MANUAL EXTRACTION OF A RECTAL FOREIGN BODY - THE IMPORTANCE OF CHOOSING THE RIGHT SURGEON

"…to be a surgeon you need the eye of a hawk, the heart of a lion and the hands of a lady…"

Vicky Gereis and Nick Taffinder
Department of Colorectal Surgery, William Harvey Hospital, Ashford, Kent, TN24 0LZ, UK

Despite of 60% of medical students being females, only 6% of Consultant Surgeons are women. Female surgeons may have some attributes that are advantageous to a surgical career such as being sympathetic, calm and organized.

However a trait that has never been mentioned and is unmistakably feminine is their hand size. We present two case reports of transanal extraction of foreign bodies in the sigmoid colon by a female surgeon. Anal sphincter integrity after the procedure was assessed using endo-anal ultrasound.

The authors have found no other reports of the hand being used to retrieve foreign bodies from above the rectum.

Subjects and Methods

Two patients with retained foreign bodies in the sigmoid colon presented to our department. The foreign bodies were a head of a broken vibrator and a plastic hairspray lid at 20 and 22 cm from anal verge respectively. After attempts using rigid and flexible sigmoidoscopy had failed, the smallest member of the team - a female surgeon - used her hand to retrieve the foreign body transanally. The hand was inserted up to the level of the distal radius. The sphincter integrity was assessed a month later by endo-anal ultrasound.

Case report 1

A 28 year old male presented to the emergency department complaining of rectal bleeding and difficulty in defecation. He reported that three days before he had a "sexual toy" inserted into his rectum by his partner. He said that the foreign body was removed but he could not recall the details of the event because he was under the influence of alcohol. An abdominal radiograph was performed that was interpreted as normal and the patient was discharged with a diagnosis of rectal mucosal injury.

Figure 1

The patient presented again a week later as a referral to the surgical team by his GP. He then mentioned that an aerosol can was inserted and removed by his partner. On examination he had mild tenderness on the left iliac fossa and on rectal digital examination a foreign body could not be felt. Abdominal radiograph was repeated that again was interpreted as "normal". On erect CXR there was no air under the diaphragm. A CT of the abdomen and pelvis was performed the next day using contrast that showed what appeared to be a cylindrical foreign body in the sigmoid colon. On interpreting the abdominal radiograph again, there is a rectangular shaped gas pattern in the upper rectum due to a non opaque foreign body not visible on plain X-ray (Figure 1).

The patient was taken to theatre where he had general anaesthesia and was placed in the lithotomy position.

Using rigid and flexible sigmoidoscopy we could visualize the edge of a plastic foreign body at 22 cm that appeared to be an aerosol lid with its blind end placed cephalad. Several attempts were made to grasp the object using biopsy forceps and graspers but it was impossible to mobilize the object even with abdominal pressure applied to facilitate caudal movement. The endoscope could not by-pass the object as it occupied the whole bowel lumen and mucosal oedema was surrounding it.

Before proceeding to laparotomy, the smallest member of the team - a female surgical trainee inserted her hand transanally to the level of the distal radius. She managed to grasp the object with her fingers but was unable to mobilize it due to its fixity to the bowel wall. We proceeded to laparotomy and found that the object had eroded and adhered to the bowel wall causing a long standing perforation of the sigmoid colon which was sealed by omentum. The foreign body was retrieved through a colostomy and a Hartmann's procedure was performed. The patient had no postoperative complications and was discharged after five days.

A month later his sphincter integrity was assessed with endo-anal ultrasound and was found to be intact. The colostomy was reversed six weeks after the operation and the patients bowel function returned to normal, without incontinence.

Case report 2

Figure 2

A 41 year old man presented to the emergency department with a few hours history of a retained foreign body into his rectum. He reported that his partner had inserted a motor vibrator but on retrieval the head had broken into his rectum. He had made several attempts of retrieving the foreign body himself that resulted in movement of the foreign body proximally and he could no longer feel it.

Abdominal examination was unremarkable and on digital rectal examination the foreign body could not be felt. Abdominal radiographs were obtained that showed clearly the metallic motor of the vibrator situated at the rectosigmoid (Figure 2).

Sigmoidoscopy revealed the object at 20 cm with its base lying distally.

The patient was treated with bed rest, analgesia and mild sedation. According to the principles of management in the literature¹ these measures help the majority of high-lying foreign bodies to move into the rectum within 12 hours.

The object did not change position assessed with sigmoidoscopy and radiographs after 48 hours so the patient was taken to theatre to attempt retrieval under general anaesthesia. The patient was placed in the prone jackknife position and was given full muscle relaxation. The foreign body could be easily visualized with rigid sigmoidoscopy at 20-23 cm but could not be grasped using biopsy forceps because it could not provide a good grasping surface although its base was relatively sharp.

The female surgeon inserted her hand easily into the rectum, grasped the head of the vibrator and after inverting it inside the bowel so that the smooth end pointed caudaly she managed to deliver it. A sigmoidoscopy was performed to ensure that there were no mucosal injuries.

The patient was kept in hospital for observation for 48 hours and discharged. A month later his sphincter was found to be intact using endo-anal ultrasound and he maintains a normal bowel function with no incontinence.

Discussion

Retained rectal foreign bodies are a common surgical problem and are often easy to remove. When the foreign body migrates into the sigmoid colon, the management is more challenging. An ideal surgical instrument would be able to grasp a large object without damaging the bowel wall. No such instrument exists. The surgeon's hand is arguably the best surgical instrument available.

Eftaiha et al1 classified colorectal foreign bodies into low and high lying and suggested principles of management that were followed in the majority of cases reviewed in the literature. However most of the authors suggest that trans-anal delivery should only be done under direct vision. Crass et al suggested that the entire hand could be inserted under general anaesthesia to retrieve foreign bodies as long as they were lying low in the rectum2. Kingsley et al3 propose that laparotomy should be considered as the primary method of treatment if the patient presents with a high-lying foreign body impacted for 24 hours or longer. We have proven that using a small hand provided a safe, cost effective method of extracting rectal and sigmoid foreign bodies by the transanal route, without damage to the anal sphincters.

We compared the diameter of female and male hands in 20 surgeons. The mean diameter in females was 5.5cm and in males 7cm. When compared to the diameter of the transanal endoscopic microsurgery (TEM) device, the female hand was only 1.7cm greater compared with 3.2cm greater for male hands. Kennedy et al showed that compromise of the anal sphincter function after TEM excision of rectal tumors was directly proportional to the length of the procedure and that the risk increased with procedures lasting more than 2 hours4. In our case the procedure lasted less than 30 minutes.

The possibility of a perforation must be taken into account, especially with long standing foreign bodies that can erode the bowel wall. Crass et al reported that all free perforations were clinically obvious with free air on abdominal radiographs, but in our case a small perforation sealed by omentum was not evident on radiographs.

A multi disciplinary approach should be used when encountering patients with colorectal foreign bodies. These patients frequently present in the emergency department and the surgical team should be involved in all cases. If there is difficulty in interpreting radiographs, a professional opinion from a radiologist should be obtained. Before attempting manipulation in theatre, consultation by a stoma nurse is advised in case a laparotomy and proximal diversion is needed. These patients are often deeply embarrassed and psychological support and confidentiality is essential. The role of the nursing staff involved in the care of the patient in that case is highly important.

Finally, we point out the need for more female surgeons and a female and male partnership. To our knowledge this is the only report of using the hand to remove foreign bodies in the sigmoid colon. We propose that the hand is a useful instrument for removing colorectal foreign bodies and that "the hands of a lady" may have an advantage.

References

1. Eftaiha M, Hambrick E, Abcarian H. Principles of management of colorectal foreign bodies. Arch Surg 1977;112:691-5

2. Crass R, Tranbaugh R, Kudsk K, Trunkey D. Colorectal foreign bodies and perforation. Am J Surg 1981;142:85-8

3. Kingsley A, Abcarian H. Colorectal foreign bodies. Management update. Dis Colon & Rectum 1985;28:941-4

4. Kennedy M, Lubowski D, King D. Transanal endoscopic microsurgery excision. Is anorectal Function compromised? Dis Colon & Rectum 2002;45:601-4

5. Cohen J, Sackier J. Management of colorectal foreign bodies. J R Coll Surg Edinb 1996;41:312-5

Correspondence :

Dr Vicky Gereis, 84 Broomfield, William Harvey Hospital, Kennington Road, Ashford, Kent, TN24 0LY
Tel: 01233 633331 ext.88575, Mob:07985282056
e-mail: gereis@btopenworld.com

Mr Nick Taffinder, Department of Colorectal Surgery, William Harvey Hospital, Kennington Road, TN24 0LZ
Tel: 01233 616676, Fax: 01233616019
e-mail: nick.taffinder@ekht.nhs.uk