Society for Surgery of the Alimentary Tract
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Michael Shockley*1, Jeffrey Simpson2, Fuad Shahin1
1General Surgery, UCF/HCA GME Consortium of Greater Orlando, Orlando, FL; 2University of Central Florida, Orlando, FL

Since laparoscopic appendectomy has become standard, complications associated with removal of the appendix have become relatively rare and minor. One well-documented, general complication of intra-abdominal surgery is adhesion formation and subsequent adhesive small bowel obstructions. The average time to presentation of adhesive small bowel obstructions after appendectomy is reported as 1.1 years. We present a case of a patient, who developed a small bowel obstruction within 48 hours of laparoscopic appendectomy due to small bowel adhesion to the staple line.

The patient presented to the hospital with 1 day of peri-umbilical abdominal pain that migrated to the right lower quadrant. She was diagnosed with acute appendicitis and underwent uncomplicated laparoscopic appendectomy. The patient was discharged the next morning when pain was controlled, tolerating diet, and voiding freely. However, she returned to the hospital on postoperative day 2 with abdominal pain, distention, and nausea. Her presenting CT scan showed diffuse small bowel distention, and she was managed for postoperative ileus. After failure to progress over a few days, repeat imaging was performed, which demonstrated decompressed bowel adjacent to the cecal staple line without improvement in small bowel distention. She underwent diagnostic laparoscopy. Her ileum was found to be adherent to the cecal staple line with a hairpin turn, causing a small bowel obstruction. The ileum was bluntly freed from the staple line, and the staple line was noted to be intact. The patient did well postoperatively with prompt return of bowel function, improvement of abdominal distention, and tolerance of diet over the next two days. She was discharged without further complication.

While adhesive small bowel obstructions are well described after intra-abdominal surgery, an immediate small bowel adhesion to the cecal staple line after laparoscopic appendectomy has not been described. There are cases of inflammatory reactions and even internal hernias related to loose staples, leading to obstruction after laparoscopic appendectomy. This obstruction was a result of her ileum adhering to the surgical site within the first 48 hours. While the adhesion was soft and easily, bluntly dissected, it was clinically impactful. This immediate adhesion and obstruction questions whether steps should be taken to isolate the staple line from nearby small bowel.

Image 1: CT After Representation to Hospital. Red arrow identifies the staple line from laparoscopic appendectomy. Adjacent to this, decompressed small bowel loops can be seen, creating a right lower quadrant transition point

Image 2: Laparoscopic Pictures. These images demonstrate a small bowel adhesion to the staple line causing a hairpin turn and small bowel obstruction (left). Also, there staple line after blunt dissection appears intact (right).

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