When Size Matters: Surgical Challenges of Giant Rectal Foreign Bodies.

Rectal foreign bodies are an uncommon but increasingly recognized presentation in emergency colorectal surgery. Object size - particularly transverse diameter - and rural, low-resource settings add complexity to both diagnosis and treatment. A 57-year-old man from a rural area of southern Colombia was referred to a regional hospital for a retained lithic rectal foreign body (a stone). Plain abdominal radiography showed a cone-shaped radiopaque object. After multiple failed transanal extraction attempts, exploratory laparotomy was performed. A conical stone approximately 15 cm in diameter at its base was found, impacted between the lower rectum and the sacral promontory. Extraction was carried out through an enterotomy at the rectosigmoid junction; during the maneuver, an upper rectal laceration occurred, which was repaired with a two-layer enterorrhaphy and protected with a loop sigmoid colostomy. The postoperative course was uneventful, and the patient was discharged in satisfactory condition. With a basal diameter of approximately 15 cm, the object was at the upper end of the diameter range reported for rigid rectal foreign bodies requiring laparotomy. Because the pelvic outlet, rather than object length, represents the anatomical constraint to transanal extraction, the object's diameter and rigidity rendered transanal removal unfeasible. Timely escalation to laparotomy with protective diversion limited the extent of the rectal injury. Early recognition of transverse diameter, rigidity, and unfavorable morphology, together with a low threshold for surgical intervention, allows favorable outcomes even with limited infrastructure, where plain radiography and sound clinical judgment remain the mainstays of management.