Internal hernia caused by a free intraperitoneal staple after laparoscopic appendectomy

Abstract

Background: Laparoscopic appendectomy is the gold standard for treatment of appendicitis. Stapled closure of the appendiceal stump is commonly performed and has several advantages. Few prior cases have demonstrated complications from free staples left within the abdomen after the stapler has been fired.
Case report: A 29-year-old female underwent laparoscopic appendectomy for acute uncomplicated appendicitis during which the appendix and mesoappendix were divided using laparoscopic gastrointestinal anastomosis (GIA) staplers. Her initial recovery was uncomplicated. She returned on postoperative day 17 with sharp mid-abdominal pain, obstipation, and emesis. Her abdomen was distended, and she had a mild leukocytosis. Computed tomography (CT) demonstrated twisted loops of dilated small bowel in the right lower quadrant with two transition points, suggestive of internal hernia with closed loop bowel obstruction. Diagnostic laparoscopy was performed through the three prior appendectomy incisions. An adhesion between the Veil of Treves and the mesentery of the ileum caused by a solitary free closed staple, remote from the staple lines, had caused an internal hernia. The hernia was reduced, and the small bowel was noted to have early ischemic discoloration. The adhesion was lysed by removing the staple from both structures. The compromised loops of bowel began to show peristaltic movement and color returned to normal, and the procedure was concluded without resection. She was discharged home the following day.
Conclusions: Gastrointestinal staplers are commonly used due to ease of use and low complication rate. It is not uncommon to leave free staples in the abdomen as retrieval can be difficult and time consuming. Our case is only the second in the literature reporting an internal hernia with closed loop bowel obstruction as a complication of retained staples. Choosing the most appropriate size staple load to reduce the number of extra staples, removing free staples, or the use of an endoloop can prevent potentially devastating complications.