Katherine Foley, MD, Chrisitan Balabanoff, MD, Ala Stanford Frey, MD, FACS, FAAP. Abington Memorial Hospital and The Children’s Hospital of Philadelphia.
BACKGROUND: A laparoscopic appendectomy is one of the most common acute pediatric surgery operations. Post-operative complications include abscess formation and both port site hematomas and hernias. There are rare reports of intestinal obstruction from loose linear staples in the adult literature, but this is the first report in a pediatric patient.
CASE PRESENTATION: A 5 year-old male presented to the emergency department with 24 hours of abdominal pain and fever. On exam he had right lower quadrant tenderness with rebound. He had a white blood cell count of 8.0 with 21 bands. An ultrasound did not reveal appendicitis, but a CT scan showed a hyperemic appendix without a fluid collection. He was given pre-operative antibiotics and taken to the operating room for a laparoscopic appendectomy. A three-trochar technique (umbilicus, suprapubic and left lateral quadrant) was used. The mesoappendix was divided with a harmonic scalpel and we used a Covidien Endo-GIA vascular load (2.5mm staple height) at the appendiceal base. The stapler was opened slowly and the appendix was removed through the umbilical port. He initially did well post operatively and was discharged on post operative day 1. However, he developed nausea and vomiting at home and returned to the emergency department on post operative day 2. His abdomen was soft and mildly distended, with minimal tenderness at the trocar sites. He was afebrile and WBC was 7.0 with 2 bands. Obstruction series showed a non-specific gas pattern with mildly dilated bowel loops. He continued to have bilious emesis and a nasogastric tube was placed with sedation. As he improved his NGT was placed to gravity, but when sips of clears were initiated he became nauseous and vomited. An obstruction series showed an increase in the dilation of loops of bowel with air fluid levels. He was taken back to the operating room for a diagnostic laparoscopy.
We identified a transition point in the proximal small bowel. All of the intestine was viable. At this location a staple was found tethering the serosa of a small bowel loop to a mesenteric lymph node, with several loops of small bowel trapped beneath. The bowel distally was collapsed and the appendiceal stump was intact. The staple was removed and enteric contents began to pass into the collapsed bowel. The bowel was run from the terminal ileum to Ligament of Treitz. Post operatively he did well. His bowel function returned on POD 3 and he was gradually advanced to a regular diet and was discharged on POD 4. He was doing well at a follow up visit 2 and 3 weeks respectively.
In the pediatric patient who develops an early small bowel obstruction after a laparoscopic appendectomy with use of an endoscopic stapler, a linear staple as a source should be included in the differential diagnosis. Additionally, an attempt at a repeat laparoscopic procedure to diagnose and treat the cause should be considered.