Laparoscopic retrieval of a hepatic foreign body in a dog

Abstract

A 4-year-old female pointer dog was presented with a 10-day history of tensed abdomen. Migration of a metallic foreign body to the liver was diagnosed using radiography and ultrasonography. Surgical retrieval of a sewing needle was successfully performed by laparoscopy using a 3-trocar technique, thus avoiding laparotomy. No intra- or post-operative complications occurred. The dog was discharged 24 hours after surgery. Ten months after surgery, the dog was in excellent physical condition with no recurrence of clinical signs. This is the first reported case of laparoscopic retrieval of a hepatic foreign body in a dog.

Foreign body ingestion is common in dogs and cats (1). Most foreign bodies pass uneventfully through the gastrointestinal tract and are eliminated in the stool. Rarely, an ingested sharp foreign body can perforate the gut and migrate into the abdominal cavity (2). Mahajan et al (3) described surgical removal of a metallic foreign body from the spleen of a dog. Surgical removal of a metallic foreign body in the liver of a dog was also reported by Choi et al (4). In these 2 previous case reports, a laparotomy was performed to remove the foreign body. In the present report, a case of sewing needle migration to the liver, which was managed laparoscopically was described. This is the first reported case of surgical removal by laparoscopy of a foreign body that had migrated into the liver in a dog.

Case description

A 4-year-old female pointer dog, weighing 22 kg was presented to the author’s institution with signs of tensed abdomen for the previous 10 d. Physical examination of the dog revealed no significant abnormality except pain on palpation of the cranial abdomen. The dog had vomited occasionally but its appetite was normal. Hematological examination and serum biochemistry were within reference ranges. Abdominal radiographs revealed a radiopaque 3.3 cm long L-shaped metallic foreign body in the upper right abdominal quadrant (Figures 1, 2). The foreign body could not be located precisely but was suspected to be in or in close relationship to the right liver lobes. Ultrasonography of the abdomen showed a hyperechoic linear structure in the liver parenchyma with distal acoustic shadowing (Figure 3). No hypoechoic pockets were observed around the foreign body on the ultrasound images. It was determined that the ultrasonographic findings and abdominal pain together gave us enough information to recommend surgical intervention to the owner. Also, removal of the foreign body was recommended due to the risk of potential major complications such as hemorrhage, peritonitis, or infection that could occur by leaving the foreign body in place. An attempt to retrieve the foreign body using laparoscopy was proposed to the owner, who was also informed of the potential need to convert to open laparotomy. After owner’s consent, exploratory laparoscopy was scheduled for the subsequent day.

Figure 1.

Lateral view of the abdomen showing a radiopaque metallic foreign body in the cranio-ventral abdomen.

Figure 2.

Ventro-dorsal view of the abdomen showing a radiopaque metallic foreign body in the right cranial quadrant.

Figure 3.

Ultrasonography of the abdomen showing a hyperechoic line representing a metallic needle (arrows) in the liver parenchyma (longitudinal view).

The dog was sedated with a combination of morphine chlorhydrate (Morphine Cooper; Lavoisier, Melun, France), 0.1 mg/kg body weight (BW), SC, and acepromazine (Calmivet; Vétoquinol, Magny-Vernois, France), 0.01 mg/kg BW, IM. Anesthesia was induced with propofol (Propovet; Zoetis, Malakoff, France), 6 mg/kg BW, IV and was maintained with isoflurane (Isoflo; Abbott Animal Health, Maidenhead, UK) in 100% oxygen in a semi-closed circle system. Monitoring of anesthesia included heart and respiratory rates, oxygen saturation, capnography, electrocardiography, and systolic and diastolic blood pressures. Cefazolin (Cefazoline; Mylan, St. Priest, France), 20 mg/kg BW, IV, was administered at induction of anesthesia. Intravenous sodium lactate (Ringer’s Lactate; Bayer, Leverkusen, Germany) was administered at 10 mL/kg BW per hour.

Laparoscopic abdominal access was obtained using a suture-less modified Hasson technique as previously described (5). Three laparoscopic portals were established for introduction of surgical instruments. The camera portal was established 1 cm caudal to the umbilicus using a pyramidal tip 8.5 cm long 11 cm trocar-cannula assembly (Karl Storz Veterinary Endoscopy, Guyancourt, France). Correct telescope position was confirmed by observation of intra-abdominal fat and pneumoperitoneum was established with CO₂ insufflation to an abdominal pressure of 12 mmHg using a pressure-regulating mechanical insufflator (Endoflator; Karl Storz Veterinary Endoscopy). Then, a 5 mm, 0°, 29 cm laparoscope (Hopkins II; laparoscope, Karl Storz Veterinary Endoscopy) was inserted into the abdomen. Two instrument portals were established using 6.5 cm long, 6 mm trocarless threaded cannulas (Ternamian Endotip cannula; Karl Storz Veterinary Endoscopy) under direct observation. The first instrument portal was established 5 cm lateral and 3 cm cranial to the umbilicus on the right side. Laparoscopic exploration of the liver lobes and gallbladder was performed. For this purpose, a laparoscopic probe (Karl Storz Veterinary Endoscopy) through the right portal was used for gentle palpation and manipulation of the liver lobes and gallbladder. The metallic foreign body was found in the right medial liver lobe on its ventral surface. One end of the metallic foreign body was in direct contact with the gallbladder wall. The second instrument portal was established 5 cm lateral and 3 cm cranial to the umbilicus on the left side. The laparoscopic probe through the right-sided instrument portal was used to elevate the right medial liver lobe into a position where the metallic foreign body was visible (Figure 4). Then, a straight laparoscopic grasper (Karl Storz Veterinary Endoscopy) was inserted into the left portal and was used to grasp the metallic foreign body (Figure 5). The laparoscopic probe was removed and replaced by another laparoscopic grasping forceps. The foreign body was manipulated between both laparoscopic graspers in order to orient the long axis of the metallic foreign body with the axis of the left gasping forceps (Figure 6). Because of the L shape of the foreign body, extraction could not be performed through the 6 mm trocarless threaded cannula. This cannula was replaced by an 11-mm non-threaded cannula (Versaport; Covidien, Mansfield, Massachusetts, USA). Finally, the metallic foreign body was pulled out through the left portal without removing the instrument cannula. Dislodging the metallic foreign body induced a slight hemorrhage that resolved spontaneously. Inspection of the area of interest at the end of the procedure did not reveal abnormalities. There was no perforation in the gallbladder wall and no bleeding from the liver at the level of the extracted foreign body. The extracted foreign body was a sewing needle. The abdomen was decompressed by CO₂ release before removal of the cannulae. The portals were closed by single simple interrupted 0 polyglyconate sutures in the musculature of the body wall and single simple interrupted sutures of 3-0 polyglyconate in the subcuticular tissue, and 4-0 nylon in the skin. The total surgical time was 31 min.

Figure 4.

Laparoscopic view of the needle buried in the liver. A 3-trocar technique was used. A laparoscopic probe inserted through the right portal was used to elevate the right medial liver lobe into a position where the metallic foreign body was clearly visible.

Figure 5.

Laparoscopic view. A straight laparoscopic grasper was placed through the left portal and was used to grasp the metallic foreign body while the laparoscopic probe was lifting the right medial liver lobe.

Figure 6.

Laparoscopic view. The foreign body was manipulated between both laparoscopic graspers in order to orient the long axis of the metallic foreign body with the axis of the left gasping forceps. The metallic foreign body was pulled out through the left portal without removing the instrument cannula.

The dog made an uneventful recovery. Morphine chlorhydrate (Morphine Cooper; Lavoisier), 0.1 mg/kg BW, SC, q4h, was administered for 24 h and meloxicam (Metacam; Boehringer Ingelheim am Rhein, Germany), 0.1 mg/kg BW, PO, q24h for 5 d after a loading dose of 0.2 mg/kg BW, SC on the first day. The primary complaint of tensed abdomen resolved by the first post-operative day and the dog was discharged 24 h after surgery. Ten months following surgery, the dog was in excellent physical condition with no recurrence of clinical signs.

Discussion

Migration of sewing needles to extra-gastrointestinal locations is uncommon in dogs and cats. Most ingested sewing needles travel through the gastrointestinal system without harm and are eliminated with the stool (1). Sewing needle migration has been reported in the myocardium, liver, spleen, urinary bladder, and cervical vertebral canal in dogs (3,4,6–8). Interestingly, in a recently published retrospective study of sewing needle foreign bodies involving 65 dogs and cats, 7 (11%) animals had sewing needles in extra-gastrointestinal locations that were not causing clinical signs (2). Choi et al (4) also presented a case in which a metallic foreign body was embedded in the liver asymptomatically and found incidentally. In the present case, tensed abdomen was the chief complaint for the previous 10 d. Because abdominal pain resolved completely the day after surgery, the author strongly suspects that abdominal pain was related to the presence of the sewing needle. In humans, sewing needles in the liver may cause abdominal pain, fever, or abnormal liver function tests (9,10).

It is of academic interest to speculate about the course taken by the sewing needle as it passes from the site of insertion to the site of removal. The history of foreign body ingestion is often missing. According to Brankov (11), perforation of the gastrointestinal tract following an ingested foreign body remained difficult to predict when peritonitis or abscess formation was not detected. The most likely path of sewing needle migration to the liver is per continuatem from the stomach. However, there was no tract detected in the stomach wall at the time of surgery to support this hypothesis. It is also possible that the needle might have accidentally penetrated through the skin into the liver. However, the owner did not notice any injury on the skin of the abdominal wall.

Before conducting surgery to remove a foreign body, it is fundamental to have a high-quality imaging work-up to gain knowledge about the exact location of the foreign body. Our case emphasizes the importance of surgical planning to minimize peri- and post-operative complications by identifying precisely the location of the foreign body. Traditionally, the diagnosis of intra-abdominal metallic foreign body is made by radiographs (2,3,11). In our dog, the radiographs identified the foreign body in the abdomen, but the exact location could not be ascertained, as individual liver lobes cannot be discriminated on plain radiographs. Ultrasonography was precise in identifying the exact site of the needle in the liver parenchyma and provided much information associated with the foreign body. In the present case, there were no hepatic pathologic changes associated with the foreign body, including gallbladder rupture, hematoma, abscess or necrosis on ultrasonographic images. It was determined that the ultrasonography and clinical presentation together gave us enough information to recommend surgical intervention to the owner. Advanced imaging techniques may be able to localize foreign bodies more precisely. For this purpose, a CT scan with three-dimensional reconstructions can be very helpful (12). Magnetic resonance imaging (MRI) would have been another option. However, artefacts and secondary image distorsion would have been observed with MRI. Also, migration of foreign materials not anchored by fibrous tissue or not fixed to bony structures remains a potential issue when the materials are exposed to the high magnetic fields used with MRI.

In humans, metallic hepatic foreign bodies may cause fatal complications such as hemorrhage, abscess, and peritonitis (13–17). If penetration is shown, the foreign body should be surgically removed. For asymptomatic liver foreign bodies, the risk-benefit ratio of extraction of foreign bodies seems to favor operation, especially if a minimally invasive approach can be used (15). Although the recommendations are to remove hepatic foreign bodies in humans, there are some authors who recommend conservative treatment. One human patient declined surgical treatment and had no subsequent symptoms or complications in the follow-ups (18).

Laparoscopy has been used to remove migrating foreign bodies from the liver in humans (15,19,20). Laparoscopic retrieval of liver foreign bodies can be accomplished safely if one end of the foreign body is protruding from the liver surface and if it can be withdrawn through the portal site. In this dog, the needle was small (1 mm in diameter), one end of the needle was visible during laparoscopy, and no adhesions of the surrounding organs to the needle were noted, so removal was successfully achieved without recourse to open laparotomy. Placement of the camera portal at the infra-umbilical position yielded good observation of all salient structures. In addition, when placing the instruments portals, care was taken to try and triangulate them around the anticipated location of the gallbladder and place them several centimeters apart so that instruments would not come easily into contact during the procedure. In the present case, no intra- or post-operative complications occurred, and the dog recovered quickly with only short-term postoperative analgesic drugs. However, several surgical potential complications could have been encountered: inadequate visualization of the needle, extensive bleeding or laceration of the liver parenchyma, loss of the needle inside the abdominal cavity during extraction, or significant adhesions of the surrounding organs with the area of interest. All these features must be discussed with the owners before surgery with the potential to convert to an open laparotomy.

It is commonly accepted that the laparoscopic approach might allow for a more rapid recovery compared with an open laparotomy. Reported advantages of laparoscopy include more detailed observations, decreased postoperative complications, and earlier ambulation (21–24). In humans, the use of simultaneous fluoroscopy during laparoscopy may also aid in the localization of the foreign body (20).

In conclusion, liver foreign body should be considered as a potential cause of abdominal pain in dogs. Ultrasonography was useful for localizing the needle in the liver parenchyma. Laparoscopy is safe, feasible, and effective for managing such cases. Laparoscopic surgery affords an additional option for removal of readily identified hepatic foreign bodies. CVJ