Figure 3: Sagittal cross-section of CT abdomen and pelvis
revealing distended loops of bowel. H: toward patient head, F: toward
patient feet.
The patient underwent urgent diagnostic laparoscopy. On initial
inspection, the bowel was distended, but was pink and well-perfused,
with white, non-exudative streaking in the wall of the bowel. Several
liters of thin turbid brown-tinged/green fluid were visualized in the
abdomen. Due to challenging visualization secondary to significant bowel
distension, the surgery was converted to open. The right colon was
adherent to the right abdominal wall at the appendectomy site causing
some partial malrotation. The adhesions/Ladd’s bands were lysed, freeing
the entire bowel. Over the dome of the liver was a round, thin-walled
air-filled structure, off a pedicle to the diaphragm (Figure 4). This
was stapled and ligated off the pedicle. There were also
cystic/pneumatosis-like changes over the diaphragm and anterior
peritoneal covering of the abdominal wall (Figure 4). There was an area
of exuberant pneumatosis of small bowel in the left upper quadrant, but
no distinct perforation was visualized (Figure 5). This was determined
to be the most likely source of pneumoperitoneum, so a stapled bowel
resection was done, and two drains were left in place. Stapled small
bowel anastomosis was performed rather than hand-sewn due to evidence
showing reduced operative time with stapled small bowel anastomosis
without a significant increase in complications (e.g., anastomotic
leak).12-15