Content uploaded by Vishwanath Golash
Author content
All content in this area was uploaded by Vishwanath Golash
Content may be subject to copyright.
42 Oman Medical Journal 2008, Volume 23, Issue 1, January 2008
Laparoscopic Removal of Large and Sharp Foreign Bodies from the Stomach
Golash V.
Introduction
Majority of the foreign bodies of different shapes and sizes
are reported to pass spontaneously without much harm to
the patients during the observation period. When foreign bodies
do not pass spontaneously endoscopic or surgical removal is
necessary. Surgery is indicated in failed endoscopic removal.
Conventionally foreign bodies are removed by laparotomy; we
present our experience with laparoscopic removal.
Case 1
A 35 year old man admitted with the history of a right upper
abdominal pain for last few days. On examination he was found to
Abstract :
Ingestion of foreign bodies is a common occurrence. Majority
would pass spontaneously without any complications.
Occasionally large and sharp foreign bodies may get stuck and
give rise to complications. Removal of large sharp foreign bodies
is recommended due to their potential of danger. Foreign bodies
can be removed by endoscopy or by laparotomy. We present the
two cases of laparoscopic removal of large sharp foreign bodies
from the stomach. Laparoscopic removal of large sharp foreign
bodies from the stomach is safe.
Received: 11 September 2007
Accepted: 19 November 2007
Address Correspondence and reprint request to: Golash V., MBBS, MS, FRCS. Sr.
Consultant Surgeon, SQH, Salalah, Sultanate of Oman.
Email: golash@omantel.net.om or haritagolash@hotmail.com
have a tender mass in right upper quadrant. An abdominal plain x-
ray showed a long radio-opaque object in the upper abdomen lying
obliquely, most probably in the stomach. (Figure 1a) Ultrasound
and the CT scan of the abdomen confirmed a metallic object,
perforating the pyloric end of the stomach and embedded in the
right lobe of the liver. e colon, gall bladder, rest of the viscera
were not affected and no there was no free fluid or gas in the
abdomen. With these findings endoscopic removal was avoided.
He was resuscitated and prepared for surgery.
Surgical Procedure: A thorough Laparoscopy was performed
through of umbilical port. ere was no free fluid, no pus. ere was
a mass in the right upper quadrant adherent to anterior abdominal
wall sealed all around by the greater omentum. e stomach and
the right lobe of liver were adherent to the mass. e hepatic flexure
of colon was not seen. e greater omentum was separated gently
from the mass which exposed the right lobe of liver. e lower half
of the stomach was adherent to liver and was separated next. It
revealed a sharp metallic foreign body, perforating through the
Case Report
Figure 1a: Plain x-ray showing a long radio-opaque object in the
upper abdomen
Figure 1b: Foreign body penetrating the liver
43
Oman Medical Journal 2008, Volume 23, Issue 1, January 2008
pyloric end of the stomach and penetrating the right lobe of liver
close to the gall bladder (Figure 1b). e hepatic flexure of colon
was not involved. e foreign body was impacted in the stomach.
A 10 cm long anterior gastrostomy was performed with the help
of ultracision to deliver the foreign body. e sharp upper end
of the foreign body was close to the esophagus-gastric junction.
e foreign body (which was an old rusted screwdriver without a
handle) was gently lifted off the stomach at its top free end and was
taken out from the stomach (Figure 1c). Both ends of the foreign
body were sharp and with great care one end was manipulated and
fed into the left lower mid-clavicular port till the end was visible
outside the abdomen (Figure 1d). e foreign body along with
trocar sheath was removed under vision (Figure 1e). e foreign
body was 15.5 cm long (Figure 1f). e gastrostomy wound was
closed in two layers and the perforating wound at the pyloric end
was closed with the omental patch in the same manner as the
closure of perforated peptic ulcer. His post operative recovery was
uneventful and was discharged home on 5th. postoperative day. He
was seen 4 months after surgery and was asymptomatic.
Case 2
An eighteen year old, morbidly obese (BMI 65) lady was
admitted with the history of having swallowed three A4 size
batteries three days prior to admission. While she was as an in-
patients she further swallowed a broken long handle of the table
spoon. She was asymptomatic. On examination per abdomen
there was no sign or symptoms of peritonitis. A plain x-ray
abdomen showed the foreign bodies in her stomach (Figure 2a). An
endoscopic removal was attempted (Figure 2b). Only three A4 size
batteries were seen but broken long end of the table spoon which
was seen earlier in the plain x-ray of abdomen was not seen in the
stomach. On entering the duodenum the tip of the long handle of
the broken spoon was visible in the third part of the duodenum
(Figure 2b). It was pulled back in the stomach with the help of the
Laparoscopic removal of foreign bodies ... Golash
Figure 1c: Gastrostomy and removal of foreign body Figure 1e: Foreign body along with port removed
Figure 1d: Foreign body fed in trocar Figure 1f: Foreign body measuring 15.5 cm
44 Oman Medical Journal 2008, Volume 23, Issue 1, January 2008
snare but was too dangerous to remove it by endoscopy for the fear
of perforation of the esophagus. It was also not possible to snare or
hold the A4 batteries. e endoscopy was abandoned and patient
was prepared for surgical removal of these foreign bodies. Patient
was consented for the laparoscopy/laparotomy removal of several
foreign bodies in the stomach. Laparoscopic approach was similar
to hiatus hernia repair. rough anterior gastrostomy foreign
bodies were removed in the retrieval bag one by one (Figure 2c).
Post operative recovery was uneventful. She was doing well two
months after the surgery.
Discussion
Removal of foreign bodies from the stomach is controversial.
Management of ingested foreign bodies varies according to the type,
size, location and patient age. Majority of foreign bodies would
pass spontaneously (90%) only 10-20% would require endoscopic
and less than 1% surgical removal. 1 Foreign bodies posing danger
because of their shape and size should be removed. Various
options available include endoscopic, surgical, laparoscopic, and
laparo-endoscopic removal of foreign body from stomach. 2 , 3, 4
Endoscopic removal is the procedure of choice and is successful
in most of patients. Endoscopic removal is more successful in
children and in cases of short duration of impaction. 5 Surgery
is required for failed endoscopic removal and for complications
like perforation and obstruction. 6, 7, 8, 9, 10 Removal of Long sharp
objects longer than 3 cm is recommended even in asymptomatic
patients. 11 e complication rate is increased in case of sharp
and impacted foreign body. Perforation is rare and is usually in
areas of physiological sphincters, acute angulations and areas of
previous surgery. Delayed presentation and silent perforations of
stomach caused by foreign bodies has also been reported. In our
patient first case, exact duration of swallowed foreign body was
not known but it looked very old and rusted .Obstruction, abscess
formation, hemorrhage, fistula and mucosal ulcerations are the
some other complications reported. In the second case although
she was asymptomatic, she had swallowed a sharp broken handle
of the table spoon, and the A4 batteries which could have busted
or eroded through the stomach.
Conventionally foreign bodies are removed from stomach by
laparotomy. Laparoscopic removal is an attractive alternative. It
is less invasive, less painful and offers faster recovery. It should be
the procedure of choice in failed endoscopic removal. Laparoscopic
removal of long and sharp foreign bodies from the stomach is
feasible.
Laparoscopic removal of foreign bodies ... Golash
Figure 2a: Plain X-ray of abdomen
Figure 2b: Foreign bodies in stomach and duodenum
45
Oman Medical Journal 2008, Volume 23, Issue 1, January 2008
References
1. Schenk C, Mugomba G, Dabidian RA, Scheuerecker H, Glaser F.
Laparoscopic extraction of a swallowed fork in a patient first diagnosed with
bulimia nervosa. Surg Endosc 2002 Feb;16(2):361.
2. Caratozzolo E, Massani M, Antoniutti M, Basso S, Monica F, Jelmoni A,
et a l. Combined endoscopic and laparoscopic removal of ingested large
foreign bodies. Case report and decisional algorithm. Surg Endosc 2001
Oct;15(10):1226.
3. Furihata M, Tagaya N, Furihata T, Kubota K. Laparoscopic removal of an
intragastric foreign body with endoscopic assistance. Surg Laparosc Endosc
Percutan Tech 2004 Aug;14(4):234-237.
4. Mazza D, Bereder I, Carret V, Bereder JM. Laparoscopic removal of
intragastric foreign bodies. Surg Laparosc Endosc Percutan Tech 20 00
Oct;10(5):329-331.
5. Park JH, Park CH, Park JH, Lee SJ, Lee WS, Joo YE et al. Review of 209
cases of foreign bodies in the upper gastrointestina l tract and clinica l factors
for successful endoscopic removal. Korean J Gastroenterol. 2004; 43:226-
233 (ISSN: 1598-9992).
6. Stricker T, Kel lenberger CJ, Neuhaus TJ, Schwoebel M, Braegger CP.
Ingested pins causing perforation. Arch Dis Child 2001 Feb;84(2):165-166.
7. Rygl M, Pýcha K. Perforation of the stomach by a foreign body in a girl with
anorexia nervosa–case report. Rozhl Chir 2002 Dec;81(12):628-630.
8. Lam PY, Marks MK, Fink AM, Oliver MR, Woodward A. Delayed
presentation of an ingested foreign body causing gastric perforation. J
Paediatr Child Health 2001 Jun;37(3):303-304.
9. Braumann C, Goette O, Menenakos C, Ordemann J, Jacobi CA. Laparoscopic
removal of ingested pin penetrating the gastric wall in an immunosuppressed
patient. Surg Endosc 2004;18:870 .
10. Omejc M. Laparoscopic removal of an ingested pin migrating into the liver.
Surg Endosc 2002 Mar;16(3):537.
11. Wishner JD, Rogers AM. Laparoscopic removal of a swallowed toothbrush.
Surg Endosc 1997 May;11(5):472-473.
Laparoscopic removal of foreign bodies ... Golash
Figure 2c: Foreign body retrieved