Annals of the Royal College of Surgeons of England (1992) vol. 74, 254-255
CASE REPORT
An unusual complication of laparoscopic cholecystectomy Dean E Boyce
MB BCh
Senior House Officer
Louis J Fligelstone
Malcolm H Wheeler MD FRCS Consultant Surgeon
BCh FRCS
Surgical Registrar
Department of Surgery, Cardiff Royal Infirmary Key words: Laparoscopic cholecystectomy; Wound hernia; Intestinal obstruction
Laparoscopic cholecystectomy is rapidly becoming one of the most widely used new techniques in modern general surgery. One of the principal advantages of this operation compared with conventional cholecystectomy is the use of small incisions, which should be surgically sound and cosmetically superior, resulting in fewer complications and a speedier recovery (1). We present a case which illustrates that even these small wounds can cause postoperative complications.
Case report A fit 66-year-old lady who had never undergone previous surgery presented with an episode of acute biliary colic, not associated with jaundice. An ultrasound scan demonstrated gallstones and the common bile duct diameter was considered to be within normal limits. She appeared to be an ideal candidate for laparoscopic cholecystectomy. At operation a pneumoperitoneum was created, two 10 mm ports inserted, one in the epigastrium and one at the umbilicus and two lateral 5 mm ports inserted. The gallbladder was removed without difficulty via the epigastric port and both 10 mm ports closed with interrupted 2/0 Vicryl® sutures to the rectus sheath and subcuticular 3/0 Vicryl sutures to the skin. The immediate recovery was complicated by postoperative nausea, which had failed to subside by day 3. She had not passed flatus, the abdomen was silent and an abdominal radiograph showed a few dilated loops of small bowel. A diagnosis of postoperative paralytic ileus was therefore made and treatment continued with oral
Correspondence to: Dr Dean E Boyce, Department of Surgery, Cardiff Royal Infirmary, Newport Road, Cardiff CF2 1SZ
Figure 1. Plain abdominal radiograph showing small bowel obstruction.
fluid restriction and intravenous fluids. She was apyrexial and investigations showed normal blood count, urea, electrolytes and liver function tests. On the following day the abdomen was distended and silent. A nasogastric tube was therefore passed. Nausea and distension persisted and by day 5, abdominal films showed features of small bowel obstruction (Fig. 1). A small swelling was now palpable inferior to the umbilicus underlying the site of insertion of one of the 10 mm ports. This swelling was minimally tender, not reducible
f~ ~ ~... .I .
and did not have a cough impulse. A diagnosis of wound hernia seemed likely and an ultrasound scan showed a herniated loop of small bowel (Fig. 2). At laparotomy, two loops of small bowel were found herniating through the site of the umbilical port producing intestinal obstruction with dilated proximal small bowel. One loop of small bowel was necrotic and required resection. The defect in the umbilical port was repaired with continuous monofilament nylon and subsequent postoperative recovery was uneventful.
-l - l
Figure 2. Ultrasound of infraumbilical region showing a hermiated loop of smal bowel.
Complication of laparoscopic cholecystectomy
255
Comment One of the main advantages of laparoscopic as opposed to conventional cholecystectomy is the small size of the wounds and corresponding decrease in postoperative pain and morbidity (2). Bowel herniation through a defect in the broad ligament after laparoscopic sterilisation has been described (3), but herniation through the site of a port has not been documented. A possible explanation is that most gynaecological laparoscopic procedures are carried out via 5, 7 and 8 mm ports, whereas the recent advent of general surgical laparoscopy has seen the introduction of larger ports. We describe a case of wound hernia through a 10 mm port leading to small bowel necrosis requiring intestinal resection. This complication illustrates the importance of meticulous repair of the rectus sheath, even in these very small incisions.
References I Grace PA, Quereshi A, Coleman J et al. Reduced postoperative hospitalisation after laparoscopic cholecystectomy. BrJ Surg 1990;78:160-62. 2 Nathanson LK, Shiri S, Cuschieri A. Laparoscopic cholecystectomy: the Dundee technique. BrJ Surg 1990;78:155-9. 3 Denton GWL, Schofield JB, Gallagher P. Uncommon complications of laparoscopic sterilisation. Ann R Coll Surg Engl 1990;72:210-1 1.
Received 3 March 1992
CASE REPORT
An unusual complication of laparoscopic cholecystectomy Dean E Boyce
MB BCh
Senior House Officer
Louis J Fligelstone
Malcolm H Wheeler MD FRCS Consultant Surgeon
BCh FRCS
Surgical Registrar
Department of Surgery, Cardiff Royal Infirmary Key words: Laparoscopic cholecystectomy; Wound hernia; Intestinal obstruction
Laparoscopic cholecystectomy is rapidly becoming one of the most widely used new techniques in modern general surgery. One of the principal advantages of this operation compared with conventional cholecystectomy is the use of small incisions, which should be surgically sound and cosmetically superior, resulting in fewer complications and a speedier recovery (1). We present a case which illustrates that even these small wounds can cause postoperative complications.
Case report A fit 66-year-old lady who had never undergone previous surgery presented with an episode of acute biliary colic, not associated with jaundice. An ultrasound scan demonstrated gallstones and the common bile duct diameter was considered to be within normal limits. She appeared to be an ideal candidate for laparoscopic cholecystectomy. At operation a pneumoperitoneum was created, two 10 mm ports inserted, one in the epigastrium and one at the umbilicus and two lateral 5 mm ports inserted. The gallbladder was removed without difficulty via the epigastric port and both 10 mm ports closed with interrupted 2/0 Vicryl® sutures to the rectus sheath and subcuticular 3/0 Vicryl sutures to the skin. The immediate recovery was complicated by postoperative nausea, which had failed to subside by day 3. She had not passed flatus, the abdomen was silent and an abdominal radiograph showed a few dilated loops of small bowel. A diagnosis of postoperative paralytic ileus was therefore made and treatment continued with oral
Correspondence to: Dr Dean E Boyce, Department of Surgery, Cardiff Royal Infirmary, Newport Road, Cardiff CF2 1SZ
Figure 1. Plain abdominal radiograph showing small bowel obstruction.
fluid restriction and intravenous fluids. She was apyrexial and investigations showed normal blood count, urea, electrolytes and liver function tests. On the following day the abdomen was distended and silent. A nasogastric tube was therefore passed. Nausea and distension persisted and by day 5, abdominal films showed features of small bowel obstruction (Fig. 1). A small swelling was now palpable inferior to the umbilicus underlying the site of insertion of one of the 10 mm ports. This swelling was minimally tender, not reducible
f~ ~ ~... .I .
and did not have a cough impulse. A diagnosis of wound hernia seemed likely and an ultrasound scan showed a herniated loop of small bowel (Fig. 2). At laparotomy, two loops of small bowel were found herniating through the site of the umbilical port producing intestinal obstruction with dilated proximal small bowel. One loop of small bowel was necrotic and required resection. The defect in the umbilical port was repaired with continuous monofilament nylon and subsequent postoperative recovery was uneventful.
-l - l
Figure 2. Ultrasound of infraumbilical region showing a hermiated loop of smal bowel.
Complication of laparoscopic cholecystectomy
255
Comment One of the main advantages of laparoscopic as opposed to conventional cholecystectomy is the small size of the wounds and corresponding decrease in postoperative pain and morbidity (2). Bowel herniation through a defect in the broad ligament after laparoscopic sterilisation has been described (3), but herniation through the site of a port has not been documented. A possible explanation is that most gynaecological laparoscopic procedures are carried out via 5, 7 and 8 mm ports, whereas the recent advent of general surgical laparoscopy has seen the introduction of larger ports. We describe a case of wound hernia through a 10 mm port leading to small bowel necrosis requiring intestinal resection. This complication illustrates the importance of meticulous repair of the rectus sheath, even in these very small incisions.
References I Grace PA, Quereshi A, Coleman J et al. Reduced postoperative hospitalisation after laparoscopic cholecystectomy. BrJ Surg 1990;78:160-62. 2 Nathanson LK, Shiri S, Cuschieri A. Laparoscopic cholecystectomy: the Dundee technique. BrJ Surg 1990;78:155-9. 3 Denton GWL, Schofield JB, Gallagher P. Uncommon complications of laparoscopic sterilisation. Ann R Coll Surg Engl 1990;72:210-1 1.
Received 3 March 1992
