Retroperitoneal left pelvic migrated Kirschner pin 10 years after thoracic osteosynthesis

This video shows the case of a patient with a past medical history of a significant kyphoscoliosis, that was treated in 1999 with a surgical fixation. Nine years later, during a control exam a Kirschner pin was found in the retroperitoneum. A detailed description is made of the dissection and extraction of the foreign body localized retroperitoneally.

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Retroperitoneal left pelvic migrated Kirschner pin 10 years after thoracic osteosynthesis

Authors

J Leroy, F Costantino, J Marescaux

Abstract

This video shows the case of a patient with a past medical history of a significant kyphoscoliosis, that was treated in 1999 with a surgical fixation. Nine years later, during a control exam a Kirschner pin was found in the retroperitoneum. A detailed description is made of the dissection and extraction of the foreign body localized retroperitoneally.

Classification

complex cases

Keywords

retroperitoneal, retroperitoneum, left pelvic migrated Kirschner pin, thoracic osteosynthesis

Media type

Surgical video

Duration

07'30''

Publication

2008-10

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E-publication

WeBSurg.com, Oct 2008;8(10).
URL: http://www.websurg.com/doi-vd01en2371.htm

Retroperitoneal left pelvic migrated Kirschner pin 10 years after thoracic osteosynthesis

1. Clinical case presentation 00'25''

This video shows the clinical case of a young patient, operated in 1999 for a kyphoscoliosis with a pectus excavatum. She had previously had a surgical fixation, and in 2008, following a CT-scan, the retroperitoneal migration of a foreign body was shown: it turned out to be a Kirschner pin.

2. Laparoscopic exploration 00'46''

In order to remove this, we first perform an abdominal exploration via a laparoscopy that was begun at the level of the sacral promontory.

3. Identification and dissection of the psoas muscle 00'56''

Here we can see the psoas muscle that we will first undo of its peritoneal covering all along the parietocolic gutter. To do this, we apply traction at the level of the colon by grasping it; this traction is internal and is performed with the help of a 5mm Ligasure. We perform the mobilization of around 15 to 20cm at the parietocolic level, which will then allow us to spot the foreign body. Once the mobilization is achieved, we can observe the fully uncovered body of the psoas muscle and the vessel that runs at the retroperitoneal level. We try to perform a small incision at the level of the psoas muscle by using the 5mm Ligasure’s monopolar coagulation. And here we can observe the sensitive nerve that runs along of the iliac artery. The patient set-up has been typical. He has been placed in a dorsal decubitus position. Three trocars have been used with the operating trocar placed at the umbilicus. The identification of the foreign body’s location has been quite difficult macroscopically, which is why we decided to superimpose the images that you have seen at the start of the video. This allows us to locate the foreign body. The dissection is done atraumatically while trying to locate the foreign body. Here we think we have identified it.

4. Radiological localisation of the pin 03'54''

You can see here on the left of the screen the radiology that helps us identify the Kirschner pin using radiology. Once the Kirschner pin has been identified, we begin the dissection that preserves the sensitive nerve we have just seen. This dissection is therefore performed completely atraumatically. In order to keep a clean operative field, we use the Ligasure’s monopolar coagulation component. Once the Kirschner pin is visualized, we begin to free it until we manage to get the distal end free.

5. Extraction 05'48''

As you can see here, the extraction is carried out with no problems. There is a small inflammatory sheath surrounding the pin, but this does not impede the extraction of the pin. In total length, the Kirschner pin measures 15cm. Manipulation of the pin was somewhat difficult because of the lack of abdominal space in relation to the length of the pin. But nonetheless, we are able to extract this through the 5mm suprapubic trocar. We then return to the operative field in order to return the colon to its place at the level of the left parietocolic fossa. And we check the hemostasis. This therefore concludes the procedure. Finally, this image shows the patient’s postoperative scar.