Boot M, Kenneth C, Sowter S
Introduction
A duodenal diverticulum perforation is a rare and life-threatening complication of an otherwise asymptomatic pathology. The majority of duodenal diverticulum perforations are secondary to diverticulitis; however other aetiologies include enterolithiasis, iatrogenic, ulceration, trauma, and foreign body. Perforation secondary to iatrogenic causes is rare, with only sixteen cases reported in the literature. This case report explores a world-first iatrogenic duodenal diverticulum perforation during right laparoscopic nephrectomy.
Method/Description
Case Description: A 69-year-old diabetic male presented for an elective right laparoscopic nephrectomy in the context of high-grade muscular invasive transitional cell carcinoma of the ureter. Relevant medical history included recent right ureteric stenting two months prior for obstructive uropathy secondary to malignant stricture. During dissection of the right kidney’s upper pole, bowel injury was observed as an enteric gas leak. The operation was converted to an open procedure, and intraoperative consultation with a general surgeon was undertaken. Perforation of a large duodenal diverticulum was identified as the cause of bowel injury. The diverticulum was located on the second part of the duodenum’s lateral wall, which occurs in approximately 3% of cases. The duodenal diverticulum was excised, and the duodenal defect’s closure was achieved with interrupted 3/0 polydioxanone suture with imbrication of the mucosa to prevent biliary obstruction. The remainder of the procedure was unremarkable. A retrospective review of computed tomography of the abdomen demonstrated a large thin-walled diverticulum arising from the second part of the duodenum abutting Gerota’s fascia of the right kidney. The patient’s post-operative recovery was complicated by hypovolemic shock and an acute kidney injury requiring a short stay in the intensive care unit. Both complications were managed conservatively, and the patient was discharged home day nine post-
operatively.
Discussion
Sixteen previously recorded iatrogenic perforations were identified in the literature with causes including endoscopy, biliary surgery, endoscopic retrograde cholangiopancreatography, laparoscopic hemicolectomy, and nasogastric tube insertion. Only one of these cases identified a diverticulum pre-operatively, three were diagnosed intraoperatively, and the remainder identified as a result of clinical deterioration. The thin wall of the diverticulum makes it vulnerable to iatrogenic injuries. Awareness and vigilance in the review of pre-operative imaging can help planning and avoid perforation. Early identification of a duodenal diverticulum before the case can allow the surgeon to take particular care during dissection in this plane. Possessing a high degree of suspicion of a perforated duodenal diverticulum on encountering signs of inadvertent enterotomy such as bubbling, and leakage of enteric fluid can lead to early detection and treatment. It is essential to seek consultation from a general surgeon or upper gastrointestinal surgeon to determine if immediate repair is required.
Consclusions
This is the first reported case in the literature of a perforated duodenal diverticulum secondary to laparoscopic surgery during a right nephrectomy. The patient experienced good outcomes due to high clinical suspicion intraoperatively after direct visualisation of perforation, allowing for appropriate early management.