ANZ Journal of Surgery | 2019
Laparoscopic removal of a toothpick perforating the upper rectum
Abstract
A 42-year-old male was referred to a colorectal surgeon with a 1-month history of perianal pain, alternating diarrhoea and constipation and rectal mucous discharge. He denied any rectal bleeding or weight loss. He also described dysuria, without urethral discharge and intermittent left testicular discomfort over the same time frame. The pain occasionally radiated to the left buttock. He was otherwise well, had no prior abdominal surgery, and no family history of colorectal cancer or inflammatory bowel disease. Of note, was a recent trip to Fiji; which predated his symptoms. On examination, the abdomen was soft with mild tenderness low in the left iliac fossa. Both testes were non-tender. There was no blood or mass lesion on rectal examination, however there was increased tenderness on the left lateral rectal wall. His white cell count, and renal function were normal. He had a C-reactive protein of 15 mg/L. Urine microscopy was unremarkable. Interestingly, his stool culture detected Yersinia. A computed tomography (CT) scan demonstrated ill-defined soft tissue thickening in the left pelvis between the bladder and rectum. Thickening of the left obturator internus muscle was also noted. This was thought to be an inflammatory process/mass arising from the left seminal vesicle or sigmoid colon (Fig. 1). An ultrasound scan of his scrotum, renal tract, left buttock and thigh was unremarkable. Subsequently he underwent colonoscopy. The terminal ileum, colon and rectum were normal throughout. The ongoing symptomatology and CT findings prompted a magnetic resonance imaging (MRI) scan for further assessment (Fig. 2). It revealed a linear foreign body, penetrating the left wall of the mid sigmoid colon. The proximal end was within the submucosa of the sigmoid colon, with a surrounding abscess. The distal end was lodged within the obturator internus muscle, causing an intramuscular abscess and surrounding myositis. The patient underwent an expedited laparoscopic exploration. There were inflammatory adhesions in the left pelvis involving the sigmoid colon and upper rectum. The adhesions were lysed to expose a well matured fistula tract arising from the left aspect of the upper rectum into the left pelvic sidewall. The tract was entered, revealing a 7-cm toothpick; which was removed. The granulation tissue was debrided, the pelvis lavaged and the left