Closed loop small bowel obstruction due to small intestine volvulus associated with early adhesion after laparoscopic appendectomy: Case report and review of the literature

Abstract

Introduction and importance

Nowadays the majority of appendectomies are undertaken laparoscopically. The associated per and postoperative complications are well established and known. However, some rare postoperative complications continue to be reported such as small bowel volvulus.

Case presentation

We report the case of 44-year-old women who developed a small bowel obstruction from acute small bowel volvulus due to early postoperative flanges five days after a laparoscopic appendectomy.

Clinical discussion

Laparoscopy is associated with less adherences and morbidity however we must be careful in post operative course. Mechanical obstruction can happen even with laparoscopy procedure.

Conclusion

Occlusion earlier after surgery even with laparoscopy procedure must be explored. Volvulus can be incriminated.

Highlights

• •Laparoscopic surgery provides less unfortunates events than open surgery
• •Volvulus can happen after laparoscopic surgery early especially in case of preoperatory difficulties, so we must be careful in post operative follow up.
• •We must explore patient with abnormality on clinical examination by tomography and even surgery

1. Introduction

Acute appendicitis is one of the most common surgical emergencies requiring acute hospital admission. Nowadays the majority of appendectomies are undertaken laparoscopically, with evidence demonstrating reduced post-operative pain, a lower rate of wound infection, faster recovery and shorter hospital stay when compared with the open procedure. It's associated per and post operative complications are well established and known. However, some rare post operative complications continue to be reported such as small bowel volvulus. Herein we report the case of small bowel volvulus after laparoscopic appendectomy. This case has been reported in line with SCARE criteria [1].

2. Presentation of case

We report the case of 44-year-old women who developed a small bowel obstruction from acute small bowel volvulus due to early post operative flanges five days after a laparoscopic appendectomy. The patient past medical history included hypothyroidism under treatment and no previous surgeries. She was admitted in the surgery department with a history of acute abdominal pain associated with vomiting and fever. Physical exam showed tenderness in the right iliac fossa. We completed by Computed tomography scan (CT-Scan) and the diagnosis of acute appendicitis was retained. Laparoscopic appendectomy was performed. The appendix was gangrenous and perforated. The base of the appendix was ligated and the appendix was then divided with scissors. The peritoneal cavity was then irrigated with normal saline until clear fluid was aspirated from the abdominal cavity. The course was marked initially by good evolution with disappearance of the fever and transit restored as gas associated with well tolerance of the diet. But at day four post operative the patient presented an acute abdominal pain associated with vomiting. Physical examination revealed that her abdomen was slightly distended and rigid with tenderness. Abdominal radiograph displayed multiple air-fluid levels in the small intestine. CT-Scan demonstrated a typical whirlpool sign in favor of closed loop bowel obstruction (Fig. 1).

Fig. 1.

C shaped small bowel loops.

With her abdominal distension and tenderness progressively worsening, emergency laparotomy was performed with a midline incision (Fig. 2).

Fig. 2.

Stigma of volvulated small bowel obstruction.

Per operatively we found a stigma of the small intestine volvulated on a loose small bowel flange with distension of the intestine upstream. Otherwise, the small bowel viability was good, the coecum and the appendectomy staple were in place. The course was marked then by good evolution and the patient was discharged at day three post operative. The follow-up at one month later was without anomalies. The patient did not report any complaints.

3. Discussion

Closed loop small bowel obstruction is a form of mechanical obstruction in which two or more points along the course of the bowel are obstructed at a single constrictive lesion. It has a high mortality rate if the correct diagnosis and subsequent laparotomy are delayed.

Small bowel obstruction due to intestinal volvulus following laparoscopic procedures is a rare but documented complication such as the case of our patient.

In the following table (Table 1), we report all the cases of small bowel volvulus after laparoscopic appendectomy that have been reported in literature so far.

Table 1.

Overview of the reported cases of small bowel volvulus after laparoscopic appendectomy.

Year	Authors	Patient's age	Sex	Presentation	Interval after appendectomy	Cause	Treatment
2014	Al Beteddini and Sherkawi [2]	17	F	Vomiting and abdomen distension	Day 1	No evident cause	Laparotomy, intwisted volvulus
2018	Hegde et al. [3]	10	M	Vomiting and abdomen distension	Day 2	No evident cause	Laparotomy, detorsion of volvulus
2018	Kakaty et al. [4]	18	F	Periumbilical pain	Day 10	Metal clip	Laparotomy, necrosis along 60 cm of the small intestine, necrotic bowel was resected, enteroenteric anastomosis was performed
2012	Macedo et al. [5]	13	M	Abdominal discomfort	Day 1	No evident cause	Laparotomy, the necrotic bowel was resected and an entero-entero-anastomosis was done.
2009	Page et al. [6]	13	M	Sudden acute abdominal pain	Day 3	Surgical staples	Laparotomy, reduction of volvulus
2002	Nottingham et al. [7]	34	M	Colicky diffuse abdominal pain	Day 10	Surgical staple	Laparotomy, reduction of the volvulus
2019	Kim et al. [8]	27	F	Epigastric pain	Day 9	Surgical staple	Laparotomy, the volvulated necrotic bowel was resected and enteroenteric anastomosis was done.
2021	González-Urquijo et al. [9]	19	M	Nausea with abdominal pain	Day 6	No evident cause, free intraperitoneal staple was found	Laparotomy, the volvulated necrotic bowel was resected and enteroenteric anastomosis was done.
2001	Cuadra et al. [10]	30	M		Day 8	Midgut volvulus with absence of congenital malformation
2002	Ly [11], [12]	21	M	Abdominal pain	Few days after laparoscopic appendectomy	Midgut volvulus due to malrotation

As our case involved a small bowel volvulus, we focused on the etiology of this particular form of volvulus after laparoscopic appendectomy.it seems important to mention that there was other form of volvulus that were reported such as coecum, or sigmoid volvulus.

The appendectomy was difficult, there were still false membranes or fibrin in small bowel that may explain this adverse event in our case.

For the most cases reported in literature the cause of the volvulus was due surgical staple. Postoperative adhesions may create an axis around which the cecum or small bowel can rotate such as the case of our patient. The particularity of this case was the early post operative adhesion associated with the volvulus.

In the eight documented cases of intestinal volvulus following the laparoscopic appendectomy, there was an interval procedure-presentation of volvulus ranging between 24 h and 10 days, in the case of our patient it was four days.

Although there are few reports of a successful resolution of intestinal volvulus without surgical intervention, it is generally agreed that, in most cases, operative management is required.

4. Conclusion

Despite its large use laparoscopy procedure is not without risks. This case is a new addition to the wide range of reported complications observed after laparoscopic procedures, such as the appendectomy. After the exclusion of more common complications, this adverse event must be mentioned especially in cases of preoperative difficulties due to complicated appendicitis. The gut volvulus should be considered when these patients deteriorate postoperatively.

CRediT authorship contribution statement

Asma SGHAIER corresponding author study concept, data collection, and surgical therapy for the patient.

Eya LAMLOUM Writing - original draft preparation.

Mehdi DEBIBI Editing and writing.

Azza SRIDI Editing and writing.

Adnene CHOUCHENE senior author and manuscript reviewer.

All the authors read and approved the final manuscript = senior author and manuscript reviewer.

All the authors read and approved the final manuscript.

Funding

None.

Ethical approval

N/A Ethical approval is exempt/waived at our institution.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Registration of research studies

N/A.

Not commissioned, externally peer-reviewed.

Guarantor

Asma Sghaier.

Declaration of competing interest

None.