A 52-year-old woman undergoes laparoscopic cholecystectomy due to recurrent episodes of biliary colic. During the surgery, a blunt trocar is inserted near the umbilicus under direct vision (ie, open technique), and pneumoperitoneum is achieved via insufflation of the abdomen with carbon dioxide. Three additional trocars are inserted, and the cholecystectomy is completed uneventfully. After a period of observation in the postanesthesia care unit, the patient is discharged home. Three days later, the patient returns to the emergency department due to persistent abdominal pain and nausea. She takes acetaminophen and hydrocodone every 6 hours. Temperature is 38 C (100.4 F), blood pressure is 120/68 mm Hg, and pulse is 104/min. Physical examination shows intact port incisions with no erythema or discharge. There is mild generalized tenderness of the abdomen with some guarding. Bowel sounds are diminished. The remainder of the examination is normal. Laboratory testing shows leukocytes at 16,000/mm³; serum electrolytes and bilirubin are normal. Abdominal x-ray reveals generalized distension of the small and large bowel, stool in the distal colon, and intraperitoneal free air. Which of the following is the best next step in management of this patient?

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Explanation: This patient who underwent laparoscopic surgery now has findings concerning for early intraabdominal infection, including persistent abdominal pain, fever, abdominal guarding, ileus (eg, diminished bowel sounds, small- and large-bowel distension), and leukocytosis. The best next step is abdominal CT scan with oral contrast to evaluate for possible unrecognized bowel injury (eg, bowel puncture when intraabdominal access is obtained, thermal injury when electrosurgical instruments are used). Bowel injuries that are recognized intraoperatively are immediately repaired. Some injuries, however, go unrecognized and may not be diagnosed until patients seek care later with symptoms arising from the spillage of gastrointestinal contents, which may cause varying degrees of inflammation. Postoperative patients with frank peritonitis do not require abdominal imaging prior to surgical reexploration (although, in practice, imaging is often obtained en route to the operating room). Patients (such as this one) with concerning findings but without frank peritonitis (eg, some guarding but no rigidity or rebound tenderness) should undergo abdominal CT scan to evaluate for bowel injury. The use of oral contrast, given by nasogastric tube if necessary, assists with detecting the site of leakage (eg, extraluminal contrast extravasation). Intraperitoneal free air, as seen on this patient's x-ray, is normally present for days following procedural pneumoperitoneum and is therefore not specific for bowel perforation. (Choice A) Rectal enemas can help treat constipation (eg, from opioid use), which may cause abdominal pain and diminished bowel sounds. However, x-ray often reveals a large amount of feces throughout the entire colon (vs just the distal colon), and fever and leukocytosis are not expected. (Choices B and E) This patient has postoperative ileus (eg, decreased bowel sounds, generalized bowel distension). Although postoperative ileus is often benign with a self-limited course (for which reassurance or supportive care may be appropriate), this patient's additional findings of fever and leukocytosis are concerning for intraabdominal infection (eg, unrecognized bowel injury) and demand further workup (eg, CT scan). (Choice D) Early findings in patients with unrecognized biliary injury, a feared complication of laparoscopic cholecystectomy, may include nausea, persistent abdominal pain, and low-grade fever; however, serum bilirubin is often elevated (vs normal). Abdominal CT scan (vs endoscopic retrograde cholangiopancreatography) is typically used to make the diagnosis of biliary injury, which often requires surgical repair. Educational objective: Bowel injury is a potential complication of laparoscopic surgery that may go unrecognized intraoperatively. Concerning postoperative findings include fever, leukocytosis, abdominal pain/guarding, and ileus. Abdominal CT scan with oral contrast can help detect the site of leakage. References: Delayed manifestations of laparoscopic bowel injury. (http://www.ncbi.nlm.nih.gov/pubmed/25975332) Laparoscopic entry techniques. (http://www.ncbi.nlm.nih.gov/pubmed/30657163)

A 52-Year-Old Woman Undergoes Laparoscopic Cholecystectomy Due to Recurrent Episodes