Laparoscopic assisted removal of rectalrectal foreign bodybody Ashish Bhanot, G. R. Patel, Mitesh Bachani, Vijayraj D. Gohil Department of Surgery, Govt. Medical College, Bhavnagar, Gujarat, India For correspondence: Ashish Bhanot, C-7 Doctors Quarters, Sir T. Hospital Campus, Bhavnagar - 364 001, Gujarat, India. E-mail: [email protected] ABSTRACT ‘Foreign’ means originating elsewhere or simply ‘outside the body.’ Foreign body rectum is not as common as other parts of the body. Rectal foreign bodies present are difficult to manage. Emergency-department Case Report procedures include rectal examination, proctoscopy and abdominal radiography. Soft or low-lying objects having an edge could be grasped and removed safely in the emergency department, but grasping hard objects is potentially traumatic and occasionally results in upward migration toward the sigmoid. Although foreign bodies can be removed in the emergency department in about two out of three cases, some 10% still require a laparotomy and a diverting colostomy to remove the object or to treat bowel perforation. We are presenting a case of laparoscopic assisted removal of tumbler using 10 mm suction cannula to push the object down. Laparoscopy helped not only in retrieval but also enabled visualizing any bowel perforation due to foreign body and its manipulation. Key words: 10 mm suction cannula, foreign body rectum, laparoscopic assisted, sigmoid colostomy How to cite this article: Bhanot A, Patel GR, Bachani M, Gohil VD. Laparoscopic assisted removal of rectal foreign body. Indian J Surg 2006;68:216-8. INTRODUCTION blood were trickling from the anus. On finger examination, there was a reduced tone of anal sphincter Rectal foreign body, although infrequent, and circumference of glass tumbler could be reached by presents a challenge in management. Here is case, the fingertip with difficulty. Proctoscopy confirmed first of its type, where laparoscopy was used to presence of tumbler in the rectum, as open-end margins assist retrieval of foreign body in the rectum as could be seen along with breach in anal canal, but the well as rule out any bowel perforation. exact length could not be assessed. The patient was taken to the X-ray department and abdominal radiography CASE REPORT was done. Radiograph confirmed the presence of radiopaque foreign body in the pelvis [Figure 1]. There A 46-year-old male presented to the emergency was no free gas under the domes of diaphragm [Figure department with complaints of bleeding per 2]. Abdominal ultrasound ruled out the presence of any rectum. History of sexual assault by three truck free fluid in peritoneum. The patient was taken to the drivers was there. When the patient refused operative room with proper consent, including consent homosexual relation, they forcibly introduced for colostomy. General anesthesia was given to the patient a glass tumbler in the patient’s rectum. Attempts after the lithotomy position dilatation of anal sphincter were made to remove it by the local physician was performed and the attempt for per rectal retrieval during which the margin of glass broke off and was tried but failed. Bimanually pushing object with bleeding started per rectum. Per abdomen was abdominal pressure applied to facilitate caudal soft and the patient also had left tunica vaginalis movement was tried but failed. Laparoscopy was hydrocele. On rectal examination, drops of fresh planned on table but the patient had previous lower abdomen scar, so introduction of the first trocar was Paper Received: May, 2005. Paper Accepted: June, 2005. done by open method in infraumblical region. Other Source of Support: Nil. Conflict of Interest: None declared. trocars were planned - one just on the right side of a 216 Indian J Surg | August 2006 | Volume 68 | Issue 4 216 CMYK Laparoscopic assisted removal of rectal foreign body Figure 1: Plain X-ray pelvis showing inverted glass tumbler in rectum Figure 3: Intraoperative photograph while foreign is being delivered per rectal Figure 2: Plain X-ray abdomen showing dilated large bowel Figure 4: Postoperative photograph three port sites loops with feacal loading supraumblical, LIF port sigmoid loop brought out for colostomy and right pararectus port drain is kept point midway between umbilicus and pubic symphsis. 3]. Rectum was palpated and inspected to rule out any Adhesions of previous surgery were there, which were breach. There was deep longitudinal tear in the lower dealt by blunt and sharp dissection. Another 10 mm part of the rectum, which required rest to heal, so port was planned at a point 3 cm medial to the left diverting sigmoid colostomy was done. Sigmoid colon anterior superior iliac spine, keeping in mind the loop was brought out from port site in left iliac fossa possibility of using it for sigmoid colostomy if required. and Ryle’s tube was kept as drain from 5 mm port site Peritoneal cavity, sigmoid colon and rectum were [Figure 4]. inspected for any evidence of perforation by foreign body. Now the foreign body was located by indirect palpation DISCUSSION using blunt suction tip. The tumbler was located and pushed down using constant pressure by blunt suction The objects homosexuals insert into their rectum are tip. At that time, fingers could be passed 1 inch beyond only limited by the capacity of their rectum, not their the margins of tumbler and the object was retrieved with imagination.[1] Eighty percent of these events occur for great difficulty using fingers of both the hands [Figure sexual stimulation and in 10% cases, it is forcibly Indian J Surg | August 2006 | Volume 68 | Issue 4 217 CMYK 217 Bhanot A, et al. introduced during sexual assault.[2] These patients grasping hard objects is potentially traumatic and typically present to the emergency department in a occasionally results in upward migration toward the delayed fashion because of embarrassment and often after sigmoid. Operating room procedures include anal multiple attempts at self-removal. A multi-disciplinary dilatation under general anesthesia, transrectal approach should be used when encountering patients manipulation, bimanual palpation if necessary and with colorectal foreign bodies. Length of time since withdrawal of the foreign body.[5] Frequently, delay in insertion and presence of rectal or abdominal pain, fever presentation and multiple attempts at self-removal lead or rectal bleeding are important elements of the history. to mucosal edema and muscular spasms, further The keys to adequate care for these patients are respect hindering removal. Few cases require laparotomy, for their privacy, determination of the type and location manually pushing object caudally towards anus. To of the foreign body and determination if removal can be avoid formal laparotomy and its morbidity, laparoscopy performed in the emergency department. can be used as modality to push low and mid-high foreign bodies in rectum. Laparoscopy also helps to identify Operating room procedures include anal dilatation under any sealed-off rectal perforation and the one which occurs general anesthesia, transrectal manipulation, bimanual during manipulation. Like any other minimally invasive palpation if necessary and withdrawal of the foreign procedures, it is patient-friendly due to small incision body.[3] The possibility of a perforation must be taken and early ambulation. The patient can be sent home early, into account, especially with longstanding foreign bodies thereby giving more confidentiality and lesser that can erode the bowel wall. A fewfree perforations psychosocial trauma. In the era of minimally invasive are clinically obvious with free air on abdominal surgery, this is another procedure that can be done by radiographs; but in few cases, small perforations sealed laparoscopy. by omentum were not evident on radiographs. If there is difficulty in interpreting radiographs, an opinion from REFERENCES a radiologist should be obtained. Before attempting any manipulation in the operation theater, consent for 1. Miller BJ, Wetzig NR. Incarcerated sigmoid bottle. Aust N Z J laparotomy and colostomy should be sought. These Surg 1990;60:729-31. 2. Barone JE, Sohn N, Nealon TF Jr. Perforations and foreign patients are often deeply embarrassed and psychological bodies of the rectum: Report of 28 cases. Ann Surg support and confidentiality are essential. The role of 1976;184:601-4. the nursing staff involved in the care of the patient in 3. Cohen JS, Sackier JM. Management of colorectal foreign such cases is highly important. The patient should be bodies. J Roy Coll Surg Edin 1996;41:312-5. [4] 4. Eftaiha M, Hambrick E, Abcarian H. Principles of management treated with bed rest, analgesia and mild sedation. of colorectal foreign bodies. Arch Surg 1977;112:691-5. Soft- or low-lying objects having an edge could be grasped 5. Barone JE, Yee J, Nealon TF Jr. Management of foreign bodies and and removed safely in the emergency department, but trauma of the rectum. Surg Gynecol Obstet 1983;156:453-7. Author Help: Sending a revised article 1) Include the referees’ remarks and point to point clarification to those remarks at the beginning in the revised article file itself. In addition, mark the changes as underlined or coloured text in the article. Please include in a single file a. referees’ comments b. point to point clarifications on the comments c. revised article with text highlighting the changes done 2) Include the original comments of the reviewers/editor with point to point reply at the beginning of the article in the ‘Article File’. To ensure that the reviewer can assess the revised paper in timely fashion, please reply to the comments of the referees/editors in the following manner. • There is no data on follow-up of these patients. Authors’ Reply: The follow up of patients have been included in the results section [Page 3, para 2] • Authors should highlight the relation of complication to duration of diabetes. Authors’ Reply: The complications as seen in our study group has been included in the results section [Page 4, Table] 218 Indian J Surg | August 2006 | Volume 68 | Issue 4 218 CMYK.