Successful Laparoscopic Removal of an Ingested Toothbrush
We describe a case report of an 18-year-old girl who had accidentally swallowed a toothbrush. Immediately following the ingestion she attended accident and emergency but was discharged home as no foreign body was visible on an abdominal plain film. Four years later she presented to our surgical out-patient clinic with vague epigastric pain, adamant that she had previously ingested a toothbrush. Ultrasound and abdominal plain films confirmed a foreign body within the stomach. Endoscopic removal was then attempted on two separate occasions but the toothbrush was found to be straddling the pylorus and partial embedded within the gastric mucosa. Therefore, despite using a polypectomy snare and biopsy forceps, the toothbrush could not be safely freed. Endoscopic mucosectomy was not considered in this particular case because the toothbrush was deeply embedded.\nThe decision was taken to perform laparoscopic removal of the toothbrush. The patient was positioned in the supine position with sacrum at the edge of the table and the legs abducted in stirrups. The patient was given 1.2 g of augmentin intravenously as antibiotic prophylaxis. The surgeon stood in between the patient's legs with the assistant on the right hand side of the patient. A Veress needle was used to establish pneumoperitoneum with a working pressure of 12 mmHg and an initial 10-mm trocar was placed supra-umbilically as the camera port. Two further 5-mm trocars were placed under direct vision in the right and left subcostal margins both in the mid-clavicular line. A Nathanson liver retractor was introduced through a 5-mm epigastric incision to allow retraction of the left lobe of the liver. With a 10-mm 30-degree laparoscope and a reverse Trendelenburg position, the outline of the toothbrush could be clearly seen projecting on to the anterior gastric wall and extending in to the duodenum [].\nUsing hook diathermy, a 4-cm gastrotomy was made in the distal anterior gastric wall overlying the toothbrush. With the aid of two graspers we were able to manipulate and gently free the partially embedded toothbrush and allow safe removal from the stomach in its entirety [].\nAn endoloop was placed around the handle of the toothbrush with the string left long. A 5-mm 0-degree laparoscope was inserted down the right lateral 5-mm port allowing the string to be delivered via the 10-mm supraumbilical port. Subsequent manipulation of the string then facilitated delivery of the handle of the toothbrush in to the port. We then removed the 10-mm port from the abdomen thus allowing the toothbrush to be retrieved through the existing incision. The 10-mm port was re-introduced and the gastrostomy was laparoscopically sutured using a continuous 2-layer intracorporeal technique with ethibond 1/0 [].\nWe did not feel that an abdominal drain or nasogastric tube were required at the end of the procedure. The total operating time was 90 minutes and the patient was given a light diet the following day. After 48 hours, the patient was discharged as she was tolerating a normal diet, was pain free, and fully mobile. The patient was followed up in the surgical out-patient clinic 6 weeks after the operation and had made a full recovery.