Abdominal drain causing early small bowel obstruction after laparoscopic colectomy.

We report a rare drain-related complication leading to small bowel obstruction after laparoscopic colectomy. An 82-year-old man developed small bowel obstruction on the second day after laparoscopic anterior resection. Emergency relaparoscopy found herniation of the small bowel mesentery into the side holes of the silicon intraabdominal drain, which led to a 90-degree acute turn of the small bowel and mechanical obstruction. The herniation was reduced, and the drain was removed laparoscopically.

CASE REPORT

An 82-year-old gentleman was admitted to our hospital for management of carcinoma of the sigmoid colon. Preoperative colonoscopy and computed tomography (CT) of the abdomen and pelvis was performed, which showed no local or distant metastasis. Laparoscopic anterior resection was performed with a 5-port technique, high ligation of inferior mesenteric vessels, and full detachment of splenic flexure. Colorectal anastomosis was performed with a double stapling technique. The mesenteric defect was left open, and the correct orientation of the anastomosis was confirmed by laparoscopy. At the end of the operation, a straight silicon French 30 drain with 3 side holes (Chimed, Italy) was inserted into the pelvis through the right iliac fossa port to drain the residual fluid after peritoneal irrigation. The drain was initially clamped to prevent air leakage. The clamp was then removed, and air vents of the trocars were opened for air decompression. On the first day after the operation, the patient was well, apart from mild abdominal distension. On the second day, he developed gross abdominal distension with a dilated small bowel on abdominal X-ray (). A nasogastric tube was inserted for decompression of the small bowel. More than one liter of bile-stained fluid drained from the nasogastric tube everyday. On the fourth day, conservative treatment failed to resolve his intestinal obstruction. Abdominal CT revealed mechanical small bowel obstruction with an abrupt change in the caliber of the small bowel at the right iliac fossa around the drain site (). Emergency laparoscopy was performed on the same day. A short segment of small bowel was found behind the silicon drain, and small bowel mesentery at the mesenteric border was firmly herniated into the side holes of the drain, leading to a 90-degree acute turn of small bowel in the z axis, where small bowel obstruction occurred (). The herniated mesentery was reduced laparoscopically. The anastomosis was intact with no air leakage upon testing and the drain was removed. The patient had a period of ileus after the operation. Bowel function returned one week after the second operation, and the patient had an uneventful recovery afterwards. Histopathology report reviewed a stage 2 moderate differentiated carcinoma of the colon (T4N0M0, AJCC 5th edition).

Abdominal x-ray showing small bowel obstruction.

Computed tomographic sacn of abdomen showing level of small bowel obstruction at the level of the abdominal drain.

Mechanism of obstruction. D=drain, M=mesentery, DSB=dilated small bowel, CSB=collapsed small bowel.

DISCUSSION

Early postoperative small bowel obstruction (SBO) is uncommon in clinical practice. It accounts for 5% of all patients with small bowel obstruction. The most common cause of postlaparotomy early SBO is adhesion band.[1] Since the development of laparoscopic surgery, there have been no reports on uncommon causes of postoperative SBO. Internal herniation through a mesenteric opening has been frequently reported in the literature. It occurs after laparoscopic-assisted right hemicolectomy, transverse colectomy, and left hemicolectomy.[2-6] Mesenteric defect after colonic resection is commonly left wide open, because closure of the mesenteric defect is technically difficult. It is also believed that a wide mesenteric opening will not cause internal herniation of the small bowel. Nevertheless, it happens in reality, though the incidence is very low. Once it happens, strangulation of small bowel usually occurs, and exploratory laparotomy and small bowel resection seems unavoidable.[2-4] Continuous closure of a mesenteric opening is strongly recommended after laparoscopic colectomy. Another common cause of postlaparoscopy SBO is trocar-site hernia. It commonly occurs in 10-mm trocar sites at the umbilicus and presents as Richter's type of hernia with SBO.[7] Rarely, it can also occur in 5-mm port sites, 3-mm port sites, and even in the preperitoneal space without a fascia defect.[8-10] Trocar-site hernia in port sites <5mm in size is probably related to long operation time and active manipulation of the ports causing extension of the port size. Duron et al[11] reported that the most common procedures causing trocar-site hernia are laparoscopic cholecystectomy, laparoscopic appendicectomy, and laparoscopic transperitoneal hernia repair. The majority of patients with trocar-site hernia require laparotomy to relieve intestinal obstruction. As trocar-site hernia is a potentially serious complication; closing all port-site defects irrespective of the size is recommended.

Drain-related complications are infrequently reported in the literature. We reported the first case of small bowel obstruction as a complication arising from the abdominal drain after laparoscopic surgery. In past literature,[12] small bowel perforation due to pressure necrosis induced by the drain has been reported after open surgery. Herniation of the small bowel through the port site after drain removal has been reported after laparoscopic surgery.[13] The unusual mechanism of small bowel obstruction by the drain in this patient has never been reported. We believe the cause is related to the suction effect, which was created during air decompression through the drain after the clamp was released at the end of the operation. The nearby small bowel was sucked into the side holes, which were situated in opposite directions. Thus, the small bowel loop was fixed in the x, y, and z axes with acute 90-degree turn at the z axis, leading to complete obstruction. Laparoscopic management has not always been possible in small bowel obstruction. Exploratory laparotomy is the common choice of treatment in acute postoperative SBO. In this patient, the level of small bowel obstruction was quite proximal, thus there was still some room for manipulation in the lower abdomen after pneumoperitoneum. Because the small bowel was viable in this patient and resection was not necessary, it could be done by a laparoscopic approach to relieve the obstruction. Reoperation was unavoidable in this patient, because the cause of SBO was not clear before the second operation, and the herniation of small bowel mesentery was very tight. Drain removal would not be possible without laparoscopic assistance.

A number of measures have been suggested to avoid such a complication. An abdominal drain should not be used unless it is deemed necessary. There should not be more than 2 side holes in the drain, and it should be placed in the pelvic cavity without small bowel nearby. A drain of reduced caliber may be helpful, as the size of the side holes will be reduced. Air decompression should be monitored under direct vision. The clamp of the drain should only be released after air decompression is completed to avoid the suction effect.