Correspondence address. 2650 Ridge Avenue, Evanston, IL 60201, USA. Tel: þ1-847-570-1365; Fax: þ1-847-733-5977; E-mail: aagos@northshore.org Received 14 October 2013; accepted 17 November 2013 Commonly linear staplers are used to perform laparoscopic appendectomies. We report a case of a small bowel obstruction caused by a staple on the appendiceal stump creating an internal hernia ,1 week after laparoscopic appendectomy. We discuss the available literature on bowel obstructions caused by staples. Most of the discussed complications were caused by staples free in the abdomen, which were remote from the staple line. Generally, loose staples do not cause problems, but if noted during the operation, we recommend removal to prevent future ob- struction. INTRODUCTION Six days later, the patient returned to the emergency room with abdominal pain for ,12 h in the periumbilical region. Laparoscopic appendectomy has been performed for .20 The pain was worse than when she had appendicitis. She years, and a variety of techniques are used to divide the appen- reported chills, nausea and vomiting. On examination, she was dix and mesoappendix including staplers and clips [1]. tender in the periumbilical region and mildly distended. She Reports of migrated or loose staples and clips have been evi- underwent CT scan, which showed a small bowel obstruction denced in the literature causing obstruction [2–8]. We report a with a transition point in the right lower quadrant (Fig. 1). She case of a straightforward laparoscopic appendectomy for was taken to the operating room for an exploratory laparos- acute appendicitis, complicated by an early small bowel ob- copy. A staple attached to the appendiceal stump on one end struction caused by an internal hernia, which formed as a had snagged a loop of small bowel and small bowel mesentery result of an incompletely deployed staple. with the other end (Fig. 2). It was causing an internal hernia and contained a small bowel loop. The staple was freed and removed laparoscopically with no full thickness defect of the CASE REPORT small bowel. The staple line was imbricated with intracorpor- A 22-year-old female presented to the emergency room with a eal Lembert sutures. The patient did well and was discharged 24-h history of periumbilical pain, associated with nausea, the following evening. vomiting and a low-grade fever. On examination, she was afebrile but focally tender in the right lower quadrant over McBurney’s point. A computed tomography (CT) scan DISCUSSION showed a dilated appendix with fat stranding. She was taken to the operating room for laparoscopic appendectomy. Three Laparoscopic appendectomy is routinely performed by firing trocars were used. The mesoappendix was divided with the a linear cutting stapler across the appendix, but there are harmonic scalpel, and the base of the appendix was divided reports in the literature of staples causing adhesions and small with an EndoGIA stapler (Ethicon Endosurgery, Cincinnati, bowel obstructions. Free staples in the peritoneum are OH, USA). The postoperative course was uncomplicated and described causing small bowel obstructions requiring reopera- the patient was discharged the next day. tion in the immediate postoperative period as well as up to Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved.# The Author 2014. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by-nc/3.0/), which permits non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com. Page 2 of 2 L.F. Petersen et al. bowel obstruction following laparoscopic appendectomy on the third postoperative day caused by a staple from the staple line of the cecum hooked to small bowel mesentery [8]. The linear staples may leave some staples free in the ab- dominal cavity when the stapler is fired over a narrow piece of tissue, such as the appendix. Most loose staples are not prob- lematic, but there are an increasing number of reports of sta- plers causing small bowel obstructions in the literature. Either suctionor a graspershouldbeusedtoretrievethese free staples if at all possible, which is recommended as well by other authors of similar case reports. The staple lines should be inspected carefully for proper deployment of staples. If doubt exists, we recommend oversewing the stable line with intracorporeal Lembert sutures. In conclusion, we report a small bowel obstruction follow- ing laparoscopic appendectomy caused by a staple remaining connected to the staple line, which had hooked on to a loop of small bowel creating an internal hernia. It is important to remove loose staples and reinforce the staple line if needed following laparoscopic appendectomy. Figure 1: Image from CT scan showing a transition point in the right lower quadrant. REFERENCES 1. Gomes CA, Nunes TA, Soares C, Jr, Gomes CC. The appendiceal stump closure during laparoscopy: historical, surgical, and future perspectives. Surg Laparosc Endosc Percutan Tech 2012;22:1–4. 2. Chepla KJ, Wilhelm SM. Delayed mechanical small bowel obstruction caused by retained, free, intraperitoneal staple after laparoscopic appendectomy. Surg Laparosc Endosc Percutan Tech 2011;21:e19–20. 3. Lorken M, Marnitz U, Schumpelick V. Free intraperitoneal clip as the cause of mechanical ileus of the small intestine. Chirurg 1999;70:1492–3. 4. Nottingham JM. Mechanical small bowel obstruction from a loose linear cutter staple after laparoscopic appendectomy. Surg Laparosc Endosc Percutan Tech 2002;12:289–90. 5. Kuehnel F, Marusch F, Koch A, Gastinger I. Retained loose linear cutter staples after laparoscopic appendectomy as the cause of mechanical small bowel obstruction. Int J Colorectal Dis 2007;22:717–8. 6. Page MP, Kim HB, Fishman SJ. Small intestinal volvulus caused by loose surgical staples. J Pediatr Surg 2009;44:1824–6. Figure 2: Staple bridging appendiceal stump staple line and loop of small 7. Huntington TR, Klomp GR. Retained staples as a cause of mechanical bowel creating an internal hernia. small-bowel obstruction. Surg Endosc 1995;9:353–4. 8. Petrocelli P, Corsale I, GIannessi S, Cerone M, Colugnat D, Matocci GC. Complications due to mechanical sutures in laparoscopic surgery: bowel 3 years following both laparoscopic appendectomy and obstruction caused by staple. Case report and literature review. Minerva vaginal hysterectomy [2 – 7]. There is one case report of a Chir 2003;58:591–4. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Internal hernia and small bowel obstruction caused by a linear cutter staple at appendiceal stump following laparoscopic appendectomy

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Oxford University Press
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Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2014.
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2042-8812
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10.1093/jscr/rjt114
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Abstract

JSCR 2014; 1 (2 pages) doi:10.1093/jscr/rjt114 Case Report Internal hernia and small bowel obstruction caused by a linear cutter staple at appendiceal stump following laparoscopic appendectomy 1 1 2,* 3 Lindsay F. Petersen , Mary C. Nally , Andrew Agos and Kyle Petty 1 2 Department of General Surgery, Rush University Medical Center, Chicago, IL, USA, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA and NorthShore Center for Simulation and Innovation, NorthShore University HealthSystem, Evanston, IL, USA *Correspondence address. 2650 Ridge Avenue, Evanston, IL 60201, USA. Tel: þ1-847-570-1365; Fax: þ1-847-733-5977; E-mail: aagos@northshore.org Received 14 October 2013; accepted 17 November 2013 Commonly linear staplers are used to perform laparoscopic appendectomies. We report a case of a small bowel obstruction caused by a staple on the appendiceal stump creating an internal hernia ,1 week after laparoscopic appendectomy. We discuss the available literature on bowel obstructions caused by staples. Most of the discussed complications were caused by staples free in the abdomen, which were remote from the staple line. Generally, loose staples do not cause problems, but if noted during the operation, we recommend removal to prevent future ob- struction. INTRODUCTION Six days later, the patient returned to the emergency room with abdominal pain for ,12 h in the periumbilical region. Laparoscopic appendectomy has been performed for .20 The pain was worse than when she had appendicitis. She years, and a variety of techniques are used to divide the appen- reported chills, nausea and vomiting. On examination, she was dix and mesoappendix including staplers and clips [1]. tender in the periumbilical region and mildly distended. She Reports of migrated or loose staples and clips have been evi- underwent CT scan, which showed a small bowel obstruction denced in the literature causing obstruction [2–8]. We report a with a transition point in the right lower quadrant (Fig. 1). She case of a straightforward laparoscopic appendectomy for was taken to the operating room for an exploratory laparos- acute appendicitis, complicated by an early small bowel ob- copy. A staple attached to the appendiceal stump on one end struction caused by an internal hernia, which formed as a had snagged a loop of small bowel and small bowel mesentery result of an incompletely deployed staple. with the other end (Fig. 2). It was causing an internal hernia and contained a small bowel loop. The staple was freed and removed laparoscopically with no full thickness defect of the CASE REPORT small bowel. The staple line was imbricated with intracorpor- A 22-year-old female presented to the emergency room with a eal Lembert sutures. The patient did well and was discharged 24-h history of periumbilical pain, associated with nausea, the following evening. vomiting and a low-grade fever. On examination, she was afebrile but focally tender in the right lower quadrant over McBurney’s point. A computed tomography (CT) scan DISCUSSION showed a dilated appendix with fat stranding. She was taken to the operating room for laparoscopic appendectomy. Three Laparoscopic appendectomy is routinely performed by firing trocars were used. The mesoappendix was divided with the a linear cutting stapler across the appendix, but there are harmonic scalpel, and the base of the appendix was divided reports in the literature of staples causing adhesions and small with an EndoGIA stapler (Ethicon Endosurgery, Cincinnati, bowel obstructions. Free staples in the peritoneum are OH, USA). The postoperative course was uncomplicated and described causing small bowel obstructions requiring reopera- the patient was discharged the next day. tion in the immediate postoperative period as well as up to Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved.# The Author 2014. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by-nc/3.0/), which permits non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com. Page 2 of 2 L.F. Petersen et al. bowel obstruction following laparoscopic appendectomy on the third postoperative day caused by a staple from the staple line of the cecum hooked to small bowel mesentery [8]. The linear staples may leave some staples free in the ab- dominal cavity when the stapler is fired over a narrow piece of tissue, such as the appendix. Most loose staples are not prob- lematic, but there are an increasing number of reports of sta- plers causing small bowel obstructions in the literature. Either suctionor a graspershouldbeusedtoretrievethese free staples if at all possible, which is recommended as well by other authors of similar case reports. The staple lines should be inspected carefully for proper deployment of staples. If doubt exists, we recommend oversewing the stable line with intracorporeal Lembert sutures. In conclusion, we report a small bowel obstruction follow- ing laparoscopic appendectomy caused by a staple remaining connected to the staple line, which had hooked on to a loop of small bowel creating an internal hernia. It is important to remove loose staples and reinforce the staple line if needed following laparoscopic appendectomy. Figure 1: Image from CT scan showing a transition point in the right lower quadrant. REFERENCES 1. Gomes CA, Nunes TA, Soares C, Jr, Gomes CC. The appendiceal stump closure during laparoscopy: historical, surgical, and future perspectives. Surg Laparosc Endosc Percutan Tech 2012;22:1–4. 2. Chepla KJ, Wilhelm SM. Delayed mechanical small bowel obstruction caused by retained, free, intraperitoneal staple after laparoscopic appendectomy. Surg Laparosc Endosc Percutan Tech 2011;21:e19–20. 3. Lorken M, Marnitz U, Schumpelick V. Free intraperitoneal clip as the cause of mechanical ileus of the small intestine. Chirurg 1999;70:1492–3. 4. Nottingham JM. Mechanical small bowel obstruction from a loose linear cutter staple after laparoscopic appendectomy. Surg Laparosc Endosc Percutan Tech 2002;12:289–90. 5. Kuehnel F, Marusch F, Koch A, Gastinger I. Retained loose linear cutter staples after laparoscopic appendectomy as the cause of mechanical small bowel obstruction. Int J Colorectal Dis 2007;22:717–8. 6. Page MP, Kim HB, Fishman SJ. Small intestinal volvulus caused by loose surgical staples. J Pediatr Surg 2009;44:1824–6. Figure 2: Staple bridging appendiceal stump staple line and loop of small 7. Huntington TR, Klomp GR. Retained staples as a cause of mechanical bowel creating an internal hernia. small-bowel obstruction. Surg Endosc 1995;9:353–4. 8. Petrocelli P, Corsale I, GIannessi S, Cerone M, Colugnat D, Matocci GC. Complications due to mechanical sutures in laparoscopic surgery: bowel 3 years following both laparoscopic appendectomy and obstruction caused by staple. Case report and literature review. Minerva vaginal hysterectomy [2 – 7]. There is one case report of a Chir 2003;58:591–4.

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Published: Jan 15, 2014

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