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