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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 5  |  Issue : 1  |  Page : 36-39

Fatal intestinal and abdominal wall ischemia post laparoscopic cholecystectomy


1 Department of General and Laparoscopic Surgery, Prince Mohammed Bin Naser Hospital, Jazan, Saudi Arabia
2 Department of General Surgery, College of Medicine, Jazan University, Jizan, Saudi Arabia

Date of Submission19-Mar-2020
Date of Acceptance24-Mar-2020
Date of Web Publication3-Oct-2020

Correspondence Address:
Dr. Mohammed Ali Fagihi
Department of General and Laparoscopic Surgery, Prince Mohammed Bin Naser Hospital, Jazan
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJL.SJL_3_20

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  Abstract 


Intestinal ischemia though it is a rare complication postlaparoscopic cholecystectomy but leads to serious devastating and fatal sequelae. Its prognosis depends on high index of suspicion and effective early treatment. Various causes have been described such as splanchnic hypoperfusion, superior mesenteric artery thrombosis, and inferior mesenteric artery thrombosis. Literature review revealed that intestinal ischemia could happen despite of correct operative techniques.

Keywords: Anterior abdominal wall, cholecystectomy, intestinal, ischemia, laparoscopics


How to cite this article:
Ayoub AH, Fagihi MA, Matar GS, Albasiouny MA, Abdelmagid MF, Sadek Zidan AE, Ayoub RA, Ajaybi YE, Meshn BA. Fatal intestinal and abdominal wall ischemia post laparoscopic cholecystectomy. Saudi J Laparosc 2020;5:36-9

How to cite this URL:
Ayoub AH, Fagihi MA, Matar GS, Albasiouny MA, Abdelmagid MF, Sadek Zidan AE, Ayoub RA, Ajaybi YE, Meshn BA. Fatal intestinal and abdominal wall ischemia post laparoscopic cholecystectomy. Saudi J Laparosc [serial online] 2020 [cited 2020 Oct 29];5:36-9. Available from: https://www.saudijl.org/text.asp?2020/5/1/36/296784




  Introduction Top


Intestinal ischemia is a rare but fatal complication postlaparoscopic cholecystectomy. From literature review, 11 reported cases where the distribution of ischemia varied from small bowel to large bowel. Up to our knowledge, no reported case of anterior abdominal wall involvement.

We report the first case of “Fatal intestinal and anterior abdominal wall ischemia after laparoscopic cholecystectomy” in a 77 Saudi male patients who had undergone laparoscopic cholecystectomy at Prince Mohammed Bin Naser Hospital, Jazan, s the Kingdom of Saudi Arabia.


  Case Report Top


A 77-year-old Saudi male patient known case of chronic hepatitis and bilateral hydronephrosis admitted as a case of chronic calculous cholecystitis for laparoscopic cholecystectomy.

  • Preoperative investigations showed: Normal complete blood count (CBC) as well as normal Liver Function Tests (LFT), blood urea nitrogen = 5.4 mmol/, creatinine = 4.9 mmol/L
  • Virology: Hepatitis B surface antigen positive and hepatitis B core antibody positive
  • Ultrasound (U/S): Distended gallbladder with thick wall and 1.5 stone impacted at its neck
  • Marked dilatation of pelvicalyceal system of the left kidney, enlarged prostate Grade 2
  • Preoperative cardiac assessment revealed patient is fit for surgery
  • Prophylactic preoperative enoxaparin was given.


Next day, the patient was shifted for laparoscopic cholecystectomy. Pneumoperitoneum was created with intra-abdominal pressure (IAP) was 15, during for laparoscopic cholecystectomy, omentum was adhered to gallbladder with adhesions disturbing the anatomy, after dissection of adhesions from gallbladder; cystic duct and artery were not identified so decision was made for retrograde cholecystectomy with endoloop, gallbladder was removed through endobag, hemostasis ensured. Anterior abdominal wall was normal [Figure 1].
Figure 1: Small bowel ischemic patches

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Operative time = 40 min

First day postoperative

The patient was doing well, no abdominal pain, taking normal diet passing flatus but still complaining of the left loin pain, vitals stable, no fever.

Urologist was consulted who referred the patient to KFCH for evaluation as outpatient visit.

Second day postoperative

The patient was doing well.

Third day postoperative

At 1:30 a.m., the patient was complaining of acute onset of abdominal pain, tachypneic, tachycardia and was irritable, he was resuscitated, CBC showed Hb 11, U/S abdomen showed marked free fluid all over the abdomen.

At 4:15 a.m., the patient was arrested cardiopulmonary resuscitation (CPR) was done patient revived then the patient was shifted to Operating Room (OR) for exploration.

Laparoscopic exploration was started which showed brownish fluid collection [Figure 1] with patches of small bowel ischemia [Figure 2], patches of large bowel ischemia [Figure 2], [Figure 3], [Figure 4], and patches of ischemia all over the anterior abdominal wall [Figure 5].
Figure 2: Turbid brownish collection

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Figure 3: Transverse colon ischemic patches

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Figure 4: Right colon ischemic patches

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Figure 5: Anterior abdominal wall ischemia

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Decision to convert to open exploratory laparotomy was made

Findings

Patches of small and large bowel ischemia turbid brownish fluid more than 2.5 L, small perforation of stomach 1 cm prepyloric area which was closed with vicryl 2/0, wash with normal saline and 2 big drains were inserted, the patient was shifted to intensive care units intubated and ventilated at 6:00 a.m.

The patient was on noradrenaline infusion, without sedation and pupils were fixed and dilated, reflexes were absent and blood pressure (BP) was 109/65.

Next day at 3:00 a.m., the patient was arrested and CPR was done but the patient passed away.


  Discussion Top


Intestinal ischemia after laparoscopic cholecystectomy is a rare but serious and often fatal complication. A literature review using PubMed and Google Scholar revealed 11 reported cases of intestinal ischemia after laparoscopic cholecystectomy.[1] The distribution of intestinal ischemia varied from involvement of small bowel to large bowel as well. Only two cases recovered whereas death was the outcome for other cases [Table 1].[2],[3] Up to our knowledge, no reported case described involvement of anterior abdominal wall apart from our case report which we have described above. Laparoscopic cholecystectomy requires the insufflation of carbon dioxide which will lead to increase IAP and therefore the blood flow through splanchnic vessels will decrease resulting in relative hypoperfusion of celiac, superior mesenteric, and renal arteries despite normal BP. In the vast majority, patients will tolerate the risk of compromised intestinal blood flow with no clinical consequences.[4],[5] Causes of intestinal ischemia after laparoscopic cholecystectomy are multiple and include splanchnic hypoperfusion which we thought it may be the possible cause in our case report other causes include thrombosis of the superior mesenteric artery (reported in three cases) and thrombosis of inferior mesenteric vein.[6],[7],[8],[9] Andrei et al. suggested another possible explanation assuming that symptomatic episodes of intestinal ischemia (mesenteric angina) before laparoscopic cholecystectomy have been misinterpreted clinically as symptomatic cholelithiasis.[10] Ass a result laparoscopic cholecystectomy with low perfusion state lead to further intestinal ischemia. For all of cases reported, IAP did not exceed 15 mmHg which means that the corrective operative technique was undertaken.
Table 1: Reported Cases of Intestinal Ischemia post Laparoscopic Cholecystectomy* (adopted from Leduc L-J et al. Intestinal Ischemia After Laparoscopic Cholecystectomy JSLS (2006) 10:236-238 & Wassenaar EB et al. Fatal Intestinal Ischemia After Laparoscopic Correction of Incisional Hernia JSLS (2007) 11:389-393

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  Conclusion Top


Intestinal ischemia after laparoscopic cholecystectomy is a rare but often fatal complication.

Causes are multiple and autopsy is needed to determine the cause. In our reported case, we thought the cause is splanchnic hypoperfusion. Intestinal ischemia after laparoscopic cholecystectomy despite of adequate operative techniques.

Consent

Written informed consent was obtained from the patient's next-of-kins for publication of this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dwerryhouse SJ, Melsom DS, Burton PA, Thompson MH. Acute intestinal ischaemia after laparoscopic cholecystectomy. Br J Surg 1995;82:1413.  Back to cited text no. 1
    
2.
Paul A, Troidl H, Peters S, Stuttmann R. Fatal intestinal ischaemia following laparoscopic cholecystectomy. Br J Surg 1994;81:1207.  Back to cited text no. 2
    
3.
Leduc LJ, Mitchell A. Intestinal ischemia after laparoscopic cholecystectomy. JSLS 2006;10:236-8.  Back to cited text no. 3
    
4.
Jaffe V, Russell RC. Fatal intestinal ischaemia following laparoscopic cholecystectomy. Br J Surg 1994;81:1827-8.  Back to cited text no. 4
    
5.
Thiele H, Lang RD. Complications after 1,000 laparoscopic cholecystectomies. Chirurg 1994;65:795-800.  Back to cited text no. 5
    
6.
Schorr RT: Laparoscopic upper abdominal operations and mesenteric infarction. J Laparoendosc Surg 1995;5:389-92.  Back to cited text no. 6
    
7.
Talbot D, Miller IT, Miller IA. Fatal intestinal ischaemia following laparoscopic cholecystectomy. Br J Surg 1995;82:1143.  Back to cited text no. 7
    
8.
Klugewitz K, Rehermann B, Seifert U, Böker KH, Stolte M, Meier PN, et al. A rare case of bloody diarrhea: Thrombosis of the V. mesenterica inferior following laparoscopic cholecystectomy. Z Gastroenterol 1998;36:35-9.  Back to cited text no. 8
    
9.
Sternberg A, Alfici R, Bronek S, Kimmel B. Laparoscopic surgery and splanchnic vessel thrombosis. J Laparoendosc Adv Surg Tech A 1998;8:65-8.  Back to cited text no. 9
    
10.
Andrei VE, Schein M, Wise L. Small bowel ischemia following laparoscopic cholecystectomy. Dig Surg 1999;16:522-4.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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