Bowel obstruction caused by an internal hernia that developed after laparoscopic subtotal colectomy: a case report

Postoperative Outcomes of Closed Versus Nonclosed Mesentery Laparoscopic Colectomy: A Retrospective Single-center Study

PURPOSE

This study aimed to clarify the clinical significance of closing the mesenteric defect in laparoscopic colectomy.

MATERIALS AND METHODS

We retrospectively evaluated 369 patients who underwent left-sided or right-sided resection via laparoscopic colectomy at our institute. Patients were stratified by open versus closed handling of the mesenteric defect. The perioperative clinical factors, surgical maneuvers, and postoperative complications were statistically analyzed.

RESULTS

No significant intergroup differences were found in the perioperative clinical factors or surgical maneuvers except for number of days to the first soft diet (P=0.0214) and postoperative complications (P=0.0379). Among the postoperative complications, only ileus occurred more frequently in the closed group than in the open group (P=0.0227).

CONCLUSIONS

This study revealed that closure of the mesenteric defect following laparoscopic colectomy might be associated with an increased incidence of postoperative ileus.

Internal hernia after laparoscopic colorectal surgery: an under-reported potentially severe complication. A systematic review and meta-analysis

BACKGROUND

Internal hernia following laparoscopic colorectal surgery is often under-reported. The aim of this review was to evaluate the occurrence rate of internal hernia following laparoscopic colorectal surgery, and to describe clinical presentation and management strategies.

METHODS

A comprehensive literature review was conducted including MEDLINE/Pubmed, EMBASE, SCOPUS, clinicaltrials.gov, and the Cochrane Database of Systematic Reviews through April 2018. The review was conducted according to MOOSE guidelines. Quality was appraised with the Methodological Index for Non-Randomized Studies (MINORS) tool. Meta-analysis was performed using a random effects model. Studies reporting data on internal hernia after laparoscopic colorectal surgery were included.

RESULTS

Ten observational studies with a total of 8453 patients were included. All included articles were non-comparative prospective or retrospective cohort studies with an average MINORS score of 8.3 (range 6-11). Summary estimate of proportion of patients developing internal hernia after laparoscopic colorectal resection was 0.5% (95% CI 0.3-0.8%). Heterogeneity was moderate (I² 46%, p = 0.03) and study size (> 1000 vs. <1000 patients) was found to have a significant contribution to heterogeneity (p = 0.002). Thirty patients (90.9%) required surgery, with 5 non-fatal and 3 fatal postoperative complications. Quality of some studies was limited; some patients were followed up for less than 1 year; primary surgical procedures included different laparoscopic approaches.

CONCLUSIONS

Occurrence rate of internal hernia after laparoscopic colorectal resection is around 5 per 1000 patients. Small-sized studies are likely to overestimate the occurrence of internal hernia. Need for reoperation is high with a substantial risk of mortality.

Long-Term Consequences of Nonclosure of Mesenteric Defects after Traditional Right Colectomy

Background

There are still discrepancies among general/colorectal surgeons regarding closure of mesenteric defect in scientific literature. This study aimed to assess the long-term consequences of nonclosure of the mesenteric defect after open right colectomy.

Methods

A 7-year retrospectively collected and continuous database revealed 212 consecutive patients who had undergone traditional right colectomy without closing the mesenteric defects at Kaohsiung Chung-Gung Memorial Hospital; all patients were operated by a single surgeon. Among these patients, 17 were excluded (those who died within 30 days after surgery or those who received an end ileostomy). The mean age of the 195 patients (58% men and 42% women) was 61.6 ± 12.6 years, and the follow-up period was 4.1 ± 2.8 years (interquartile range 0.09 ~ 10.4).

Results

Forty-four patients (22.5%) encountered intestinal obstruction. Nine (20.4%) required surgical intervention. The cause of intestinal obstruction was adhesion (n=1), ventral hernia (n=1), and cancer recurrence (n=7). Conservative treatment was successful in 35 patients. The intestinal obstruction group (n = 44) were similar to the no-intestinal obstruction group (n = 151) in terms of the following parameters: age, sex, previous abdominal surgery, indication for colectomy, and procedure related complications. Carcinomatosis was found to increase the incidence of intestinal obstruction. No patient developed intestinal obstruction because of the nonclosure of mesenteric defects after right colectomy.

Conclusion

This study suggested that routine procedure of closing the mesenteric defect after open right colectomy might not be beneficial. Additional studies with extended long-term follow-up periods are needed to confirm the benefits of the nonclosure.

Internal hernia following laparoscopic colorectal surgery: single center experience

Although internal hernias are rare complications of laparoscopic colorectal surgery, they can lead to serious outcomes and are associated with a high mortality of up 20 %.

AIM OF THE STUDY

The aim of this study was to describe our experience regarding internal herniation following laparoscopic colorectal surgery.

MATERIALS AND METHODS

From 2009 to 2015, more than 1,093 laparoscopic colorectal procedures were performed, and 6 patients developed internal herniation. Data were obtained from patients' charts and reviewed retrospectively. Perioperative course and outcomes were analyzed.

RESULTS

All patients were previously operated due to colorectal cancer. Two patients presented with ischemia at laparotomy, and 2 had endoscopic examinations before surgery. One patient was diagnosed with cancer on screening colonoscopy. One patient died after laparotomy.

CONCLUSION

Internal herniation that develops following laparoscopic colorectal surgery may be associated with a high mortality. More efforts should be made to identify risk factors of internal herniation, as this could indicate which patients would benefit from closure of mesenteric defects during laparoscopic colorectal surgery.

Prevention of internal hernias and pelvic adhesions following laparoscopic left-sided colorectal resection: the role of fibrin sealant

BACKGROUND

Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant diseases. This growing experience has also resulted in more reports of postoperative complications from the minimally invasive approach to primary colorectal resection. Small bowel obstruction from internal hernias and pre-sacral adhesions is an uncommon but not negligible complication. However, there is little literature specific to this topic with recommendations for different methods to prevent it. We report our original technique of closing the mesenteric defect and covering the pre-sacral fascia by using fibrin sealant to prevent this complication.

METHODS

From January 2005 to December 2014, a total of 1079 patients underwent elective laparoscopic left colorectal resection (left hemicolectomy or anterior rectal resection) in our department. In the first 298 procedures, the mesenteric defect was left open, while in the following 781 procedures, it was closed using fibrin sealant with the aim of preventing postoperative small bowel obstruction.

RESULTS

Among the first 298 patients, three (1%) required reoperation for small bowel obstruction due to internal hernia (0.33%) or critical pre-sacral adhesions (0.66%). These complications did not occur in the subsequent series in which all 781 patients were treated with fibrin sealant prophylactic closure of the mesenteric defect.

CONCLUSION

In our experience, fibrin sealant closure of the mesenteric defect has demonstrated to be safe and effective in preventing postoperative small bowel obstruction that remains a complication both in open and in laparoscopic colorectal surgeries.

The risk of internal hernia or volvulus after laparoscopic colorectal surgery: a systematic review

AIM

To determine the incidence of internal hernias after laparoscopic colorectal surgery and evaluate the risk factors and strategies in the management of this serious complication.

METHOD

Two databases (MEDLINE from 1946 and Embase from 1949) were searched to mid-September 2015. The search terms included volvulus or internal hernia and laparoscopic colorectal surgery or colorectal surgery or anterior resection or laparoscopic colectomy. We found 49 and 124 articles on MEDLINE and Embase, respectively, an additional 15 articles were found on reviewing the references. After removal of duplicates, 176 abstracts were reviewed, with 33 full texts reviewed and 15 eligible for qualitative synthesis.

RESULTS

The incidence of internal hernia after laparoscopic colorectal surgery is low (0.65%). Thirty-one patients were identified. Five cases were from two prospective studies (5/648, 0.8%), 20 cases were from seven retrospective studies (20/3165, 0.6%) and six patients were from case reports. Of the 31 identified cases, 21 were associated with left-sided resection, four with right sided resection, two with transverse colectomy, one with a subtotal colectomy and in three cases the operation was not specified. The majority of cases (64.3%) were associated with a restorative left sided resection. Nearly all cases occurred within 4 months of surgery. All patients required re-operation and reduction of the internal hernia and 35.7% of cases required a bowel resection. In 52.2% of cases, the mesenteric defect was closed at the second operation and 52.6% of cases were successfully managed laparoscopically. There were three deaths (0.08%).

CONCLUSION

Mesenteric hernias are a rare but important complication of laparoscopic colorectal surgery. The evidence does not support routine closure for all cases, but selective closure of the mesenteric defect during left-sided restorative procedures in high-risk patients at the initial surgery may be considered.

Clinical Significance of Closure of Mesenteric Defects in Laparoscopic Colectomy: A Single-Institutional Cohort Study

BACKGROUND

The effect of closure of mesenteric defects to prevent complications, such as internal hernia, during laparoscopic colectomy remains controversial and is a subject of debate.

PURPOSE

This retrospective single-institution study aimed to clarify the clinical significance of mesenteric defect closure during a laparoscopic colectomy.

METHODS

We evaluated 58 patients who underwent laparoscopic right-side colectomy or transverse colectomy. The statistical relevance of complications, surgical maneuvers, and clinical factors was examined.

RESULTS

The mesenteric defects were closed in 30 patients and not closed in 28 patients. Two patients with ileus and 1 with a deep incisional surgical site infection required a second surgery. The reoperation rate was significantly higher in the nonclosure group than in the closure group (11% vs. 0%, respectively; P=0.033).

CONSIDERATION

Serious complications requiring reoperation occurred only in the nonclosure group. The procedure for closing the defect did not extend the operation time or increase the bleeding.