Laparoscopic Extirpation of a Fork From the Duodenum

BACKROUND:
A woman who had accidentally swallowed a fork during a dinner party was admitted to our Department of General and Abdominal surgery. Different techniques have been described for removing foreign bodies (FB) from the stomach or the duodenum. Endoscopical techniques are widely and successfully used, but not in each case.
Here, we present the laparoscopic retrieval of a 15 cm fork from the duodenal bulb.

METHODS:
A 23-year-old woman was admitted with progressive abdominal pain two weeks after swallowing a plastic fork while attempting to induce vomiting during a party.
On the day of admission to our emergency room, she presented with leukocytosis, otherwise normal laboratory findings and mild epigastric tenderness without peritonism. She was afebrile with normal vital signs and had no significant events in her past medical history. Prior to admission, she ate normal meals.
A routine X-ray examination did not show the expected FB. The preoperative upper endoscopy, on the other hand, showed a plastic fork, tines up, right behind the pylorus in the duodenal bulb: The tines were deeply buried in the wall of the intestine. The handle was irremovably lodged in the opposite part of the duodenum. In consequence, the indication for laparoscopic extirpation was given, especially due to uncertainty concerning further lesions or the presence of an abscess within the abdominal cavity. Perforating objects and objects larger than 7 cm ought to be removed surgically to prevent oesophageal perforation.

The patient was placed in supine position with the surgeon standing between her legs. Four trocars, two 10-mm and two 5-mm, were used (ApplyMedical, USA). We expected peritonitis and extreme tissue swelling with adhesions in the upper abdominal cavity, but only saw a slightly swollen duodenum with very few fibrin stripes and roughly 250 ml of white, exudative, intraperitoneal fluid. The fork tines, which had perforated the duodenal bulb, could be seen. There were no liver injuries. The tines were held with a clamp, and the perforated intestinal wall was carefully dissected with the monopolar hug (STORZ, Germany) and later with the ACE Harmonic Scalpel (ETHICON, USA) due to bleeding.
After the tines were freed, the 15cm plastic fork was extracted in proximal direction through the perforation injury. There was no severe necrosis, and debridement was not necessary. The bowel was irrigated and continuously sutured with 3-0 PDS.
Finally, the fork was retrieved without problems from the abdominal cavity through the 10mm trocar incision.

RESULTS:
Operating time was 60 minutes, blood loss estimated at roughly 100 ml with no blood transfusion. The patient’s postoperative course was uneventful. Hospital stay was 4 days. The patient tolerated a gradual reintroduction of liquid and solid foods; she was well and asymptomatic one year after the operation.

CONCLUSION:
A fork may be swallowed, but cannot spontaneously pass through the gastrointestinal tract. Early removal should be advised to avoid perforation and to minimize morbidity.
Laparoscopic removal is a safe and feasible method of managing FBs that are not removable endoscopically.


Session: Podium Video Presentation

Program Number: V046

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