Pneumoretroperitoneum After Procedure for Prolapsed Hemorrhoid
A previously healthy 27-year-old female who had a grade-3 prolapsing hemorrhoid was treated with PPH at a local private hospital. She was discharged on the second postoperative day without any specific symptoms. She visited the Emergency Department of our institution on the evening of the discharge day due to a sudden onset of abdominal pain and fullness. Physical examination showed a diffuse abdominal tenderness, but the degree was not as severe as that seen in a typical case of peritonitis. On rectal digital examination, the staple line was noted at approximately 4 cm above the anal verge, and the defect was located at the right side of patient. There was no bleeding evidence in either the patient's history or on examination. Vital signs were stable except for a mild fever (37.5℃). The white blood cell count was 13 × 106/mL. A plain abdominal radiograph and a computed tomography (CT) scan showed extensive retroperitoneal gas ( and ). Air bubbles were also found at the subcutaneous layer of the anterior abdominal wall on the CT scan. A laparoscopic evaluation was performed at 55 hours after the original surgery. Exploration of the peritoneal cavity and the retroperitoneal space revealed no necrosis, abscess or fecal material. The retro-rectal tissue, however, was markedly edematous and vascular. A closed suction drain was placed at the retroperitoneal space, and a loop sigmoid colostomy was created.\nThe rectal staple line was inspected after the abdominal procedure. Partial staple-line dehiscence, which was consistent with the preoperative digital examination, was noted at the right side of the patient (). The defect was closed with 4-0 vicryl after massive irrigation. An overstitching was done throughout the staple line to prevent possible future dehiscence. The postoperative course was uneventful, and oral feeding was resumed on the second postoperative day. At the 2-month follow-up, a gastrografin enema showed the absence of leaks, and the colostomy was closed. During follow-up, she has had no residual problems, including staple-line stenosis.