輔仁醫學期刊　第 15卷　第 3期　2017

Case Report

167

Laparoscopic Removal of Intra-Abdominal Intrauterine Device:

A Case Report and Literature Review

Shih-Chun Lin1, Wei-Hung Chen1, Hung-Ju Yang1,

Yi-Shing Yao1, Sio-iong Chang1, Teng-Kai Yang1,2,*

ABSTRACT

Introduction: Uterine perforation with an intra-abdominal intrauterine device (IUD) resulting in consultation to a general surgeon is rare. However, migrated IUD due to uterine perforation, regardless of the severity of symptoms, should be promptly removed surgical-ly to avoid further bowel perforation or obstruction. We report a case of intra-abdominal IUD utilizing laparoscopic removal. Case: A 28-year-old woman who suffered from vaginal spot-ting for six months following levonorgestrel IUD (Mirena®, Bayer, Leverkusen, Germany) implantation. An initial diagnostic workup, including the performance of a transvaginal ultra-sound, pelvis X-ray, and pelvic computed tomography (CT) scan, was completed to localize the IUD. Then, laparoscopy was performed to remove the device smoothly. Conclusions: Intra-abdominally-located IUDs due to uterine perforation are usually diagnosed by gynecol-ogists, but further consultation to general surgeons can be encountered sometimes. Imaging studies such as pelvic X-ray or abdominal CT are recommended to assess adjacent organ in-volvement or perforation. Laparoscopic extraction are feasible and beneficial in most cases.

Keywords: intrauterine device, intra-abdominal, uterine perforation, contraception

1 Department of Surgery, Yonghe Cardinal Tien Hospital, New Taipei City, Taiwan2 School of medicine, Fu-Jen Catholic University, New Taipei City, Taiwan* Reprint requests and Corresponding author: Teng-Kai Yang (circulas1@yahoo.com.tw)

INTRODUCTION

Intrauterine devices (IUD) are one of the most common forms of reversible contraception used in developing countries, with the United Nations re-porting that around 14% of women worldwide

were relying upon this method of birth control in 2009. Though IUD use is generally safe, effec-tive and tolerable, the expulsion or migration of an IUD has been reported rarely, with potentially seri-ous complications. Uterine perforations are rarely encountered following IUD implantation, and can result in the IUD migrating to the pelvic or intra-

DOI 10.3966/181020932017091503006

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Shih-Chun Lin Wei-Hung Chen Hung-Ju Yang Yi-Shing Yao Sio-iong Chang Teng-Kai Yang　

Fu-Jen Journal of Medicine Vol.15 No.3 2017168

abdominal cavity due to uterine rupture[1-3]. Patients with uterine perforation might pres-

ent with different signs and symptoms, depending on the distance of IUD migration and the intra- abdominal organ(s) it may have interfered with. Some individuals might appear symptomless, while others may suffer from severe symptoms. A migrat-ed IUD that has perforated the uterus, regardless of the severity of symptoms, however, should be promptly removed surgically in order to avoid fur-ther bowel perforation or obstruction[2]. Herein, we report a case of intra-abdominal IUD that uti-lized laparoscopic removal.

CASE REPORT

A 28-year-old, gravid 2, para 2 woman was ad-mitted to our ward with the presentation of vaginal spotting since six months, which was not long after she had undergone levonorgestrel IUD (Mirena®, Bayer, Leverkusen, Germany ) implantation at a gynecological clinic. Neither difficulty nor com-plication was noted upon placement of the device. Her medical history revealed no previous abdomi-nal or urological surgery. She reported visiting the gynecological clinic since implantation, where a series of examinations were performed. The phys-ical examination revealed a lack of visualized IUD strings, followed by a transvaginal ultrasound that revealed no signs of IUD in the uterus. Then, a pel-vis X-ray study was obtained, which showed the IUD in the pelvic cavity (Figure 1). An abdominal/pelvic computed tomography (CT) scan localized the IUD in the cul-de-sac, left posterolateral to the uterus, with mild ascites (Figure 2). The patient was referred to one of our general surgeons, and a laparoscopic procedure was arranged after obtain-

ing informed consent from the patient. The patient was placed in the Trendelenburg

position. A 10-mm cannula trochar was inserted below the umbilicus in line with the standard pro-cedure. Two additional accessory trochars were placed at the left lower quadrant area and Mc-Burney’s point, respectively. Two 5-mm grasping forceps were introduced through the cannulas to el-evate the uterus and obtain traction of the bowel. The IUD was identified in the pouch of Douglas, with mild adhesion and ascites seen after careful ob-servation (Figure 3). It was mobilized and removed by endo-bag smoothly, without electrocautery, un-der laparoscopic guidance. A Jackson-Pratt drain catheter was inserted after the procedure. The post-operative course was uneventful, and the patient was discharged 48 hours after the operation.

DISCUSSION

Though IUD use is a safe, well-tolerat-ed choice of long-term contraception for women, associated issues such as lower urinary tract symp-toms, stone formation around the IUD, uterovesical fistula and even stricture of the recto-sigmoid co-lon have been seen[1, 3]. Uterine perforation is one of the most serious complications associated with IUD implantation, as the device can perforate through the uterine wall and into the digestive, gy-necologic or urinary system organs[4].

Patients present with a variety of symptoms following uterine perforation of an IUD, albeit pre-dominantly pelvic pain and/or vaginal bleeding, while others might be asymptomatic with a missing IUD string at pelvic examination[2, 3, 5]. Severe associated morbidities have been reported, includ-ing infection with abscess formation, intravesical

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　Laparoscopic Removal of Intra-Abdominal Intrauterine Device: A Case Report and Literature Review

輔仁醫學期刊　第 15卷　第 3期　2017 169

calculi, bowel infarction, rectal strictures and rec-touterine fistula[3, 4, 6]. Although vaginal spotting is a common symptom of the micronized proges-terone effect that occurs following Mirena® (Bayer, Leverkusen, Germany) insertion, vaginal spotting due to a misplaced IUD should as well be associ-ated with other signs of device migration, such as missing threads, abdominal pain or pregnancy[7]. Further examinations such as X-ray are warrant-ed to differentiate between progesterone effect and IUD misplacing.

Risk factors contributing to uterine perfora-tion include type of IUD (i.e., copper), insertion technique, insertion in the postpartum period, lacta-tion and amenorrhea[8, 9]. Compared with copper intrauterine devices (Cu-IUDs), newer levonorg-estrel-releasing intrauterine systems (LNG-IUS) have been utilized significantly for years. A retro-spective study of 75 patients (54 LNG-IUS and 21 Cu-IUD) treated surgically for uterine perforation showed that 71% of perforations were symp-tomatic. Asymptomatic patients were diagnosed during follow-up visits or because of unintend-ed pregnancy. Common symptoms were abnormal bleeding and/or abdominal pain and pregnancy. In-tra-abdominal adhesion and pregnancy are more common among women using Cu-IUDs than those using LNG-IUS[5]. In addition to the known risk factors attributed to intra-abdominal IUD pres-ence, other possible considerations associated with IUD uterine perforation are breastfeeding at time of insertion and time of less than 36 weeks since previous delivery. Clinicians and women who de-cide to use IUD contraception should be aware of the risk factors, and should adjust the timing of in-sertion accordingly. Mirena® insertion should be delayed until six weeks after delivery[10].

Figure 1. An X-ray shows the IUD in the pelvic cavity.

Figure 2. A CT scan shows the IUD in the cul-de-sac, left posterolateral to the uterus (white arrow).

Figure 3. Visualization of the IUD during laparoscopic procedures (white arrow).

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Shih-Chun Lin Wei-Hung Chen Hung-Ju Yang Yi-Shing Yao Sio-iong Chang Teng-Kai Yang　

Fu-Jen Journal of Medicine Vol.15 No.3 2017170

If a misplaced IUD is suspected, the diagnosis of IUD/IUS perforation is usually straightforward. If no IUD string can be visualized on speculum ex-amination, a combination of transvaginal ultrasound and abdominal X-ray are often sufficient to success-fully diagnose a uterine perforation. Abdominal CT scan/magnetic resonance imaging are also good op-tions to help locate a migrated IUD, and to assess for complications such as perforation of the uterus or nearby organs, the presence of adhesions, or ab-scess formation, in a hospital setting[5, 11].

The World Health Organization recommends that an intra-abdominal IUD should be removed as soon as possible after the diagnosis has been made, regardless of type, locations or symptoms[12]. According to the literature, laparoscopic surgery should be the first option in removing a perforated IUD, as improvement of the technique of minimal-ly invasive surgery has been widespread, and it is typically safer and with fewer complications. Con-version to laparotomy after attempted laparoscopic removal may be needed in cases involving bow-el perforation, sepsis, or major adhesion[13-15]. It is necessary to visualize the entire device before it is removed because applying force to a partly visible device may cause serious damage to near-by structures if the device is partially embedded. Preoperative localization of the device can lower the risk of organ injury and the need to change to open surgery. The risks of open surgery conversion mostly depend on the final site of the misplaced IUD. The removal of a displaced IUD that involves both abdominal and pelvic organs has a higher risk of open surgery and those related only to pelvic or-gans had the lower risk[4, 16].

In conclusion, though intra-abdominal IUD presence due to uterine perforation is usually diag-

nosed by gynecologists, further consultation with general surgeons can occur, especially for those with distal IUD migration to the digestive sys-tem or with intestine perforation. The symptoms of IUD migration can be nonspecific, requiring a high degree of suspicion. Imaging techniques such as pelvic X-ray or abdominal CT are recom-mended to check for adjacent organ involvement or perforation if IUD migration is suspected[17]. Laparoscopic removal of intra-abdominal IUD is feasible and beneficial in most cases.

REFERENCES

[1]. Aydogdu O and Pulat H: Asymptomatic far-migration of an intrauterine device into the abdominal cavity: A rare entity. Can Urol As-soc J 6: E134-136, 2012.

[2]. Gill RS, Mok D, Hudson M, et al: Lapa-roscopic removal of an intra-abdominal intrauterine device: case and systematic re-view. Contraception 85: 15-18, 2012.

[3]. Carmody K, Schwartz B and Chang A: Extra-uterine migration of a mirena(R) intrauterine device: a case report. J Emerg Med 41: 161-165, 2011.

[4]. Cetinkaya K, Kumtepe Y and Ingec M: Mini-mally invasive approach to cases of lost intra-uterine device: a 7-year experience. Eur J Obstet Gynecol Reprod Biol 159: 119-121, 2011.

[5]. Kaislasuo J, Suhonen S, Gissler M, et al: Uterine perforation caused by intrauterine de-vices: clinical course and treatment. Hum Reprod 28: 1546-1551, 2013.

[6]. Boortz HEM, D.A.; Ragavendra, N.: Mi-gration of intrauterine devices: radiological

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　Laparoscopic Removal of Intra-Abdominal Intrauterine Device: A Case Report and Literature Review

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findings and implications for pateint care. Ra-dioGraphics 32: 335-352, 2012.

[7]. Hidalgo M, Bahamondes L, Perrotti M, et al: Bleeding patterns and clinical performance of the levonorgestrel-releasing intrauterine sys-tem (Mirena) up to two years. Contraception 65: 129-132, 2002.

[8]. Heinberg EM, McCoy TW and Pasic R: The perforated intrauterine device: endoscopic re-trieval. JSLS 12: 97-100, 2008.

[9]. Kaislasuo J, Suhonen S, Gissler M, et al: In-trauterine contraception: incidence and factors associated with uterine perforation--a pop-ulation-based study. Hum Reprod 27: 2658-2663, 2012.

[10]. Heinemann K, Reed S, Moehner S, et al: Risk of uterine perforation with levonorgestrel-re-leasing and copper intrauterine devices in the European Active Surveillance Study on Intra-uterine Devices. Contraception 91: 274-279, 2015.

[11]. Derrick BJ, Jafri FN, Saul T, et al: Perforated uterus with displacement of intrauterine de-vice. J Emerg Med 44: 1144-1145, 2013.

[12]. Mechanism of action, safety and efficacy of intrauterine devices. Report of a WHO Sci-entific Group. World Health Organ Tech Rep Ser 753: 1-91, 1987.

[13]. Sharifiaghdas F, Mohammad Ali Beigi F and Abdi H: Laparoscopic removal of a migrated intrauterine device. Urol J 4: 177-179, 2007.

[14]. Sun CC, Chang CC and Yu MH: Far-migrat-ed intra-abdominal intrauterine device with abdominal pain. Taiwan J Obstet Gynecol 47: 244-246, 2008.

[15]. Ozgun MT, Batukan C, Serin IS, et al: Surgical management of intra-abdominal mis-

located intrauterine devices. Contraception 75: 96-100, 2007.

[16]. Mosley FR, Shahi N and Kurer MA: Elective surgical removal of migrated intrauterine con-traceptive devices from within the peritoneal cavity: a comparison between open and lapa-roscopic removal. JSLS 16: 236-241, 2012.

[17]. Takahashi H, Puttler KM, Hong C, et al: Sig-moid colon penetration by an intrauterine device: a case report and literature review. Mil Med 179: e127-129, 2014.

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Shih-Chun Lin Wei-Hung Chen Hung-Ju Yang Yi-Shing Yao Sio-iong Chang Teng-Kai Yang　

Fu-Jen Journal of Medicine Vol.15 No.3 2017172

腹腔鏡移除腹腔內子宮內避孕器： 病例報告和文獻回顧

林世俊 1，陳維鴻 1，楊弘如 1，姚逸興 1，曾邵勇 1，楊登凱 1,2,*

中文摘要

引言：因腹腔內子宮內避孕器（Intrauterine device, IUD）而導致子宮穿孔且需要諮詢外科醫師的狀況不常見。無論症狀輕微或嚴重與否，因子宮穿孔而移位的子宮內

避孕器，都需要立即進行手術取出，以避免造成進一步的腸穿孔或腸阻塞等併發症。

以下案例是一個藉由腹腔鏡手術將子宮內避孕器取出的個案。

案例：本個案的是一名 28歲的女性，在植入蜜蕊娜子宮內避孕器（levonorgestrel IUD - Mirena）後不久開始出現陰道點狀出血症狀，並持續了 6個月。我們藉由陰道超音波，骨盆攝影和骨盆腔電腦斷層掃描等檢查來定位子宮內避孕器所在點。定位完成

後既進行腹腔鏡手術，安全的將子宮內避孕器取出。

結論：腹腔內子宮內避孕器造成的子宮穿孔，多數是由婦科醫師診斷出來，但有

時會遇到需要進一步諮詢一般外科醫生的情況。此時我們建議安排骨盆腔攝影和骨盆

腔電腦斷層掃描，以確認鄰近器官是否受到影響或穿孔。對於大多數情況，腹腔鏡移

除術是可行並且有利的。

關鍵字：子宮內避孕器、腹腔內、子宮穿孔、避孕

1 永和耕莘醫院 外科部2 輔仁大學醫學院 收稿日期：2017年 2月 13日 接受日期：2017年 5月 2日* 通訊作者：楊登凱　電子信箱：circulas1@yahoo.com.tw

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