September 22, 2010
INADVERTENT INJURY TO THE SMALL INTESTINE DURING APPENDECTOMY! A CASE REPORT
Anyanwu, E.B.a, Akhator, A.b aDepartment of Family Medicine, Delta State University Teaching Hospital, Oghara. bDepartment of Surgery, Delta State University Teaching Hospital, Oghara. Abstract Appendicitis is a relatively common ailment in most general medical practices in the country. The usual treatment is a surgical intervention known as appendectomy. Occasionally, there may be some complications post-operatively such as bleeding and infection. We hereby report an unusual complication that occurred intra-operatively which was a clean laceration of part of the small board while entering the peritoneum. Keywords: Clean laceration, Appendectomy, small bowel Corresponding Author: Dr. E. B. Anyanwu. Department of Family Medicine, Delta State University Teaching Hospital, Oghara. P.O. Box 7 Oghara, Delta State Nigeria. E-mail: firstname.lastname@example.org Tel: +2348035701711 Case Presentation A middle aged working class man presented into a busy general practice clinic with a history of right sided abdominal pain of about five days duration. He said that the pain has gradually worsened over the five days period and that he knew that it would go this way some day. He claimed that he has been having similar pains over the same part of his abdomen for over a three year period and that he has been diagnosed as a case of appendicitis a long time before now. Surgery has been offered to remove the appendix but he refused because he says that he has been afraid that he might not survive the surgical procedure. Apparently, over the years, he has been on oral antibiotics which he buys from across the counter in chemist shops whenever the pain recurs. He claims that he had always been successful with this practice as the pains always goes away. But then, the present episode has defied all the antibiotics and analgesics that he has taken, as the pain was getting worse over the days. In the past episodes, he usually starts to feel better after about two to three days of ingesting capsule ampiclox, tablet flagyl and either paracetamol or brufen. But, in the present abdominal pain crisis, the pain rather than decrease was actually getting worse and more excruciating in nature. He subsequently reported to the clinic/hospital where he was examined and found to have positive rovsing sign, positive umbilical tapping sign, marked guarding and rebound tenderness was marked over the McBurney’s point. A diagnosis of acute on chronic appendicitis was made and the nature of the illness and the chosen line of management were explained to him. He readily agreed for surgery this time and because he claimed that he had been warned that the appendix could “burst” inside his abdomen and this would mean that he would require a more extensive surgery to be done. He obviously did not want this. Routine laboratory investigations which included urine microscopy, full blood count, retroviral screening after counseling was done. Consent for surgery was obtained from him. During surgery, with patient under general aneasthesia, the muscles were split as usual and the peritoneal membrane was identified and on incising the membranes so as to enter into the peritoneal cavity, a gush of greenish bubbling fluid was noted. Our suspicious was proved so when we finally entered into the peritoneum and discovered that a laceration had been made on the anti-mesenteric border of the small intestine, at about 20cm away from the illeo–colic junction. The greenish substance that we saw earlier proved be intestinal content gushing out from the freshly made laceration. There was no peritoneal soilage. The laceration was subsequently closed in two layers and the appendix removal successfully. The anterior abdominal wall was closed in layer and adequate post-operative care was instituted. The patient recovered and was then discharged home well. Discussion Inflammation of the appendix, otherwise known as acute appendicitis is a relatively common diagnosis in the general practice hospital where the patient presented. The appendix is a small, blind muscular tube which is attached to the tip of the ceacum. The appendix is considered by most authorities to be a vestigial organ and its inflammation or appendicitis is the most common cause of an acute abdomen in young adults (1). Acute appendicitis is relatively rare in infants, and becomes increasingly common in childhood and early adult life. The incidence is equal amongst both males and females before puberty. In teenagers and young adults, the male to female ratio is 3:2 until about the age of 25 years when the male dominance declines (1). Acute appendicitis is associated with bacterial proliferation within the lumen of the appendix, usually of a mixed growth of both aerobic and anaerobic organisms (1). The initiating event leading to appendicitis is usually an obstruction of the lumen of the appendix by a faecolith. A faecolith is composed of faecal materials, calcium phosphate, bacteria and epithelial debris. When the appendix becomes obstructed, the process of events is accumulation of normal mucus secretion, proliferation of contained bacterial, pressure atrophy of the mucosa which allows access into the deeper tissue planes by bacteria, inflammation of the walls of the organ with vessel thrombosis, and eventual gangrene and then perforation of the necrotic appendix wall. The treatment of acute appendicitis is known as appendectomy or surgical removal of the organ. The sooner this is done, the better so as to protect against perforation. During the surgery on our client, apparently a part of the small intestine was caught up with the peritoneal membrane and was unknowingly cut into by the operator. Luckily, the laceration and the accident were recognised and repaired immediately. This kind of small bowel trauma has been reported in gynoceological procedures before now. If this accident had not been recognized and repaired, there would have been peritoneal soiling with faecal matter, resulting into general peritonitis and possible death. But it was recognized and repaired with good results. We have decided to report this incidence so as to highlight the possibility of its occurring during appendicular surgeries and to also call for more caution during this surgery so as not catch any parts of the bowel while incising the peritoneal membrane. Reference Russal, R.C.G., Williams, N.S., and Bulstrode C.J.K (2000). The Vermiform Appendix. Bailey and Love’s Short Practice of Surgery. 23rd Edition. Russal, R.C.G., Williams, N.S., and Bulstrode C.J.K (EDS). Arnold Publishers, London 2000 Pp 1076 – 1092.