Foreign body perforation of the distal ileum: an unusual cause of right iliac fossa pain managed via single incision laparoscopic surgery (SILS) approach

Abstract

A 61-year-old woman was seen by the emergency general surgical team with a 2-week history of right iliac fossa pain. Imaging revealed the possibility of a distal ileum perforating foreign body. Using a single incision laparoscopy surgery (SILS) approach, this diagnosis was confirmed at operation. This emerging technique meant a much smaller incision could be used than traditional exploratory laparotomy, with the benefit of less postoperative pain and a faster recovery. This case highlights an uncommon cause for abdominal pain and the importance of close liaison with radiologists and the low threshold for use of laparoscopy as a diagnostic tool. We advocate the use of SILS in the emergency setting for appropriate cases.

Background

Right iliac fossa pain is among the most common presentations seen by the emergency general surgical team.¹ The diagnosis is not always clear based on the history, examination findings and laboratory tests, hence imaging is often used in diagnosis. Perforation due to accidental ingestion of foreign body is an unusual cause for this presentation and radiological appearances can be equivocal.² It may be necessary to confirm the diagnosis operatively. Single incision laparoscopy surgery (SILS) is an emerging technique which is used although sparingly in elective colorectal resections and in well-selected emergency general surgical procedures.³ We demonstrate some advantages of SILS in this case.

Case presentation

A 61-year-old woman was referred to the emergency general surgical team with a 2-week history of abdominal pain. She described the pain as intermittent cramping with occasional shooting pains, felt most prominently in the right iliac fossa. There was some associated nausea but no vomiting. There was no change in bowel habits and appetite and no fever. The pain became acutely worse when the patient slipped from a standing position, landing heavily on her right side, prompting her presentation to the emergency department. The patient has a medical history of diverticulosis, hypertension and previous total abdominal hysterectomy and bilateral salpingo-oophorectomy. On initial examination, she was markedly tender in the right iliac fossa with signs of local peritonism. Her blood pressure was 135/80 mm Hg, pulse 85 bpm and temperature 37.2°C.

Investigations

Urinalysis was negative for leucocytes and nitrites. Blood tests showed a white cell count of 15.6×10⁹/L, C reactive protein of 2.4 mg/L, haemoglobin of 150 g/L, estimated glomerular filtration rate (eGFR) >90 mL/min/1.73 m² with urea, creatinine, sodium and potassium within normal limits. Initial differential diagnosis included appendicitis and diverticulitis, though the history was atypical for both. Given the diagnostic uncertainty and clinical status of the patient, an urgent CT of the abdomen and pelvis with intravenous contrast was organised. This did not show diverticulitis and the appendix could not be clearly visualised. It did show, however, a curvilinear, needle-like structure within the distal ileum traversing the bowel wall. There was a small gas pocket adjacent to the tip, seemingly outside the bowel lumen (figure 1). There was also peri-ileal fat stranding. This unusual appearance was thought unlikely to be artefact. In light of these findings, the patient was questioned further, however she had not knowingly ingested any foreign body and there were no signs of percutaneous puncture. A repeat CT scan without contrast was performed to exclude the possibility of artefact. The same curvilinear structure was identified (figure 2).

Figure 1.

Initial CT with intravenous contrast.

Figure 2.

Repeat non-contrast CT for confirmation of foreign body.

Treatment

The patient was given intravenous co-amoxiclav 1.2 g and metronidazole 500 mg and prepared for theatre. A diagnostic laparoscopy was performed using a 10 mm laparoscope via an umbilical port. The distal ileum and adjacent peritoneal lining were inflamed. A tapering foreign body was seen protruding 2 cm through the wall of the terminal ileum, approximately 10 cm from the ileocecal junction (figure 3), correlating with the CT findings. There was no peritoneal contamination observed. The umbilical incision was extended to 5 cm to accommodate a GelPoint advanced-access port, for SILS access. A 10 mm laparoscope and additional grasper were used via the SILS port. The bowel was traced, with no other observed pathology. Maintaining visualisation of the sharp tip of the foreign body, the perforated section of ileum was then delivered safely into the midline incision (figure 4). The foreign body was pulled through the ileum wall, leaving a 1–2 mm defect. This was closed extracorporeally with layered sutures (figure 5). The abdomen was closed following extensive laparoscopic washout.

Figure 3.

Laparoscopic photograph of foreign body protruding through ileal wall.

Figure 4.

Bowel delivered into single incision laparoscopy surgery incision.

Figure 5.

Defect sutured.

Outcome and follow-up

The patient recovered well after surgery. She was mobilising, eating and drinking on day 1 and was discharged on postoperative day 5 with oral antibiotics. The foreign body macroscopically appeared to be stiff vegetable matter or a semi-flexible piece of plastic.

Discussion

This case highlights the clinical approach to an unusual presentation, the importance of liaison with radiology and the benefits of SILS in place of exploratory laparotomy.

It is postulated that the foreign body was inadvertently swallowed some weeks prior to presentation and may have become stuck at the distal ileum, causing the preceding pain. The perforation may have occurred when the patient fell onto her right side. Interpretation of the initial CT was aided by face-to-face discussion between surgeon and radiologist and the decision for repeat imaging was made collaboratively.

SILS is an emerging technique and has been used in elective and emergency general surgery operations although sparingly. Suggested benefits include better assessment through a small incision, shorter recovery times and better cosmesis.⁴ A SILS approach offered several benefits over laparotomy in this case. First, the initial diagnostic portion was rapid. Second, using a laparoscopic grasper to deliver the affected section of bowel into the 5 cm SILS incision meant that a long midline incision was avoided. Traditionally a long incision would have been necessary in order to achieve adequate exposure for diagnosis and repair of the injured bowel. Third, delivering the affected section of small bowel into a long midline incision may have necessitated some blind traction of the small bowel. This would have risked further damage caused by the sharp tip of the foreign body. In our approach, the sharp tip was maintained under constant visualisation, thereby avoiding further damage.

A laparoscopic-assisted approach to similar cases has been described, however this usually necessitates extending one of the incisions to allow the bowel to be delivered and enterotomy performed.⁵ We were able to perform this procedure via a single incision which likely had benefits for the patient of comparatively less postoperative pain and a shorter postoperative stay.

Learning points.

• Diagnostic uncertainty in the emergency general surgical setting can be overcome by close liaison with radiologists and prompt surgical exploration where appropriate.

• Single incision laparoscopy surgery (SILS) had the benefit over both open and laparoscopic approaches in this case as the pathology could be safely delivered laparoscopically into an ‘open’ operative field without having to make a large incision.

• SILS should be considered as an alternative to laparotomy in appropriate cases.