Management of intestinal obstruction following laparoscopic donor nephrectomy.

Internal hernias are a rare cause of small bowel obstruction. Following laparoscopic bariatric surgery, specifically gastric bypass and laparoscopic colonic resections, there has been an increase in the incidence of internal hernias. This has been due to either a mesenteric or mesocolic defect being not closed or completely missed. Small bowel loops usually herniate through these defects and present as intestinal obstruction. Internal hernia following laparoscopic donor nephrectomy is a rare complication. The need for presenting this case is the rarity of its occurrence, to stress the fact that following major abdominal laparoscopic surgery the mesenteric or mesocolic defects should be closed, and that this complication was managed laparoscopically, through the same port sites as used earlier for the donor nephrectomy.

INTRODUCTION

Internal hernias are one of the rare causes of small bowel obstruction. These hernias may be either congenital or acquired. More than 50% of internal hernias reported in the literature have been paraduodenal. The other types of internal hernia that have been described include transmesenteric, supra- and/or perivesical, intersigmoid, foramen of Winslow, and rarely, omental hernias.[1] Paraduodenal hernia is usually a congenital anomaly due to non-fusion of the mesocolon with the parietal wall that leaves a potential space. It manifests commonly in adults in the age group of 50–60 years and usually presents as intestinal obstruction.[2] Internal hernias in todays’ era of advanced laparoscopic surgery are usually due to rents or defects in the mesentery. We present a case of intestinal obstruction due to internal herniation following laparoscopic donor nephrectomy, followed by a brief discussion.

CASE REPORT

A 47-year-old lady presented with a history of vomiting and constipation for the past 5 days. This was 8 days after she underwent a laparoscopic donor nephrectomy. Upper gastrointestinal (GI) endoscopy revealed large amount of bile stained fluid in the stomach. A CECT suggested dilatation of the stomach, duodenum and proximal jejunum with features of bowel obstruction in the mid jejunum, with the loops lying in left renal fossa [Figure 1]. A provisional diagnosis of obstructed left para duodenal hernia was made. Patient was explored laparoscopically, through the same port sites that were made earlier for the nephrectomy (two 10 mm ports, one at the level of umbilicus on the left side lateral to rectus muscle and another in the midclavicular line just above the left anterior superior iliac spine; two 5-mm ports, one subcostal in the midclavicular line and another in the anterior axillary line in the lumbar region). Herniation of small bowel was noted in the left paraduodenal space [Figure 2]. The herniation had occurred through a defect in the transverse mesocolon which probably would have occurred during the donor nephrectomy procedure. The loop of bowel was densely adhered to the tail of the pancreas and had to be dissected of it and reduced [Figure 3]. The integrity of the bowel was intact. The defect in the mesocolon was sutured [Figure 4]. Patient had an uneventful recovery and was discharged from hospital on the 5th postoperative day.

Figure 1

CECT scan showing obstructed bowel loops in the left renal fossa

Figure 2

Image showing herniated bowel loops

Figure 3

Image showing obstructed bowel loops being separated from the tail of pancreas

Figure 4

Image showing the end result following the closure of the mesocolic defect

DISCUSSION

The increased use of laparoscopy for colonic resections, bariatric surgery, specifically the procedure of gastric bypass and laparoscopic nephrectomies have resulted in an increase in the postoperative complication of intestinal obstruction due to internal hernias. Internal hernias have also been reported after liver transplantation specifically where the biliary continuity is restored through a Roux-en-Y choledochoenteric anastomosis.[1] These hernias usually occur through the mesenteric or mesocolic defects that are either deliberately or inadvertently made during the above mentioned procedures and are not subsequently closed.

In view of the fact that internal herniation of small bowel occurs through the transmesenteric or transmesocolic defects, it is generally recommended that these rents or openings should be specifically sutured and closed to prevent postoperative intestinal obstruction. In a retrospective review of 1,064 cases of laparoscopic gastric bypass, Comeau and colleagues[3] strongly recommended complete closure of all mesenteric defects to avoid internal hernias and their associated complications. However, following laparoscopic right colectomy for neoplasia in 530 consecutive patients, over a 7-year period, Cabot et al.[4] displayed data that did not support routine closure of mesenteric defect. The incidence of intestinal obstruction was not statistically significant in their series when these transmesenteric defects were not sutured. They, however, stressed the need for more extended long-term follow-up in these series. Most publications dealing with internal hernias following laparoscopic procedures in todays age do insist on closing mesenteric defects.[5-8]

The diagnosis of intestinal obstruction due to internal herniation is usually difficult to be made by clinical signs and symptoms. A preoperative diagnosis is usually difficult. Plain radiographs as well as contrast-enhanced CT may sometimes suggest upper small gut obstruction. CECT usually shows the jejunum massed in the left renal fossa as was reported in our case.[1] Though our case was not a true congenital paraduodenal hernia, the internal herniation had occurred into the left paraduodenal space through the mesocolic defect.

Surgical management of internal hernias has been traditionally performed by laparotomy, reduction of the hernia contents and closure of the defect.[56] The first laparoscopic repair of a paraduodenal hernia was performed in 1998.[9] Subsequently, laparoscopic repairs, using mesh as well as meshless have been performed by many groups.[21011] Intestinal obstruction due to internal hernias following laparoscopic radical nephrectomy and laparoscopic donor nephrectomy, though few, have been reported in the literature.[578] Management in most of these cases has been exploration through either a laparotomy or laparoscopy. If the entrapped bowel is viable and not gangrenous, it can be usually reduced laparoscopically and the mesenteric or mesocolic rent sutured subsequently, as was done in our case.[811]

Laparoscopic donor nephrectomy is the procedure of choice today, for procurements of kidneys across many centres, worldwide. Small bowel obstruction due to internal hernia following this procedure though rare can lead to significant morbidity in an otherwise normal and healthy person.[8] We do stress the need to be vigilant while mobilizing the colon and to suture any mesenteric or mesocolic defect deliberately or inadvertently made during the procedure. This will definitely prevent internal herniation and subsequent small gut obstruction. The other aspect to be highlighted is that in the current era, laparoscopy can be the modality of management especially in those patients who are haemodynamically stable and there is no suggestion of bowel necrosis or gangrene.[811]