Successful Laparoscopic Removal of a Self-Inflicted Thermometer that Spontaneously Migrated into the Peritoneal Cavity Jovo Bogdanović 1,2, Vuk Sekulić1,2*, Tijana Koković3, Senjin Djozić1, Dragan Vulin4 Keywords: adult; bladder; bladder perforation; foreign body; laparoscopy. 1Clinic of Urology, Clinical Center of Vojvodina, Novi Sad, Serbia. 2Faculty of Medicine Novi Sad, University of Novi Sad, Novi Sad, Serbia. 3Radiology Center, Clinical Center of Vojvodina, Novi Sad, Serbia. 4Clinic of Abdominal & Endocrine Surgery, Clinical Center of Vojvodina, Novi Sad, Serbia. *Correspondence: Clinical Center of Vojvodina, Hajduk Veljkova Str 1-9, Novi Sad 21000, Serbia. Phone +381 63 515010. Fax + 381 21 529929. E mail: vuk.sekulic@mf.uns.ac.rs. Received January 2017 & Accepted August 2017 A sixty-three-year-old Caucasian male was referred to emergency service 10 hours after self-infliction of a mercu- ry glass thermometer into the urethra. The patient presented without abdominal or voiding symptoms. Radiological imaging confirmed the presence of a thermometer in the peritoneal cavity, without signs of contrast leakage from the bladder. The patient underwent suture of the perforation site with a subsequent successful removal of the for- eign body using laparoscopic approach. Recovery was uneventful. To the best of our knowledge, we are not aware of any previous report of laparoscopic removal of a mercury glass thermometer from the peritoneal cavity. Laparoscopic removal of fragile items, such as a thermometer, is obvious- ly feasible but associated with substantial risks. INTRODUCTION There is a myriad of reported foreign bodies in the bladder(1). Sexual pleasure is the main reason for insertion, followed by inquisitiveness and mental or psychiatric disorders(2). However, an occasional item, such as a thermometer, inadvertently slips into the bladder. Intraperitoneal migration of this foreign body is a rare event, and there are only a few reports in the literature(3,4). CASE REPORT A sixty-three-year-old Caucasian male was referred to emergency service 10 hours following inadvertent self-in- fliction of a mercury glass thermometer through the urethra. The patient denied abdominal or voiding symptoms. His past history did not reveal the treatment of serious health conditions including psychiatric diseases. Physical ex- amination was unremarkable. There were no signs of urethrorrhagia or macroscopic hematuria. Urinalysis rvealed 10 to 15 red blood cells in the high power field. Although the thermometer was shown frankly on plain X-ray of CASE REPORT Figure 1. Cystogram confirming an absence of extravasation of contrast from the bladder and the thermometer in the peritoneal cavity in the coronal (Figure 1a) and oblique plane (Figure 1b). Figure 2. CT scan showing intraperitoneal localization of the ther- mometer and an absence of contrast extravasation from the blad- der. Case Report 5071 A "Ghost" Thermometer-Bogdanović et al. the pelvis, an ultrasound surprisingly failed to show it in the bladder. Thereafter, a cystogram with 300 ml saline and 30 ml of iodine contrast showed no signs of con- trast extravasation from the bladder (Figures 1a&b). A CT scan confirmed this finding (Figure 2). The patient requested a laparoscopic removal of the foreign body despite possible risk of potential intraperitoneal spill- age of mercury. The decision to attempt laparoscopic removal was made following several successful remov- als of similar items from the laparoscopic training box. The procedure was performed under general anesthesia using three trocars: a 10 mm camera port was placed beneath the umbilicus and additional two ports (5 and 12 mm) were placed bilaterally in the middle of the line between umbilicus and spina iliaca anterior superior, taking care to avoid injury to epigastric vessels. A small tear of parietal peritoneum near the median umbilical ligament was sutured. The thermometer was found in the peritoneal cavity. It was inserted into the 12 mm port and both items together were pulled out undam- aged. After half-hour the procedure was completed leaving a peritoneal drain and three-way 18-Fr Foley catheter in the bladder. The drain and the catheter were removed on postoperative day 3 and 7, respectively. Recovery was uneventful. DISCUSSION The medical thermometer has not been an unusual foreign body in the bladder(1). Insertion of this device into the bladder was more frequent in females, due to the short urethra and common attempts to measure a basal core temperature in the vagina or urethra for re- productive reasons. Passage of a thermometer through the male bladder is more difficult due to the length and curvatures of the urethra(1,2). Diagnosis of the thermometer in the bladder or perito- neal cavity is not challenging because glass and mer- cury are clearly radiopaque on X-ray. However, some- times it may be difficult to prove radiologically a route of passage of the foreign body, because of the lack of contrast extravasation. All reported foreign bodies have been removed safe- ly by the open surgical procedures(3,4). To the best of our knowledge, laparoscopic removal of a mercury glass thermometer from the peritoneal cavity has not been reported previously. The technique of laparoscop- ic removal is quite easy. However, this procedure is associated with a risk of injury of surrounding organs with glass fragments as well as spillage of mercury into the peritoneum, and potential systemic toxic effects of mercury on the central nervous system and kidneys. Furthermore, enterocutaneous and rectal fistulas, gran- uloma formation and intestinal obstruction following intraperitoneal mercury exposure have been reported previously(5,6). Some of these risks can be lowered by usage of a retrieval bag. CONFLICT OF INTEREST The authors report no conflict on interest. ACKNOWLEDGEMENT The authors are thankful to Mrs. Giorgia Solaja for help in improving writing style of the manuscript. REFERENCES 1. van Ophoven A, de Kernion JB. Clinical management of foreign bodies of the genitourinary tract. J Urol 2000; 164: 274-87. 2. Bogdanović J, Sekulić V, Trivunić-Dajko S, Herin R. Re: Palmer et al.: Urethral Foreign Bodies: Clinical Presentation and Management Urology. 2017; 100; 256-8 3. Kiriyama T, Motonaga I, Ichikawa T: Foreign body migration from the bladder. J Urol 1976;115: 530-1. 4. Nie J, Zhang B, Duan YCet al.. Intestinal obstruction due to migration of a thermometer from bladder to abdominal cavity: a case report. World J Gastroenterol. 2014;20:2426- 8. 5. Mazer-Amirshahi M, Bleecker ML, Barrueto, FJr. Intraperitoneal Elemental Mercury Exposure from a Mercury-Weighted Bougie. J Med Toxicol. 2013; 9: 270–3. 6. Haas NS, Shih R, Gochfeld M. A patient with postoperative mercury contamination of the peritoneum. J Toxicol Clin Toxicol. 2003;41:175–80 Vol 14 No 06 November-December 2017 5072