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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 1  |  Issue : 1  |  Page : 18-20

Successful laparoscopic removal of ingested fork


1 Department of Surgery, Tbilisi State Medical University; Department of Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
2 Department of Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
3 Department of Surgery, Tbilisi State Medical University, Tbilisi, Georgia

Date of Submission09-Dec-2015
Date of Acceptance27-Jan-2016
Date of Web Publication1-Apr-2016

Correspondence Address:
Zaza Demetrashvili
Department of Surgery, Tbilisi State Medical University, 33 Vazha-Pshavela ave, Tbilisi 0177
Georgia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2468-5585.179565

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  Abstract 

Most ingested foreign bodies (FBs) pass through the gastrointestinal tract without any problems, although their passage depends on shape and size. When a FB is relatively large, endoscopic removal may be utilized in most cases (the success rate was 95%), but sometimes surgery is required. We present a case report of a 27-year-old woman with epilepsy who had swallowed a fork in a suicide attempt. A plain abdominal radiograph confirmed a FB (fork) in the stomach with no visible pneumoperitoneum. On objective examination, the abdomen was soft and nontender with no peritoneal irritation. After a failed attempt at endoscopic removal, the laparoscopic intervention was undertaken. The operation was performed under general anesthesia utilizing open laparoscopy (Hasson's technique). As a result, the fork was successfully removed without further complications. After 72 h, she was discharged from the hospital without any complications. The patient was followed up after 4 weeks and made a full recovery.

Keywords: Foreign body, gastrointestinal, laparoscopic management


How to cite this article:
Demetrashvili Z, Loladze D, Vibliani K, Metreveli T. Successful laparoscopic removal of ingested fork. Transl Surg 2016;1:18-20

How to cite this URL:
Demetrashvili Z, Loladze D, Vibliani K, Metreveli T. Successful laparoscopic removal of ingested fork. Transl Surg [serial online] 2016 [cited 2019 Mar 21];1:18-20. Available from: http://www.translsurg.com/text.asp?2016/1/1/18/179565


  Introduction Top


Most ingested foreign bodies (FBs) pass through the gastrointestinal tract without any problem, although their passage depends on FBs' shape and size.[1],[2] Some cases, when an FB passes through the gastrointestinal tract without any problems, are not even recognized by the patient. When an FB is relatively large, endoscopic removal may be successful in most cases, but sometimes laparoscopy or laparotomy is required.[3],[4] We present a case report of an ingested fork requiring laparoscopic removal.


  Case Report Top


The patient was a 27-year-old woman with epilepsy. She was operated upon for vertebral compressive fractures several years ago. The patient had swallowed a fork as an apparent suicide attempt. The patient was taken to the hospital 24 h after the incident. A plain abdominal radiograph confirmed a FB (fork) in the stomach. Pneumoperitoneum was not visible [Figure 1]. On objective examination, the abdomen was involved in breathing and was soft and nontender with no peritoneal irritation. Endoscopic removal was attempted, but it was unsuccessful. The tines of the fork were directed upward, so the risk of injuring esophagus and perforation was high. Then we tried to rotate the fork, but the size did not give us an opportunity. Furthermore, the tines were deeply imbedded in the mucosal layer, thus rendering endoscopic removal unsuccessful.
Figure 1. Abdominal plain radiograph confirmed a foreign body (fork) in stomach, pneumoperitoneum is not visible. Radiograph shows cortical screws and plates they were used to fix compressive vertebral fractures several years ago

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The decision was made to perform laparoscopic removal of the fork. The patient was positioned in the supine position under general anesthesia. Open laparoscopy (Hasson's technique) was performed with pneumoperitoneum and an intra-abdominal working pressure of 12 mmHg. An initial 12 mm trocar was placed para-umbilically as the camera port. Two further 5 mm trocars were placed under direct vision in the left and right subcostal margins, both of them in the mid-clavicular line. A fourth 12 mm trocar was placed in the right paramedian line. The patient was then placed in Trendelenburg position. Using forceps and hook diathermy, a 4 cm gastrotomy was performed in the distal anterior gastric wall. After this, the fork was gently removed from the stomach into the peritoneal cavity. Any other pathologies in the abdomen were not found. The paraumbilical incision was expanded and under direct vision, the fork was removed from the abdomen [Figure 2]. All ports were placed in primary places, and gastrotomy was laparoscopically sutured using vicryl 2.0 with an interrupted 2-layer technique. The total time of operation was 100 min. The patient was given a light diet. After 72 h, the patient was discharged from the hospital without any complications. The patient was followed up after 4 weeks and had made a full recovery.
Figure 2. Para-umbilical incision was expanded and under direct vision, the fork was removed from abdomen

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  Discussion Top


There are many factors associated with the ingestion of FBs. Patients are most often children aged 6 months to 3 years. In adults, ingestion most typically affects the age range of 15–30 years.[2],[5] In children, ingestion of FBs is often unintentional whereas. In adults, it is commonly caused by psychiatric disorders or development delay, sometimes it can be accidental fortuitous. Ingestion of FBs mostly happens, when a patient suffers from schizophrenia, bulimia or epilepsy.[1],[5],[6] Our case is associated with the patient's neurological disorder as she suffered from epilepsy.

A total of 80–90% of ingested FBs will pass through the gastrointestinal tract without any problems, but those longer than 6 cm and wider than 2.5 cm will rarely be able to transit the retroperitoneal duodenal loop. Because of this, FBs have to be removed, to avoid complications such as perforation, obstruction, bleeding, ulceration, or fistula formation.[1],[2],[7] The decision, whether remove the FB or not, depends on several factors: The FB's shape, size, location, the patient's age and clinical condition, and the time elapsed from ingestion.[2],[3],[4] To avoid perforation or other complications, especially if the FB is located in the esophagus, it is advisable to remove the FB within 24 h.[4],[8] The cases of disc or button battery ingestion require furthermore attention because they could rapidly lead to liquefactive necrosis and perforation. These should undergo urgent endoscopic removal.[9]

Most ingested FBs can be removed endoscopically with a success rate of 95%.[1],[6],[10] In our case, endoscopic removal was attempted but, unfortunately, was unsuccessful.

Surgical management is rarely indicated in the context of foreign body ingestion. It is considered only when endoscopic retrieval has failed, or when complications of FB ingestion have occurred.[2],[3],[4],[7] In this case, our choice was to either use laparoscopy or open laparotomy. The benefits of laparoscopic approach in abdominal surgery are well-known, such as reduced postoperative pain and ileus, smaller incisions and superior cosmetic results, shorter duration of hospitalization, earlier return to work, and decreased the incidence of incisional hernias.[2],[3] Because of these advantages, we decided to perform laparoscopic removal of the FB, which was successful. It should be pointed out that while reviewing literature, we could not find a single case, where laparoscopic removal of a fork was described, because of this, our case is really interesting.

In conclusion, there are several methods to remove FBs from the gastrointestinal tract. If possible, endoscopic removal is the preferred choice. If endoscopic removal cannot be applied, either laparoscopy or laparotomy can be performed depending on local expertise. In our case, the ingested FB was a fork, which could not pass spontaneously through the gastrointestinal tract and had a significant risk of causing complications, so laparoscopic removal was performed successfully.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Velitchkov NG, Grigorov GI, Losanoff JE, Kjossev KT. Ingested foreign bodies of the gastrointestinal tract: Retrospective analysis of 542 cases. World J Surg 1996;20(8):1001-5.  Back to cited text no. 1
    
2.
Ambe P, Weber SA, Schauer M, Knoefel WT. Swallowed foreign bodies in adults. Dtsch Arztebl Int 2012;109(50):869-75.  Back to cited text no. 2
    
3.
Ribas Y, Ruiz-Luna D, Garrido M, Bargalló J, Campillo F. Ingested foreign bodies: Do we need a specific approach when treating inmates? Am Surg 2014;80(2):131-7.  Back to cited text no. 3
    
4.
Kramer RE, Lerner DG, Lin T, Manfredi M, Shah M, Stephen TC, Gibbons TE, Pall H, Sahn B, McOmber M, Zacur G, Friedlander J, Quiros AJ, Fishman DS, Mamula P; North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Endoscopy Committee. Management of ingested foreign bodies in children: A clinical report of the NASPGHAN Endoscopy Committee. J Pediatr Gastroenterol Nutr 2015;60(4):562-74.  Back to cited text no. 4
    
5.
Wright CC, Closson FT. Updates in pediatric gastrointestinal foreign bodies. Pediatr Clin North Am 2013;60(5):1221-39.  Back to cited text no. 5
    
6.
Pelta R, Sahota A, Bemarki A, Salama P, Simpson N, Laine I. Foreign body ingestion: Characteristics and outcomes in a lower socioeconomic population with predominantly intentional ingestion. Gastrointest Endosc 2009;69(3):426-33.  Back to cited text no. 6
    
7.
Goh BK, Chow PK, Quah HM, Ong HS, Eu KW, Ooi LL, Wong WK. Perforation of the gastrointestinal tract secondary to ingestion of foreign bodies. World J Surg 2006;30(3):372-7.  Back to cited text no. 7
    
8.
Chen T, Wu HF, Shi Q, Zhou PH, Chen SY, Xu MD, Zhong YS, Yao LQ. Endoscopic management of impacted esophageal foreign bodies. Dis Esophagus 2013;26(8):799-806.  Back to cited text no. 8
    
9.
Panella NJ, Kirse DJ, Pranikoff T, Evans AK. Disk battery ingestion: Case series with assessment of clinical and financial impact of a preventable disease. Pediatr Emerg Care 2013;29(2):165-9.  Back to cited text no. 9
    
10.
Sugawa C, Ono H, Taleb M, Lucas CE. Endoscopic management of foreign bodies in the upper gastrointestinal tract: A review. Wold J Gastrointest Endosc 2014;6(10):475-81.  Back to cited text no. 10
    


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