Small bowel volvulus (SBV) is defined as the torsion of a small bowel loop around its mesentery axis. It may result in partial or complete obstruction. That condition after laparoscopic appendectomy has rarely been described. The diagnosis of SBV may be suggested by an abdominal computed tomography (CT) scan that shows the “whirlpool sign”, which is caused by twisting of the small bowel, mesentery, and mesenteric vessels1.

A 19-year-old man with no past medical history was admitted to the emergency department on postoperative day 6, after an uneventful laparoscopic appendectomy for a suppurative appendix. The appendectomy was performed with a 3-trocar technique and the appendiceal stump and mesoappendix were secured with an EndoGIA™ stapler (Ethicon Endosurgery, Cincinnati, OH, USA), with no complications. The patient presented with severe diffuse abdominal pain, accompanied by nausea, with no vomiting. Physical examination revealed normal vital signs, mild diffuse abdominal tenderness, and reduced bowel sounds.

The laboratory work-up showed normal hemoglobin of 13.7 g/dl and elevated white blood count of 14.5 × 1010. There were no other abnormal lab results. An abdominal X-ray showed no abnormalities, but an abdominal CT scan identified free fluid in the perihepatic and perisplenic regions, as well as a whirlpool sign on the mesentery of the terminal ileum, in the sagittal view, suggesting SBV (Fig. 1A). Diagnostic laparoscopy was performed, visualizing free hematic fluid and necrosis of the terminal ileum, secondary to a volvulus at that site. The procedure was converted to open surgery and the terminal ileum volvulus was then devolvulated. Necrosis was found 10 cm from the ileocecal valve, compromising 40 cm of the terminal ileum (Fig. 1B). A loose staple was observed on the peritoneal surface of the small bowel mesentery, 7 cm from the distal region of the necrotic bowel. A 50 cm intestinal resection was completed, followed by a stapled side-to-side anastomosis, using GIA™ 60 blue (Covidien, Mansfield, Massachusetts, USA). The patient had a satisfactory immediate postoperative outcome, referring only to mild pain during the first postoperative day. Oral diet was reintroduced on postoperative day 3. He was discharged home on the fifth postoperative day, with adequate oral intake and regular bowel movements.

Figure 1.

(A) Sagittal view of the CT scan. The red arrow indicates the whirlpool sign in the mesentery of the terminal ileum. (B) Intraoperative image showing bowel ischemia.

(0.11MB).

We cannot be sure of the exact mechanism of our patient’s volvulus. However, a few similar cases have been reported in the literature (Table 1). Page et al.2 and Nottingham3 described a 13-year-old patient and a 34-year-old patient, respectively, each of whom underwent laparoscopic appendectomy, employing a linear cutting stapler. They presented with abdominal pain on their third and tenth postoperative days, caused by SBV. In both cases, the volvulus was thought to be the result of a loose linear cutter staple in the abdominal cavity. In each case, the staple was caught in the peritoneal surface of the small bowel mesentery. Other theories of SBV after a laparoscopic appendectomy include patient positioning, inclination, bowel mobilization, and changes in the pneumoperitoneum. Nonetheless, those theories have not been well studied4. Similar to the two cases just described, we found a free staple snagged in the peritoneal surface of the small bowel mesentery, with no adhesion bands nearby. Given the widespread use of stapler/cutter devices, staples are likely becoming one of the most common foreign bodies in the abdominal cavity but only a few reports have described surgical staples causing adhesion-like complications, such as bowel obstruction or volvulus2.

Diagnosis can be made through several modalities. For instance, a plain abdominal X-ray can appear normal, or reveal some bowel distension. Our patient’s initial x-ray revealed no abnormalities. Ultrasound has been previously used in the pediatric population to identify duodenal obstruction with SBV5. However, that imaging study is somewhat vulnerable due to the dependence on operator experience. A CT scan can detect the whirlpool sign, which is highly suggestive of intestinal volvulus, showing the twisting of the mesenteric vessels. However, the study’s sensitivity and specificity have not been evaluated6. In our case, the whirlpool sign was only seen in the sagittal view of the CT scan, and with the aid of a radiologist, we made the final diagnosis. The fact that the sign was not visible in the axial view made the diagnosis a challenge. Furthermore, a CT scan can be used to detect bowel infarction or ischemia (bowel-wall thickening or pneumatosis), so the study is more sensitive in the advanced stage of the disease. It can also be used to rule out other severe intra-abdominal diseases7.

In conclusion, we presented the case of a young adult patient that underwent laparoscopic appendectomy and presented with SBV, six days after his procedure. Even though we cannot be absolutely certain, we hypothesized that the volvulus resulted from a loose staple in the abdominal cavity that acted as a “hook” in the mesentery, causing rotation around its axis. As laparoscopic bowel stapling becomes more customary, there may be more reports of problematic staples that have been left in situ. We suggest removing all staples left in situ at the end of a laparoscopic procedure, to prevent any complication a loose staple could cause8.