CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 5 (2014) 1044–1046
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.casereports.com
Small bowel volvulus with no malrotation after laparoscopic appendicectomy: Case report and literature review Osama S. Al Beteddini ∗ , Emad Sherkawi Johns Hopkins Aramco Healthcare, Saudi Aramco, PO Box 76, Dhahran 31311, Eastern Province, Saudi Arabia
a r t i c l e
i n f o
Article history: Received 15 June 2014 Received in revised form 27 October 2014 Accepted 28 October 2014 Available online 4 November 2014 Keywords: Small bowel volvulus Midgut volvulus Small bowel obstruction Laparoscopy Appendicectomy Complication
a b s t r a c t INTRODUCTION: Small bowel volvulus, as a complication of laparoscopic surgery, is a rarely reported clinical entity. We present a case of a young female who developed small intestinal volvulus after laparoscopic appendicectomy. She had this complication in the absence of malrotation or other previous abdominal operations. PRESENTATION OF CASE: A 17-year-old woman presented with acute appendicitis. After an uneventful laparoscopic appendicectomy, she developed acute small intestinal obstruction on the second postoperative day. A prompt laparotomy showed small bowel volvulus, which was reduced, with no evidence of malrotation. She had an uneventful recovery and was discharged within 3 days of the second operation, in a stable condition. DISCUSSION: This article presents a review of the literature of this rare cause of small intestinal obstruction after laparoscopic surgery, stressing on the importance of early diagnosis and treatment. A discussion of the potential factors predisposing to this entity is presented, emphasising the need of a higher-evidence study as to its aetiology and prevalence. CONCLUSION: Small bowel volvulus is a rare complication of laparoscopic surgery, but its early diagnosis and prompt treatment is essential to avoid morbid outcomes. Surgery is the therapeutic mainstay. © 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
1. Introduction
2. Report of a case
Small bowel volvulus, related to congenital midgut malrotation, has long been reported as a cause of intestinal obstruction in the paediatric population. However, its occurrence in the adult population, in the absence of malrotation and in relation to laparoscopic surgery is a clinical rarity. In this article, we present the case of a 17-year-old girl who presented with small bowel volvulus on the second day after a laparoscopic appendicectomy. She was explored and the volvulus was reduced. There was no evidence of intestinal vascular compromise. After her second operation, she had an uneventful recovery. In reporting this case, we would like to emphasise the importance of a prompt diagnosis of this rare entity and the need of emergent surgical intervention as a therapeutic measure, shedding light on the potential factors predisposing to this diagnosis.
A 17-year-old woman presented to our care with a 36-h history of vomiting, anorexia and mid-abdominal pain that started to shift to the right lower quadrant. Upon examination, she looked unwell, with guarding and rebound tenderness over the right iliac fossa. A blood work-up showed a white cell count of 20,000/mm3 . The patient was diagnosed with acute appendicitis and was promptly taken to the operating theatres for laparoscopic exploration. Intra-operatively, she showed a severely inflamed appendix. The appendiceal base was very friable and gangrenous. During dissection, the appendix was perforated and faecolith spilled into the peritoneal cavity. Otherwise, the operation continued smoothly, the appendiceal stump was secured and the spillage was controlled and cleared. The pneumoperitoneum was completely deflated at the end of the procedure and the patient’s recovery from anaesthesia was uneventful. After a favourable course during the first post-operative day, the patient started to feel unwell, having had several episodes of vomiting. Physical examination showed a distended abdomen with no signs of peritonitis. Blood tests revealed a white cell count of 21,000/mm3 with neutrophilia. The diagnosis of paralytic ileus was suggested and supportive therapy, in the form of intravenous fluids, nasogastic intubation and bowel rest, was initiated. The third post-operative day did not show any clinical improvement. An
∗ Corresponding author. Tel.: +966 502512572; fax: +966 138773695. E-mail addresses: [email protected] (O.S. Al Beteddini), [email protected] (E. Sherkawi).
http://dx.doi.org/10.1016/j.ijscr.2014.10.091 2210-2612/© 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
CASE REPORT – OPEN ACCESS O.S. Al Beteddini, E. Sherkawi / International Journal of Surgery Case Reports 5 (2014) 1044–1046
Fig. 1. A CT scan view of the abdomen showing small bowel obstruction.
intravenous contrast-enhanced computed tomography scan of the abdomen and pelvis (Fig. 1) showed that the small bowel is dilated throughout with transition into collapsed small bowel loops within the right lower quadrant of the abdomen. No definite drainable collections could be noted. Showing no clinical or para-clinical improvement, the patient was re-taken to the operating theatres. Due to the grossly distended abdomen and to avoid any possible bowel injury while introducing the trocars to perform an exploratory laparoscopy, an open approach was elected. The laparotomy showed small bowel obstruction due to a clockwise twist of the totality of the bowel on itself except for the terminal ileum that was fixed in its place. No evidence of intestinal malrotation could be found. The diagnosis of small bowel volvulus was suggested. The volvulus was untwisted and no intestinal vascular compromise was noted. After the second intervention, the patient had an uneventful recovery and was discharged after 2 days. 3. Discussion Intestinal malrotation is a well described clinical entity in the paediatric age group, with an estimated incidence of 1 in 6000 live births.1 The clinical presentation varies from an incidental finding in an otherwise asymptomatic child to the acute presentation of small bowel volvulus. Most patients develop symptoms during the first month of life.1,2 The presentation of small bowel volvulus due to intestinal malrotation in later life is reported.3,4 Midgut volvulus
1045
may, further, present secondary to complications from previous surgery, including adhesive bands or stomas.5 However, the occurrence of small bowel volvulus in the early post-operative period after laparoscopic surgery, and in the absence of malrotation or other previous surgery, is a rarely reported clinical entity with few cases noted in medical literature. Caudra et al.6 presented the case of a 30-year-old man who developed midgut volvulus, 8 days after laparoscopic appendicectomy. No evidence of congenital malrotation was found upon re-exploration. In 2008, Ferguson et al.7 published a literature review on intestinal volvulus following laparoscopic surgery. In this review, he postulated several factors including congenital malrotation, previous surgery and intra-operative factors, including pneumoperitoneum, bowel handling and patient positioning as possible aetiologies of intestinal volvulus after laparoscopic surgery. In a retrospective study conducted by Huang et al.8 on small bowel volvulus among adults, the importance of a low threshold for diagnosis and early surgical intervention were overemphasised to prevent vascular compromise, bowel gangrene and a subsequent high mortality rate. In another retrospective study by Gürleyik and Gürleyik9 , small bowel volvulus constituted 8% of all cases of mechanical intestinal obstruction and 13% of small bowel obstruction. In 48% of patients presenting with volvulus, no cause could be found. Upon studying the aetiological factors leading to small bowel volvulus after laparoscopic surgery, no definitive cause-effect relations can be drawn. However, predisposing factors could include intra-operative handling of the bowels, patient positioning and lateral inclinations of the operating table, pneumoperitoneum and stasis and intestinal bloating related to anaesthetic agents and tissue hypoperfusion.2,7 Fast decompression of the pneumoperitoneum may also be a predisposing factor.2 Stating the above factors, all of these would have well been at the basis of our case report. The severe bloating that the patient has experienced, early on after the procedure, could have resulted from paralytic ileus due to the pathology itself, anaesthetic agents and secondary to bowel handling. The resultant intestinal distension could have caused the twist. As mentioned previously; however, no solid conclusions can be made. 4. Conclusion The possibility of small bowel volvulus after laparoscopic surgery as a cause of small bowel obstruction must be considered despite the rarity of the diagnosis, so as to avoid deleterious complications resulting in sepsis, short bowel syndrome and ultimately death. Adherence to sound laparoscopic surgical practices cannot be overemphasised, as excessive handling of the bowels in the roomy, CO2 -inflated abdomen and steep inclinations upon patient positioning may well be at the basis of this rare complication after laparoscopic surgery. Conflict of interest Nothing to declare. Funding Nothing to declare. Ethical approval Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy
CASE REPORT – OPEN ACCESS 1046
O.S. Al Beteddini, E. Sherkawi / International Journal of Surgery Case Reports 5 (2014) 1044–1046
of the written consent is available for review by the Editor-in-Chief of this journal on request. Author contributions Emad Sherkawi has operated on the patient. He provided necessary material to write the article. He reviewed the article. Osama S. Al Beteddini has written the article. References 1. Townsend CJR, Beauchamp RD, Evers BM, Mattox KL. Sabiston textbook of surgery: the biological basis of modern surgical practice. 19th ed. Philadelphia: Saunders; 2012. p. 1843–4. 2. Macedo M, Velhote MC. Midgut volvulus after laparoscopic appendectomy. Einstein (Sao Paulo) 2012;10(1):103–4.
3. Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, et al. Schwartz’s principles of surgery. 9th ed. New York: McGraw-Hill; 2010. 4. Vricella LA, Barrett WL, Tannenbaum IR. Intestinal obstruction from midgut volvulus after laparoscopic cholecystectomy. Surg Endosc 1999;13: 1234–5. 5. Lay OS, Tsang TK, Caprini J, Gardner A, PollackJ, Norman E. Volvulus of the small bowel: an uncommon complication after laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech 1997;7(1):59–62. 6. Caudra AS, Khalife ME, Char DJ, Wax MR, Halpern D. Intestinal obstruction from midgut volvulus after laparoscopic appendectomy. Surg Endosc 2002;16(1): 215. 7. Ferguson L, Higgs Z, Brown S, McCarter D, McKay C. Intestinal obstruction following laparoscopic surgery: a literature review and case report. J Laparoendosc Adv Surg Tech 2008;18(3):405–10. 8. Huang JC, Shin JS, Huang YT, Chao CJ, Ho SC, Wu MJ, et al. Small bowel volvulus among adults. J Gastroenterol Hepatol 2005;20(12):1906–12. 9. Gürleyik E, Gürleyik G. Small bowel volvulus: a common cause of mechanical intestinal obstruction in our region. Eur J Surg 1998;164(1):51–5.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports journal homepage: www.casereports.com
Small bowel volvulus with no malrotation after laparoscopic appendicectomy: Case report and literature review Osama S. Al Beteddini ∗ , Emad Sherkawi Johns Hopkins Aramco Healthcare, Saudi Aramco, PO Box 76, Dhahran 31311, Eastern Province, Saudi Arabia
a r t i c l e
i n f o
Article history: Received 15 June 2014 Received in revised form 27 October 2014 Accepted 28 October 2014 Available online 4 November 2014 Keywords: Small bowel volvulus Midgut volvulus Small bowel obstruction Laparoscopy Appendicectomy Complication
a b s t r a c t INTRODUCTION: Small bowel volvulus, as a complication of laparoscopic surgery, is a rarely reported clinical entity. We present a case of a young female who developed small intestinal volvulus after laparoscopic appendicectomy. She had this complication in the absence of malrotation or other previous abdominal operations. PRESENTATION OF CASE: A 17-year-old woman presented with acute appendicitis. After an uneventful laparoscopic appendicectomy, she developed acute small intestinal obstruction on the second postoperative day. A prompt laparotomy showed small bowel volvulus, which was reduced, with no evidence of malrotation. She had an uneventful recovery and was discharged within 3 days of the second operation, in a stable condition. DISCUSSION: This article presents a review of the literature of this rare cause of small intestinal obstruction after laparoscopic surgery, stressing on the importance of early diagnosis and treatment. A discussion of the potential factors predisposing to this entity is presented, emphasising the need of a higher-evidence study as to its aetiology and prevalence. CONCLUSION: Small bowel volvulus is a rare complication of laparoscopic surgery, but its early diagnosis and prompt treatment is essential to avoid morbid outcomes. Surgery is the therapeutic mainstay. © 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
1. Introduction
2. Report of a case
Small bowel volvulus, related to congenital midgut malrotation, has long been reported as a cause of intestinal obstruction in the paediatric population. However, its occurrence in the adult population, in the absence of malrotation and in relation to laparoscopic surgery is a clinical rarity. In this article, we present the case of a 17-year-old girl who presented with small bowel volvulus on the second day after a laparoscopic appendicectomy. She was explored and the volvulus was reduced. There was no evidence of intestinal vascular compromise. After her second operation, she had an uneventful recovery. In reporting this case, we would like to emphasise the importance of a prompt diagnosis of this rare entity and the need of emergent surgical intervention as a therapeutic measure, shedding light on the potential factors predisposing to this diagnosis.
A 17-year-old woman presented to our care with a 36-h history of vomiting, anorexia and mid-abdominal pain that started to shift to the right lower quadrant. Upon examination, she looked unwell, with guarding and rebound tenderness over the right iliac fossa. A blood work-up showed a white cell count of 20,000/mm3 . The patient was diagnosed with acute appendicitis and was promptly taken to the operating theatres for laparoscopic exploration. Intra-operatively, she showed a severely inflamed appendix. The appendiceal base was very friable and gangrenous. During dissection, the appendix was perforated and faecolith spilled into the peritoneal cavity. Otherwise, the operation continued smoothly, the appendiceal stump was secured and the spillage was controlled and cleared. The pneumoperitoneum was completely deflated at the end of the procedure and the patient’s recovery from anaesthesia was uneventful. After a favourable course during the first post-operative day, the patient started to feel unwell, having had several episodes of vomiting. Physical examination showed a distended abdomen with no signs of peritonitis. Blood tests revealed a white cell count of 21,000/mm3 with neutrophilia. The diagnosis of paralytic ileus was suggested and supportive therapy, in the form of intravenous fluids, nasogastic intubation and bowel rest, was initiated. The third post-operative day did not show any clinical improvement. An
∗ Corresponding author. Tel.: +966 502512572; fax: +966 138773695. E-mail addresses: [email protected] (O.S. Al Beteddini), [email protected] (E. Sherkawi).
http://dx.doi.org/10.1016/j.ijscr.2014.10.091 2210-2612/© 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
CASE REPORT – OPEN ACCESS O.S. Al Beteddini, E. Sherkawi / International Journal of Surgery Case Reports 5 (2014) 1044–1046
Fig. 1. A CT scan view of the abdomen showing small bowel obstruction.
intravenous contrast-enhanced computed tomography scan of the abdomen and pelvis (Fig. 1) showed that the small bowel is dilated throughout with transition into collapsed small bowel loops within the right lower quadrant of the abdomen. No definite drainable collections could be noted. Showing no clinical or para-clinical improvement, the patient was re-taken to the operating theatres. Due to the grossly distended abdomen and to avoid any possible bowel injury while introducing the trocars to perform an exploratory laparoscopy, an open approach was elected. The laparotomy showed small bowel obstruction due to a clockwise twist of the totality of the bowel on itself except for the terminal ileum that was fixed in its place. No evidence of intestinal malrotation could be found. The diagnosis of small bowel volvulus was suggested. The volvulus was untwisted and no intestinal vascular compromise was noted. After the second intervention, the patient had an uneventful recovery and was discharged after 2 days. 3. Discussion Intestinal malrotation is a well described clinical entity in the paediatric age group, with an estimated incidence of 1 in 6000 live births.1 The clinical presentation varies from an incidental finding in an otherwise asymptomatic child to the acute presentation of small bowel volvulus. Most patients develop symptoms during the first month of life.1,2 The presentation of small bowel volvulus due to intestinal malrotation in later life is reported.3,4 Midgut volvulus
1045
may, further, present secondary to complications from previous surgery, including adhesive bands or stomas.5 However, the occurrence of small bowel volvulus in the early post-operative period after laparoscopic surgery, and in the absence of malrotation or other previous surgery, is a rarely reported clinical entity with few cases noted in medical literature. Caudra et al.6 presented the case of a 30-year-old man who developed midgut volvulus, 8 days after laparoscopic appendicectomy. No evidence of congenital malrotation was found upon re-exploration. In 2008, Ferguson et al.7 published a literature review on intestinal volvulus following laparoscopic surgery. In this review, he postulated several factors including congenital malrotation, previous surgery and intra-operative factors, including pneumoperitoneum, bowel handling and patient positioning as possible aetiologies of intestinal volvulus after laparoscopic surgery. In a retrospective study conducted by Huang et al.8 on small bowel volvulus among adults, the importance of a low threshold for diagnosis and early surgical intervention were overemphasised to prevent vascular compromise, bowel gangrene and a subsequent high mortality rate. In another retrospective study by Gürleyik and Gürleyik9 , small bowel volvulus constituted 8% of all cases of mechanical intestinal obstruction and 13% of small bowel obstruction. In 48% of patients presenting with volvulus, no cause could be found. Upon studying the aetiological factors leading to small bowel volvulus after laparoscopic surgery, no definitive cause-effect relations can be drawn. However, predisposing factors could include intra-operative handling of the bowels, patient positioning and lateral inclinations of the operating table, pneumoperitoneum and stasis and intestinal bloating related to anaesthetic agents and tissue hypoperfusion.2,7 Fast decompression of the pneumoperitoneum may also be a predisposing factor.2 Stating the above factors, all of these would have well been at the basis of our case report. The severe bloating that the patient has experienced, early on after the procedure, could have resulted from paralytic ileus due to the pathology itself, anaesthetic agents and secondary to bowel handling. The resultant intestinal distension could have caused the twist. As mentioned previously; however, no solid conclusions can be made. 4. Conclusion The possibility of small bowel volvulus after laparoscopic surgery as a cause of small bowel obstruction must be considered despite the rarity of the diagnosis, so as to avoid deleterious complications resulting in sepsis, short bowel syndrome and ultimately death. Adherence to sound laparoscopic surgical practices cannot be overemphasised, as excessive handling of the bowels in the roomy, CO2 -inflated abdomen and steep inclinations upon patient positioning may well be at the basis of this rare complication after laparoscopic surgery. Conflict of interest Nothing to declare. Funding Nothing to declare. Ethical approval Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy
CASE REPORT – OPEN ACCESS 1046
O.S. Al Beteddini, E. Sherkawi / International Journal of Surgery Case Reports 5 (2014) 1044–1046
of the written consent is available for review by the Editor-in-Chief of this journal on request. Author contributions Emad Sherkawi has operated on the patient. He provided necessary material to write the article. He reviewed the article. Osama S. Al Beteddini has written the article. References 1. Townsend CJR, Beauchamp RD, Evers BM, Mattox KL. Sabiston textbook of surgery: the biological basis of modern surgical practice. 19th ed. Philadelphia: Saunders; 2012. p. 1843–4. 2. Macedo M, Velhote MC. Midgut volvulus after laparoscopic appendectomy. Einstein (Sao Paulo) 2012;10(1):103–4.
3. Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, et al. Schwartz’s principles of surgery. 9th ed. New York: McGraw-Hill; 2010. 4. Vricella LA, Barrett WL, Tannenbaum IR. Intestinal obstruction from midgut volvulus after laparoscopic cholecystectomy. Surg Endosc 1999;13: 1234–5. 5. Lay OS, Tsang TK, Caprini J, Gardner A, PollackJ, Norman E. Volvulus of the small bowel: an uncommon complication after laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech 1997;7(1):59–62. 6. Caudra AS, Khalife ME, Char DJ, Wax MR, Halpern D. Intestinal obstruction from midgut volvulus after laparoscopic appendectomy. Surg Endosc 2002;16(1): 215. 7. Ferguson L, Higgs Z, Brown S, McCarter D, McKay C. Intestinal obstruction following laparoscopic surgery: a literature review and case report. J Laparoendosc Adv Surg Tech 2008;18(3):405–10. 8. Huang JC, Shin JS, Huang YT, Chao CJ, Ho SC, Wu MJ, et al. Small bowel volvulus among adults. J Gastroenterol Hepatol 2005;20(12):1906–12. 9. Gürleyik E, Gürleyik G. Small bowel volvulus: a common cause of mechanical intestinal obstruction in our region. Eur J Surg 1998;164(1):51–5.
Open Access This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
