Case Report
Open Access
Laparoscopic Removal of Retained Artery Forceps Causing
Internal Hernia
Saleh Alzahrani1*, Awadh Alqahtani2
King Abdulaziz Medical City National Guard Hospital –Riyadh
King Khalid Hospital - King Saud University –Riyadh
King Khalid Hospital - King Saud University –Riyadh
*Corresponding author:Saleh Alzahrani, Department of Surgery, king Abdulaziz Medical City National Guard Hospital –Riyadh, Tel no: 96604378613; E-mail:
@
Received: 04 October, 2016; Accepted: 20 October , 2016; Published: 29 October, 2016
Citation: Alzahrani S, Alqahtani A (2016) Laparoscopic Removal of Retained Artery Forceps Causing Internal Hernia. SOJ Surgery
3(3): 1-3. DOI: http://dx.doi.org/10.15226/2376-4570/3/3/00131
Abstract
Retained foreign bodies are a surgical complication resulting
from foreign materials accidently left in a patient’s body. It is rare
but potentially dangerous error. It is also under-reported and carries
serious medico-legal consequences.
Here, we present an interesting case of retained artery forceps post laprotomy and total abdominal hysterectomy bilateral salpengioophrectomy and ventral hernia repair treated by laparoscopy
Conclusion: Retained instruments in intra-abdominal surgery can cause serious complication. It should be treated surgically. Laparoscopic exploration and removal can be done safely. Preventive measures against retained instruments must follow strict protocols for surgical instruments handling in theatre.
Keywords: Retained intra-abdominal artery forceps; Intestinal obstruction; Intestinal strangulation; Laparoscopy; Case report
Here, we present an interesting case of retained artery forceps post laprotomy and total abdominal hysterectomy bilateral salpengioophrectomy and ventral hernia repair treated by laparoscopy
Conclusion: Retained instruments in intra-abdominal surgery can cause serious complication. It should be treated surgically. Laparoscopic exploration and removal can be done safely. Preventive measures against retained instruments must follow strict protocols for surgical instruments handling in theatre.
Keywords: Retained intra-abdominal artery forceps; Intestinal obstruction; Intestinal strangulation; Laparoscopy; Case report
Introduction
Retained foreign body in the abdominal cavity following
surgery is a recurrent problem. However the incidence is grossly
underestimated [2] and rarely reported [3]. The rarity of reported
cases may be due to medico - legal implications or the surgeon’s
unwillingness to advertise his errors. The incidence of retained
foreign body in literature is 1 per 1000 to 1500 laparotomies [4].
Retained foreign body in peritoneal cavity is one of the known
but avoidable complications of abdominal surgery. It is more
liable to occur when surgery is done in a non-ideal environment
and negligence or ignorance on part of the medical personnel. It
is the responsibility of the operating surgeon and the theatre staff
to ensure that no foreign body is left inside the peritoneal cavity
before closure of the abdominal cavity. Retained foreign bodies
are of various types and include sponges/gauzes, artery forceps,
other metal instruments, surgical needles, surgical drains, and
rubber tubes. The surgical sponges/gauzes are the most common
retained foreign body because of its common usage, small size
and amorphous structure [5] Retained artery forceps are much rarer. Retained artery forceps remain inert and induce their
effects through mechanical means giving rise to pressure effects
resulting in abdominal pain or direct tissue/viscous injury leading
to tissue strangulation or perforation of viscous leading to for
example peritonitis or vascular injury resulting in hemorrhage
[1]. The clinical presentation of retained intra-abdominal foreign
material may be acute or delayed [6, 7]. Such patient present in the
surgical units with increasing abdominal pain, abdominal mass,
discharging sinus, intra-abdominal abscesses and acute or subacute
intestinal obstruction. Whilst many patients will present
within days or few weeks after the initial surgery and have a relaprotomy
for retrieval of the foreign body, some patients with
intra-abdominal foreign material may go unnoticed for years
or even decades. However many of this subset of patients will
have chronic abdominal symptoms such as abdominal pain or
discomfort. The pre-operative diagnosis is based on high index
of suspicion. The pre-operative diagnosis is based on history,
clinical examination, plain abdominal radiographs, ultrasound,
CT and MRI scans [1]. Management of retained material should
be surgical through exploration and save removal. Laparoscopic
exploration and removal was not published before for artery
forceps. We present a case of retained artery forceps during
laprotomy for uterine mass and hernia repair which was managed
successful by laparoscopy.
Case Report
56 year old housewife women presented to emergency
department with complain of three days of abdominal pain,
vomiting and distension. She is three weeks status post laprotomy
for huge uterine mass and ventral hernia. She underwent total
abdominal hysterectomy bilateral salpengioophrectomy and on
lay mesh repair of ventral hernia. Post operative course was un
eventual. She was discharged day five post operatively. Upon
presentation to emergency department she had no fever, no
urinary or respiratory symptoms. History of constipation. No
other associated symptoms. Examination showed calm patient
dehydrated with stable vital sign. Abdominal examination showed distended abdomen with midline healed wound and
localize peritonitis in right iliac and supra-pubic area. Bowel
sound was hyperactive. Rectal exam showed soft stool no blood.
Other clinical examination was unremarkable. Laboratory work
showed only White blood cell of 15,000 others were normal.
Imaging showed retained forceps intra-abdominally [Figure 1-2].
She was diagnosis with retained artery forceps causing small
bowel obstruction. Laparoscopic exploration was established
through right upper quadrant access using verse needle and
total of three 5 mm trocars. Adehesolysis and exposing artery
forceps done by running the small bowel. There was small bowel
loop herniated through the opening of jaw of forceps causing
obstruction (internal hernia) [figure1]. Opening of the forceps
jaws laparoscopiclly released the obstruction. Bowel loops were
healthy and there was no resection. Retrieval of forceps through
right upper quadrant by extending the wound under vision. Post
operative course was uneventful and patient discharged day five.
Discussion
Retained foreign body in a patient after surgery is an
uncommon but dangerous error and it is grossly under estimated
[2]. However many of the cases of retained foreign body are
not reported [3]. The rarity of the reported cases may be due
to medico-legal reasons. In literature the incidence of retained
Figure 1: (A) Plan film showed artery forceps. (B) illustrated digram
showed mechanism of bowel obstruction caused by artery forceps.
Figure 2: (A) C.T scan sagittal view of preoperative finding (uterine
mass and ventral hernia).
(B) Coronal view C.T showed bowel obstruction arrow pointing to
artery forceps.
foreign body is quoted as 1: per 1000 to 1500 laparotomies [4].
In our environment, the incidence is unknown because no local
data exist. The most common retained foreign body is abdominal
sponge because of its common usage and amorphous structure
[5]. The clinical presentation of retained materials may be acute
or delayed [6, 7]. While many retained foreign materials are
identified and retrieved immediately or shortly after surgery
some may remain unidentified for years or decades [8, 9]. Intraabdominal
retained artery forceps are much rare. Retained
metal like artery forceps are inert and exert their effect through
mechanical means like direct tissue damage causing ischemia,
pressure effect giving rise to pain and discomfort [10] or forming
an axis on which loops of bowel entangle leading to intestinal
obstruction and strangulation or a loop of bowel going through
the ‘eye’ of the retained artery forceps and getting trapped
leading to strangulation [11]. They may also penetrate hollow
organs for example gut leading to peritonitis or blood vessels
leading to hemorrhage. In our case internal hernia of bowel loops
through instrument was the cause of obstruction. A retrospective
study found that retained instruments and sponges following
an operation occurred more frequently in emergency surgery,
especially where there was an unplanned change in the operative
procedure, in patients with high mean body mass index [3, 13].
Others noted that huge intra-abdominal tumors or mass are risk
factors as in our case. Other risk factors are fatigued surgical
team, staff changes during operation, and failure to account for
all sponges and instruments, leaving closure of abdominal wound
to a junior, sometimes inexperienced [14]. In a case we present,
there was two teams operating gynecology and general surgery.
Exploratory laprotomy remains the mainstay of treatment to
retrieve retained intra-abdominal foreign material. Laparoscopic
removal is minimal invasive approach to avoid laprotomy
especially post hernia repair with mesh. It allows better
exploration and avoid midline repair. Post operative adhesion
are limiting factor for completing laparoscopic exploration. But it
is not always dense. In our case were manageable especially the
hernia repair was on lay. Extracting instrument was challenging
as we worked with five mm troacr. Right upper quadrant trocar
site was extended and the forceps removed under vision.
Conclusion
A case of retained large artery forceps following hysterectomy
and hernia repair is presented. Retained foreign body is avoidable
and could be a costly error.. All preventive protocols must be
observed under the strict guidance and full responsibility of
the surgeon. The need to investigate properly a patient who
complains of chronic abdominal symptoms following laparotomy
should be encouraged as this will aid in making early diagnosis
of retained foreign material before more serious complications
of intestinal obstruction or strangulation, or peritonitis, intraabdominal
abscesses or enterocutanous fistula supervenes.
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