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Incarceration of a colonoscope in an inguinal hernia

1994; Elsevier BV; Volume: 40; Issue: 3 Linguagem: Inglês

10.1016/s0016-5107(94)70099-0

1097-6779

K Yamamoto, Shailesh C. Kadakia,

Esophageal and GI Pathology

Various complications of colonoscopy have been reported, including perforation, hemorrhage, cardiovascular mishaps, and bacteremia.1Williams CB Waye JD Colonoscopy and flexible sigmoidoscopy.in: Textbook of gastroenterology. JB Lippincott, Philadelphia1991: 2249-2265Google Scholar Although impaction of an endoscope within a hiatal hernia during retroflexion has been well described,2Schrock TR Complications of gastrointestinal endoscopy.in: 4th ed. Gastrointestinal disease: pathophysiology, diagnosis, management. WB Saunders, Philadelphia1989: 216-222Google Scholar only two other reports in the literature describe a colonoscope incarceration within a hernia sac.3Leisser A Delpre G Kadish U Colonoscope incarceration: an avoidable event.Gastrointest Endosc. 1990; 36: 637-638Abstract Full Text PDF PubMed Scopus (18) Google Scholar, 4Leichtmann GA Feingelrent H Pomeranz IS Novis BH Colonoscopy in patients with large inguinal hernias.Gastrointest Endosc. 1991; 37: 494Abstract Full Text PDF PubMed Scopus (8) Google Scholar In a third report, a colonoscopy could not be successfully completed even under fluoroscopic guidance because of an unsuspected inguinal hernia.5Fulp SR Gilliam JH Beware of the incarcerated hernia.Gastrointest Endosc. 1990; 36: 318-319Abstract Full Text PDF PubMed Scopus (7) Google Scholar In this case the presence of the hernia was detected only after a barium study. We report a case of an incarcerated colonoscope during a routine surveillance colonoscopy in an 83-year-old man who had a history of colonic adenomas that were removed in the distant past. Of note, on physical examination he was found to have a rather large left inguinal hernia that was not reducible. No bowel sounds were audible within the hernia sac. By patient history the hernia was present for many years, although some increase in the size occurred during the last 12 months. After the patient was given conscious sedation with meperidine and midazolam, the procedure was performed without difficulty until, at approximately 70 cm, the colonoscope could not be advanced although the lumen was clearly visible. Attempts at “reducing” a presumed loop were unsuccessful and resulted in significant left lower quadrant pain as well as resistance to retrograde withdrawal. Thus, the colonoscope appeared to be inexplicably frozen in position. On examining the left inguinal hernia sac, it was clear that the colonoscope had become incarcerated within the hernia sac. Even with gentle external traction, the colonoscope could not be withdrawn. The patient was taken immediately to the fluoroscopy suite, where the colonoscope was found to be within the hernia sac as expected (Fig. 1). However, there was an absence of complex loop such as alpha or gamma loop. Under fluoroscopic guidance, the colonoscope was slowly and carefully withdrawn by gentle traction without incident. The procedure was terminated, and the patient was referred to surgery for consideration for hernia repair. At operation, a large incarcerated hernia including the sigmoid colon was found. It was noted that the loop of bowel was particularly adherent to the hernia sac, and because of its large size an extended surgical incision had to be made to reduce the hernia. The most common structure within an incarcerated inguinal hernia is the small bowel,6Grosfeld JL Groin hernia in infants and children.in: 3rd ed. Hernia. JB Lippincott, Philadelphia1989: 81-105Google Scholar although all intra-abdominal contents are potentially at risk. In our case fluoroscopic guidance was crucial when external pressure failed to extract the colonoscope, although an attempt at manual reduction has been reported to be successful by others.4Leichtmann GA Feingelrent H Pomeranz IS Novis BH Colonoscopy in patients with large inguinal hernias.Gastrointest Endosc. 1991; 37: 494Abstract Full Text PDF PubMed Scopus (8) Google Scholar As can be appreciated from the radiograph, in our case, if an imaginary line was to be drawn from the anterior superior iliac spine and the pubic symphysis, this represents the area of the inguinal ligament. This area (arrows) corresponds to a narrowing of the scope, probably representing the mouth of the hernia. One can further appreciate the hernia sac itself containing the colonoscope (arrowheads). If an alpha or gamma loop was present, forcefully extracting the colonoscope through a narrow orifice could have resulted in severe injury, a situation that fortunately we did not encounter. Only the use of fluoroscopy would have demonstrated this potentially dangerous predicament. In summary, we report a rarely encountered complication of colonoscopy with the first radiograph in the literature demonstrating an incarcerated colonoscope within a hernia sac. Although manual reduction can be attempted, if the colonoscope cannot be extracted easily, fluoroscopy is crucial to identify potential alpha or gamma loops that can precipitate further problems if forceful extraction is attempted. The presence of an inguinal hernia is not a contraindication to colonoscopy.7American Society for Gastrointestinal Endoscopy Gastrointestinal endoscopy: diagnostic and therapeutic procedures.in: American Society for Gastrointestinal Endoscopy, Manchester, Mass.:1990: 9-12Google Scholar Even so, a careful history and physical examination before colonoscopy is important because it can alert the endoscopist to be mindful of a potential hazard such as the one we encountered. The opinions and assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.