|Year : 2021 | Volume
| Issue : 4 | Page : 559-561
A case of unusual evisceration through laparoscopic port site
Mathews James, G Senthil, R Kalayarasan, Biju Pottakkat
Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Submission||12-Sep-2020|
|Date of Decision||25-Nov-2020|
|Date of Acceptance||08-Dec-2020|
|Date of Web Publication||06-Sep-2021|
Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
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
| ¤ Introduction|| |
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. 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|| |
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.
| ¤ Discussion|| |
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., 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,, with the most common being small bowel. Almost all these cases were open surgeries. Very few cases of evisceration through port sites have been reported in the literature. 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., Falidas et al. described evisceration 15 h after drain removal.
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. Bhangu et al. described a case of port site evisceration of the appendix following drain removal. 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.,, 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.,,, 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., 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. Moreover, laparoscopy leads to less parietal wall adhesions that can prevent such eviscerations. Bowel strangulation and incarceration account for most common morbidities arising from drain site evisceration. 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. As the adage goes, prevention is better than cure. Routine drainage has become unpopular and prophylactic drainage indications should be minimized in uncomplicated cases. 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.,
In laparoscopic surgeries, placement of drains through 5-mm ports has been recommended,, 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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]