A 60-year-old male was admitted with acute abdominal pain and fever. Computed tomography (CT) of the abdomen revealed free air. Diagnostic laparoscopy showed a toothpick perforating the ventricle, and the toothpick was removed successfully. This condition is severe with a reported mortality of 9.6%. A practical guideline based on 136 cases was presented in 2014. Endoscopy was found to be superior to CT in identifying toothpicks as well as offering therapeutic intervention, rendering endoscopy the first choice in diagnostic and treatment. Subsequently CT or ultrasound is recommended in the unresolved patient.