its ease of use and patient tolerance has made it popular among gastroenterologists and patients alike .
currently , capsule endoscopy is most commonly used to evaluate obscure gastrointestinal bleeding , but its indications are broadening .
various reports have described the capsule becoming impacted or retained in the small bowel , requiring retrieval .
a 74-year - old female had a history of unidentified gastrointestinal bleeding and underwent a capsule endoscopy .
the patient was not able to spontaneously pass the capsule and had intermittent obstructive symptoms .
her past medical history was significant for severe copd , and she had undergone hysterectomy and appendectomy in the past .
the gastroenterologist performed a colonoscopy , and the capsule was visualized in the terminal ileum .
attempts at endoscopic removal of the capsule were not successful . therefore , she was seen in the surgery clinic for removal of the capsule .
a decision was made to perform a laparoscopic exploration to evaluate the entire small bowel and colon to identify any associated pathology . just before the procedure ,
an abdominal x - ray was taken , confirming the presence of the retained capsule in the right lower quadrant ( figure 1 ) .
after proper informed consent was obtained , the patient was taken to the operating room .
laparoscopic instruments were placed through 4 trocars . the patient was found to have adhesions from her previous hysterectomy , which were divided without difficulty .
intraoperative examination of the small bowel revealed a stricture in the terminal ileum just proximal to the ileocecal valve with a bulge consistent with the retained capsule ( figure 2 ) .
the mesenteric vessels were controlled with the ligasure device ( us surgical corporation , norwalk , ct ) and 2.0-mm vascular loads of the endo - gia stapler ( us surgical corporation , norwalk , ct ) .
the colon was transected distal to the cecum , and then delivered through a 4-cm infraumbilical incision .
careful inspection revealed the capsule in the terminal ileum at an area that was significantly strictured .
the small bowel was transected proximal to the strictured area , and the specimen was sent to pathology .
next , a side - to - side anastomosis was formed between the ileum and the colon with a 3.5-mm endo - gia stapler and the incision was closed .
she was advanced to sips of clear liquid on the evening of postoperative day 1 .
she was tolerating oral intake , but on postoperative day 4 she developed abdominal distension consistent with an ileus .
on postoperative day 5 , she had passage of flatus and was restarted on her clear liquid diet . by postoperative day 7 , she was tolerating her diet well with no nausea or vomiting and was discharged home .
she was seen several weeks later in the surgery clinic and was doing well without any complications .
final pathology demonstrated no evidence of inflammatory bowel disease or malignancy . despite the fact that no pathologic bleeding site was found ,
the patient has had no further bleeding or obstructive symptoms at 1-year follow - up .
after proper informed consent was obtained , the patient was taken to the operating room .
laparoscopic instruments were placed through 4 trocars . the patient was found to have adhesions from her previous hysterectomy , which were divided without difficulty .
intraoperative examination of the small bowel revealed a stricture in the terminal ileum just proximal to the ileocecal valve with a bulge consistent with the retained capsule ( figure 2 ) .
the bowel was extensively evaluated , and no other abnormalities were found . an ileocectomy was chosen to remove both the stricture and the retained video capsule .
the mesenteric vessels were controlled with the ligasure device ( us surgical corporation , norwalk , ct ) and 2.0-mm vascular loads of the endo - gia stapler ( us surgical corporation , norwalk , ct ) .
the colon was transected distal to the cecum , and then delivered through a 4-cm infraumbilical incision .
careful inspection revealed the capsule in the terminal ileum at an area that was significantly strictured .
the small bowel was transected proximal to the strictured area , and the specimen was sent to pathology . next
, a side - to - side anastomosis was formed between the ileum and the colon with a 3.5-mm endo - gia stapler and the incision was closed .
the patient tolerated the procedure well . she was advanced to sips of clear liquid on the evening of postoperative day 1 .
she was tolerating oral intake , but on postoperative day 4 she developed abdominal distension consistent with an ileus .
on postoperative day 5 , she had passage of flatus and was restarted on her clear liquid diet . by postoperative day 7 , she was tolerating her diet well with no nausea or vomiting and was discharged home .
she was seen several weeks later in the surgery clinic and was doing well without any complications .
final pathology demonstrated no evidence of inflammatory bowel disease or malignancy . despite the fact that no pathologic bleeding site was found ,
the patient has had no further bleeding or obstructive symptoms at 1-year follow - up .
since its introduction several years ago , capsule endoscopy has rapidly become an important diagnostic modality in the evaluation of several gastrointestinal conditions .
the ease of administration and the ability to visualize the entire small bowel are two of the main advantages of capsule endoscopy .
as patients request less invasive approaches to their medical care , primary care physicians and surgeons alike will be increasingly exposed to capsule endoscopy .
video capsule endoscopy is most commonly used to detect obscure gastrointestinal bleeding not located by endoscopy . the role of video capsule endoscopy
has expanded to inflammatory bowel disease , small - bowel neoplasms , malabsorption disorders , iatrogenic disease ( nsaid strictures ) , radiation enteritis , clarification of previous imaging , and chronic abdominal pain .
capsule endoscopy has been contraindicated in patients with known small - bowel obstruction , strictures , extensive crohn 's disease , swallowing disorders , pseudo obstruction , motility disorders , cardiac pacemakers , and defibrillators .
relative contraindications include pregnancy , chronic nsaid use , extensive diverticular disease , gastroparesis , and previous pelvic or abdominal surgeries .
recently , capsule endoscopy has been reported for use in the evaluation for recurrent small - bowel obstruction and strictures . in one study , 19 patients with suspected small - bowel obstruction underwent capsule endoscopy .
a definitive diagnosis was made in 32% of the cases . in 3 cases , the capsule was retained and laparotomy was required , but in no instance was the capsule the cause of an acute small - bowel obstruction .
although controversial , this provides an example of the potential for expansion of this new technology .
the retention rate appears to be between 0.75% to 3% but may be higher in patients with crohn 's disease .
if the capsule has not passed after 7 days , then a plain film is obtained .
endoscopic retrieval and extraction by push - and - pull enteros - copy with the double - balloon technique have been used with success . as presented in this case , surgical retrieval
in fact , it is widely felt that a retained capsule is diagnostic of a clinically relevant stricture or mass .
we describe a safe laparoscopic retrieval of a capsule endoscopy retained in the terminal ileum secondary to scar tissue .
a review of capsule endoscopy at 2 referral centers revealed 7 of 197 capsules retained .
the surgical findings included nonspecific inflammatory strictures ( twice ) , a radiation stricture , a crohn 's stricture , and an umbilical hernia .
two cases of open surgical retrieval of an impacted capsule requiring stricturoplasty and a segmental resection have recently been reported in patients with known crohn 's disease .
retention or nonpassage of the capsule endoscopy is an uncommon occurrence that is likely to become a more frequent surgical situation as the indications for the technology broaden . in the meantime ,
for example , many would recommend small bowel follow through or enteroclysis before capsule endoscopy in patients with known crohn 's disease or suspected strictures .
in addition , a standard bowel preparation or even a dose of metoclopramide before capsule administration has been shown to increase the rate of complete small - bowel examinations . in the near future , dissolvable radio - opaque patency capsules may prove beneficial for patients with known small - bowel strictures .
as in our case , patients with strictures in the small bowel or intraabdominal scar tissue may make passage of the capsule difficult to predict . using the fundamentals of safe laparoscopy and maintaining the principles of surgical management in specific disease processes
 video capsule endoscopy is now a first - line tool in evaluating and diagnosing gastrointestinal bleeding , inflammatory bowel disease , and small bowel neoplasms . 
 capsule nonpassage or retention is an uncommon but clinically significant occurrence . 
 how to best retrieve these retained capsules is currently being debated . 
 we report a laparoscopic approach for the retrieval of a retained capsule in the terminal ileum . 
INTRODUCTION
CASE REPORT
Operative Procedure
Postoperative Course
DISCUSSION