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 ¤ Introduction
 ¤ Unusual case
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 Table of Contents     
UNUSUAL CASE
Year : 2021  |  Volume : 17  |  Issue : 4  |  Page : 559-561
 

A case of unusual evisceration through laparoscopic port site


Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission12-Sep-2020
Date of Decision25-Nov-2020
Date of Acceptance08-Dec-2020
Date of Web Publication06-Sep-2021

Correspondence Address:
Mathews James
Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_221_20

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 ¤ Abstract 

Drain site eviscerations have been reported as a rare complication following abdominal surgery. An 82-year-old women was diagnosed with carcinoma stomach and underwent laparoscopic subtotal gastrectomy. A few hours following removal of the duodenal stump drain, she developed small bowel evisceration through the drain site. It was successfully managed with immediate bedside release of fascial constriction followed by definitive repair later. Although herniations and eviscerations via larger drain sites have been reported, eviscerations from small laparoscopic port sites used for drains are rare. Here, we report the first case of small bowel evisceration with strangulation through a 5-mm port site.


Keywords: Drain, evisceration, hernia, port site, strangulation


How to cite this article:
James M, Senthil G, Kalayarasan R, Pottakkat B. A case of unusual evisceration through laparoscopic port site. J Min Access Surg 2021;17:559-61

How to cite this URL:
James M, Senthil G, Kalayarasan R, Pottakkat B. A case of unusual evisceration through laparoscopic port site. J Min Access Surg [serial online] 2021 [cited 2021 Dec 8];17:559-61. Available from: https://www.journalofmas.com/text.asp?2021/17/4/559/325621





 ¤ Introduction Top


Abdominal drains have been in use since the times of Hippocrates, especially after surgeries involving anastomoses. With the advent of laparoscopy, drains were routinely placed via port sites. 'They serve to check for an early leak, prevent a peritoneal collection and facilitate healing. Many studies have failed to show the superiority of using drains.[1] Drain site herniation, evisceration, migration of drain, ascending infection and perforation of a viscus are potential morbidities after drain placement, albeit rare. Drain site evisceration constitutes an emergency with risk of strangulation of the viscus. Even though drain site eviscerations have been reported after open surgeries, evisceration of small bowel through a 5-mm port site used for drain placement has never been reported.


 ¤ Unusual case Top


An 82 year old “lady” was diagnosed with carcinoma distal stomach. She presented with abdominal discomfort and recurrent episodes of vomiting. Imaging revealed resectable tumour, and she underwent laparoscopic subtotal gastrectomy, isoperistaltic antecolic gastrojejunostomy with D2 lymphadenectomy. Five-port technique was used with one 5 mm in the right anterior axillary line just above the pararectal port. After specimen extraction through a small midline incision, a 16 Fr non-suction drain was kept near duodenal stump and was brought out through the 5-mm port. All 12-mm port sites were repaired. The surgery lasted around 275 min. Post-operatively, the patient had lower respiratory tract infection which was managed appropriately with antibiotics and chest physiotherapy. Her duodenal stump drain was removed on post-operative day 5, and an occlusive dressing was applied. She developed drain site pain and increased soakage of the dressing, 7 h after the drain removal. Removal of dressing revealed evisceration of a small bowel loop with strangulation [Figure 1]. Immediate bedside release of the narrow fascial constriction was done under local anaesthesia with simultaneous use of warm surgical pads and high-flow oxygen. Subsequently, she underwent reduction of eviscerated bowel with repair of the defect in the emergency theatre. Bowel recovered its normal peristalsis but was hyperaemic after resuscitation with warm gauzes and 100% oxygen [Figure 2]. She was restarted on oral diet after 4 days and was discharged uneventfully.
Figure 1: Strangulated segment of eviscerated small bowel

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Figure 2: Hyperaemic bowel loop after resuscitation

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 ¤ Discussion Top


Drain site evisceration, although rare, is not uncommon. Common complications of placing drains include drain site sepsis, bleeding, migration, kinking and knotting of drains, intestinal obstruction, fistulae or erosion into viscera with peritonitis and herniation.[1],[2] Several case reports are there in the literature, documenting evisceration of multiple organs from larger drain site such as small bowel, omentum, appendix,  Fallopian tube More Details, ovary and gallbladder,[3],[4] with the most common being small bowel.[2] Almost all these cases were open surgeries. Very few cases of evisceration through port sites have been reported in the literature.[5] Most reports have documented the occurrence of evisceration after 3–8 h in concurrence, with our case notwithstanding cases reported up to 24–48 h after drain removal.[2],[4] Falidas et al. described evisceration 15 h after drain removal.[6]

To prevent evisceration during removal of drains, stoppage of any negative suction and 360° rotations to break the adhesions between viscera and drain have been recommended.[4] Bhangu et al. described a case of port site evisceration of the appendix following drain removal.[7] Here, we describe the first case of small bowel evisceration through port site that was used for drain placement. Evisceration has been documented with smaller drains (6 mm), suggesting that size is not the only factor despite the fact that most cases were reported in patients with a drain size of 10 mm or more.[1],[3],[6] Rather than the size, the nature of tract plays an important role. Usage of port site for drain placement increases the risk of evisceration as they have a straight tract which does not approximate well on deflating pneumoperitoneum unlike a zigzag tract. Chronic smoking, poor nutritional status, obesity, general debility, use of steroids, drain tract, location in midline, multiple insertions of trocar during surgery, making of side holes in drain, duration, pathology for undergoing surgery, peritoneal inflammation and increased abdominal pressure have been proposed as contributing factors.[2],[3],[4],[8] Raised intra-abdominal pressure from multiple causes such as straining during vomiting, cough, defecation or micturition has been proposed as the most common predisposing factor.[2],[6] In our case, the presence of lower respiratory tract infection-induced cough, old age, malignancy-induced debilitation as well as use of port site for drain led to the evisceration despite having a normal body mass index of 21 kg/m2 and lacking any comorbidities. Even though our port size was 5 mm, prolonged surgery and manipulation of the port tend to enlarge its size without ever having re-inserted it during surgery. This widening happens more in the muscular and fascial planes and is thus less appreciated clinically since the skin level opening remains relatively unyielding. Multiple reinsertions and difficult manoeuvrings exert undue force and torque on the fascia.[9] Moreover, laparoscopy leads to less parietal wall adhesions that can prevent such eviscerations.[10] Bowel strangulation and incarceration account for most common morbidities arising from drain site evisceration.[2] Mortality is extremely low in this condition. Immediate management for a case of impending strangulation must be extending the incision on bedside with local anaesthesia, as was done in this case. This will relieve the vascular congestion and preclude a bowel resection with anastomosis. It is prudent to take the patient for emergency repair of the defect under general anaesthesia. Repair can be attempted under laparoscopy or open, as the condition permits. Hemandas et al. described a similar case of small bowel evisceration which developed a patch of impending ischemia while awaiting emergency theatre, forcing a repair under local anaesthesia in the ward procedure room.[11] As the adage goes, prevention is better than cure. Routine drainage has become unpopular and prophylactic drainage indications should be minimized in uncomplicated cases.[6] Myriad recommendations include 'Z' technique, purse string closure of wound, preplaced fascial sutures placed at time of drain insertion, oblique tract of the drain and progressive shortening of drain before removal.[2],[11]

In laparoscopic surgeries, placement of drains through 5-mm ports has been recommended,[12],[13] since the frequency of incisional hernia through this tract is significantly lower. However, even with 5-mm port, the risk of evisceration or hernia is real, though rare. Hence, we suggest avoiding placing drain through port site whenever feasible, rather inserting a drain with an oblique tract. The straight tract, prolonged surgery and instrument manipulation tend to undermine the safety of a small port.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names 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.
Samarawickrama MB, Senavirathna R, Hapuarachchi U. Drain site abdominal hernia: Known but rare complication of abdominal drains, a case report and a review of drain site complications. IOSR J Pharm IOSRPHR 2017;7:10-4.  Back to cited text no. 1
    
2.
Makama JG, Ameh EA, Garba ES. Drain site hernia: A review of the incidence and prevalence. West Afr J Med 2015;34:62-8.  Back to cited text no. 2
    
3.
Tidjane A, Tabeti B, Boudjenan Serradj N, Bensafir S, Ikhlef N, Benmaarouf N. Laparoscopic management of a drain site evisceration of the vermiform appendix, a case report. Int J Surg Case Rep 2018;42:29-33.  Back to cited text no. 3
    
4.
Saini P, Faridi MS, Agarwal N, Gupta A, Kaur N. Drain site evisceration of fallopian tube, another reason to discourage abdominal drain: Report of a case and brief review of literature. Trop Doct 2012;42:122-4.  Back to cited text no. 4
    
5.
Bloom DA, Ehrlich RM. Omental evisceration through small laparoscopy port sites. J Endourol 1993;7:31-2.  Back to cited text no. 5
    
6.
Falidas E, Mathioulakis S, Vlachos K, Pavlakis E, Villias C. Strangulated intestinal hernia through a drain site. Int J Surg Case Rep 2012;3:1-2.  Back to cited text no. 6
    
7.
Bhangu JS, Exner R, Bachleitner-Hofmann T. Trocar-site evisceration of the vermiform appendix following laparoscopic sigmoid colectomy: A case report. Int J Surg Case Rep 2017;31:273-5.  Back to cited text no. 7
    
8.
Duraker N, Büyükaşik K, Helvacioğlu Y. Drain site evisceration of the appendix: Report of a case. Surg Today 1997;27:651-2.  Back to cited text no. 8
    
9.
Lim DR, Hur H, Min BS, Baik SH, Kim NK. Trocar site hernia after use of an 8-mm bladeless trocar in robotic colorectal surgery. J Minim Invasive Surg 2015;18:137-40.  Back to cited text no. 9
    
10.
Stommel MW, Ten Broek RP, Strik C, Slooter GD, Verhoef C, Grünhagen DJ, et al. Multicenter observational study of adhesion formation after open-and laparoscopic surgery for colorectal cancer. Ann Surg 2018;267:743-8.  Back to cited text no. 10
    
11.
Hemandas A, Mitchell C, Aikoye A. Small bowel evisceration following removal of an abdominal drain. Ir J Med Sci 2012;181:265-7.  Back to cited text no. 11
    
12.
Gass M, Zynamon A, von Flüe M, Peterli R. Drain-site hernia containing the vermiform appendix: Report of a case. Case Rep Surg 2013;2013:198783.  Back to cited text no. 12
    
13.
Manigrasso M, Anoldo P, Milone F, De Palma GD, Milone M. Case report of an uncommon case of drain-site hernia after colorectal surgery. Int J Surg Case Rep 2018;53:500-3.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]



 

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