She is currently doing well at the third year of follow-up. Intestinal injuries resulting from ventral perforation during discectomy are rare, but may cause dramatic consequences. To date, 22 cases of intestinal injury following lumbar disc surgery have been reported in the literature [ 1 - 3 , 6 - 10 , 13 - 18 , 20 ] Table 1. Sixteen of them occured during conventional discectomies and 6 in microsurgical procedures. However, visceral injuries during transabdominal discectomy were excluded from this review as the mechanism of the damage is mainly retraction injury.
Intestinal injury was first reported by Harbison [ 7 ] in Shwartz and Brodkey [ 16 ] later reported the first case of intestinal injury after microdiscectomy. Fourteen cases of these have occured following surgery at the disc level of L5-S1 [ 1 , 2 , 8 - 10 , 13 , 15 , 17 , 18 , 20 ]. Only three cases have been reported at the L4-L5 interspace [ 2 , 7 , 16 ]. In five cases there were no details about the level of the injury [ 3 , 6 , 14 ]. Small intestine is more likely to be injured than the large intestine, since the root of the mesentery of the small intestine arises in front of the vertebral column, extending obliquely from second lumbar vertebra to the right sacroiliac joint [ 18 ].
There were two injuries for both of the sigmoid colon and the jejunum and only one in the appendix. Pappas et al. Clinical manifestations of such injuries may be extremely variable. Diagnosis is established intraoperatively if the intestinal mucosa is removed together with the disc specimen [ 2 , 7 ].
It should be duely noted that this is most commonly recognised with the signs of acute abdomen within a few days following the surgery, as in our case. So, postoperative abdominal complaints should be carefully evaluated by surgeon in terms of intestinal injury. Abdominal radiograph or tomography may be helpful for the diagnosis. In fact, in one-third of the cases radiological examinations of the abdomen have shown free air in the peritoneal cavity [ 1 , 8 , 9 , 16 , 17 , 20 ]. Kollbrunner [ 13 ] has reported a peculiar case presented with bowel obstruction.
In this case, stenosis of the sigmoid colon has been suggested to develop as a result of local scarring and fibrosis of organization of hematoma from a retroperitoneal bleeding. Occasionally, diagnosis may not be made for several weeks and months due to formation of a mature intraabdominal abscess which gradually develops and induces only mild symptoms at the onset. Shwartz and Brodkey [ 16 ] detected sigmoid colon laceration and abdomino-pelvic abscesses on the 19th day after microdiscectomy. Wound infection with positive culture of intestinal pathogenes can be another manifestation of such injuries [ 2 ].
In the case reported by Shaw et al. A fistulogram showed an unexpected communication between the cutaneous drainage site, through the disc space to the small bowel.
Visceral and general surgery
In addition, many authors have reported cases of discitis in association with the intestinal injury [ 2 , 6 , 15 , 16 , 18 ]. The unique case regarding the appendix injury due to lumbar disc surgery had been reported by Birkeland and Taylor [ 2 ] in In this case, injury of the appendix was incidentally found at the laparotomy due to an intra-abdominal arteriovenous fistula 2. This patient also had a history of the wound infection which required antibiotic therapy of nine months besides two debridements to heal.
To our knowledge, the present case is the first report of appendix injury as a complication of lumbar microdiscectomy. We detected the appendix was partially transected nearly at midlevel and was free of mucosal and muscular layers in distal part. A possible explanation of this is that pituitary rongeur grasped the appendix unintentionally during the discectomy and the distal part of the appendix was cored out along with the disc material.
The definitive treatment of intestinal injury depends on both the site and the extent of injury together with the period of time between damage and laparotomy. Early diagnosis and treatment may prevent potentially fatal outcomes.
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Hoff-Olsen and Wiberg [ 8 ] have reported a mortality due to septicemia because of an ileal injury which was treated in only two days postoperatively. The avoidance of the ventral perforation is the most important manevuer in prevention of visceral injuries. The most offensive surgical instrument in this issue is the pituitary rongeur [ 2 , 3 , 11 ]. Several authors have recommended that the depth of disc space penetration with instruments should be kept to less than 3 cm [ 2 , 16 , 2 ].
Depth marking of instrument may be useful to prevent the surgeon from inserting it too deep [ 11 ]. Moreover, the failure to withdraw the whole volume of irrigant instilled into the disc space should raise the suspicion of ventral perforation and subsequent intestinal injury. Although the pathologic examination of the disc specimen is not routine, it is rational if any doubt is present.
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In one case of Birkeland and Taylor [ 2 ], diagnosis was ascertained by detecting small piece of tissue identified as bowel wall in the disc material. Another operative strategy is to carry out a limited discectomy rather than a radical discectomy. Birkeland and Taylor [ 2 ] have stated that total discectomy is inadvisable even in the hands of experienced surgeons, and only removal of easily retrievable material from the disc space is required for effective surgical treatment.
StuDoQ Pankreas. StuDoQ Rektumkarzinom. Weitere Register. Most read articles by the same author s A. Litvin, Intelligent medical systems in diagnosing and treating inflammatory diseases of the pancreas systematic review , Herald of Pancreatic Club: Vol 38 No 1 : Herald of Pancreatic Club A. Litvin, A.
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