A strangulated internal hernia beneath the left external iliac artery after radical hysterectomy with laparoscopic pelvic lymphadenectomy: a case report and literature review

Two cases of strangulated bowel obstruction due to exposed vessel and nerve after laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer

BACKGROUND

The majority of small bowel obstructions (SBO) are caused by adhesion due to abdominal surgery. Internal hernias, a very rare cause of SBO, can arise from exposed blood vessels and nerves during pelvic lymphadenectomy (PL). In this report, we present two cases of SBO following laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer, one case each, of which obstructions were attributed to the exposure of blood vessels and nerves during the procedures.

CASE PRESENTATION

Case 1: A 68-year-old man underwent laparoscopic perineal rectal amputation and LLND for rectal cancer. Four years and three months after surgery, he visited to the emergency room with a chief complaint of left groin pain. Computed tomography (CT) revealed a closed-loop in the left pelvic cavity. We performed an open surgery to find that the small intestine was fitted into the gap between the left obturator nerve and the left pelvic wall, which was exposed by LLND. The intestine was not resected because coloration and peristalsis of the intestine improved after the hernia was released. The obturator nerve was preserved. Case 2: A 57-year-old man underwent a robot-assisted rectal amputation with LLND for rectal cancer. Eight months after surgery, he presented to the emergency room with a complaint of abdominal pain. CT revealed a closed-loop in the right pelvic cavity, and he underwent a laparoscopic surgery with a diagnosis of strangulated SBO. The small intestine was strangulated by an internal hernia caused by the right umbilical arterial cord, which was exposed by LLND. The incarcerated small intestine was released from the gap between the umbilical arterial cord and the pelvic wall. No bowel resection was performed. The umbilical arterial cord causing the internal hernia was resected.

CONCLUSION

Although strangulated SBO due to an exposed intestinal cord after PL has been a rare condition to date, it is crucial for surgeons to keep this condition in mind.

Internal Herniation of Small Bowel Underneath Iliac Vascular Axis After Pelvic Surgery: A Systematic Review

Internal abdominal hernias are rare entities that most commonly present with acute small bowel obstruction. These hernias can be congenital or acquired. While congenital hernias are considered the most common type, acquired hernias are becoming more common. Recently, a rare type of internal herniation has been reported underneath iliac vasculature in patients who have undergone pelvic lymph node dissection in the past. This study was carried out to assess the prevalence of this rare type of internal hernia. Two reviewers searched the literature in three online databases using the Cochrane methodology for systematic reviews. The search of databases yielded 70 articles. The studies which reported internal herniation underneath iliac vasculature were included. Studies that reported herniation underneath other pelvic organs or vasculature were excluded. After screening, 17 articles were deemed suitable and selected. All 17 cases reviewed underwent pelvic lymph node dissection in the past. The median latency period between index surgery and clinical presentation with the incarcerated hernia was 20 months. All 17 cases were managed surgically with small bowel resection carried out in 13 cases. Eleven authors reported closing the hernia defect with various techniques, while five decided not the close it. All 17 cases were alive at the time of discharge from the hospital, with a mean hospital stay of 12.7 days. Given our findings, there should be a high index of suspicion of internal hernia in patients presenting with small bowel obstruction with a history of pelvic lymph node dissection. In our review, internal herniation was always preceded by pelvic lymph node dissection, so the closure of the peritoneum should be considered while pelvic lymph node dissection is carried out.

Internal hernia caused by exposed structures after laparoscopic lateral lymph node dissection for rectal cancer: A case report

Internal hernias secondary to exposed structures after lateral lymph node dissection (LLND) for rectal cancer are rare. A 53-year-old man who underwent laparoscopic ultra-low anterior resection and bilateral LND presented to our emergency department with sudden-onset severe abdominal pain and vomiting. Computed tomography demonstrated a closed loop obstruction of the intestine in the right lateral pelvic cavity and a significantly dilated small bowel in the abdominal cavity. Laparoscopic surgery revealed small bowel migration into the space between the right ureter and umbilical artery. The herniated bowel was laparoscopically reduced, and the small bowel exhibited no ischemic changes. Meanwhile, the hernial orifice was left unrepaired. The patient was discharged on the seventh postoperative day without complications. An internal hernia caused by exposed structures after lymphadenectomy should be a differential diagnosis in patients who have undergone LLND for rectal cancer and then present with severe abdominal pain and vomiting.

Strangulated Small Bowel Internal Hernia Under the External Iliac Artery After Robotic Cystoprostatectomy

Small bowel obstruction is a common surgical pathology encountered in the emergency department. The most common cause of small bowel obstruction is adhesions secondary to previous abdominal surgery. While strangulated external hernias are also a common cause of obstructions encountered, internal hernias leading to obstruction are rare. We present a 76-year-old male who presented with an acute abdomen and was later diagnosed with an internal hernia underneath his right external iliac artery.  Internal herniation underneath the iliac vasculature is a recent phenomenon encountered very rarely after the natural anatomy has been disturbed in patients who have undergone pelvic lymph node dissection. Patients with a previous history of pelvic lymph node dissection should be suspected of having an internal hernia if they present with an acute abdomen. Closure of the peritoneum should also be considered in these patients as it may help prevent herniation.

Intestinal ischemia due to internal hernia beneath the right external iliac artery after laparoscopic hysterectomy and lymphadenectomy: A case report

INTRODUCTION AND IMPORTANCE

The occurrence of an internal hernia beneath the external iliac artery is rare but may occur after pelvic lymphadenectomy. The challenging treatment of this rare condition should be tailored to the patient's clinical and anatomical characteristics.

CASE PRESENTATION

We present the case of a 77-year-old woman with previous history of laparoscopic hysterectomy and adnexectomy with extended pelvic lymphadenectomy for endometrial cancer. The patient was admitted in the emergency department because of severe abdominal pain and a computed tomography scan showed signs of internal hernia. The laparoscopy confirmed such a finding below the right external iliac artery. A small bowel resection was deemed necessary and the defect was closed with an absorbable mesh. The post-operative course was uneventful.

CLINICAL DISCUSSION

Internal hernia beneath the iliac artery is a rare condition after pelvic lymphadenectomy. The first challenge is the hernia reduction, which can be safely carried out laparoscopically. Secondly, a patch or a mesh should be used to close the defect if a primary peritoneal suture is not feasible, but it requires to be fixed in the small pelvis. The use of absorbable material is a valuable option and should leave a fibrotic area that covers the hernia defect.

CONCLUSION

A strangulated internal hernia beneath the external iliac artery is a possible complication after extensive pelvic lymph node dissection. The laparoscopic approach to treat bowel ischemia and to close the peritoneal defect with a mesh, should reduce as much as possible the risk of internal hernia recurrence.

Ileal Obstruction Secondary to Internal Hernia Under the External Iliac Artery: A Case Report and Literature Review

Bowel obstruction is one of the most common causes of surgical admission. Most of these patients are managed with non-operative management, often resolving 24 to 48 hours after admission. If conservative management fails in patients with adhesional bowel obstruction, surgery is usually the only other option. Surgery often involves the division of adhesions and resection of the non-viable intestine. Occasionally, unexpected findings require quick but safe interventions, including discussions with other specialities.

This report presents a patient who had previously undergone robotic radical cystectomy, pelvic lymphadenectomy and ileal conduit formation. He was admitted with bowel obstruction and failed conservative management. During laparotomy, a loop of ileum had herniated under the right external iliac artery and was ischaemic necessitating resection-anastomosis. We discuss the management of this patient and the available literature regarding this rare presentation.

Strangulated small bowel obstruction caused by isolated obturator nerve and pelvic vessels after pelvic lymphadenectomy in gynecologic surgery: two case reports

Background

Although small bowel obstruction (SBO) is a major complication occurring after abdominal surgery, few reports have described strangulated SBO after pelvic lymphadenectomy (PL). This report describes two cases of strangulated SBO caused by a skeletonized obturator nerve and pelvic vessels after laparoscopic PL during gynecologic surgery.

Case presentation

Case 1: A 57-year-old woman with endometrial cancer underwent a laparoscopic semi-radical total hysterectomy with PL. Nine months after the operation, she visited our emergency room complaining about subacute pain spreading in the right groin, right buttock, and dorsal part of the right thigh. She had no abdominal pain. Although her symptoms were not typical, computed tomography (CT) revealed strangulated SBO in the right pelvis. Laparoscopic surgery revealed that the small bowel was ischemic. Then we converted to open surgery. We transected the right obturator nerve and umbilical artery, which constructed an internal hernia orifice in the right pelvis, followed by resection of the ischemic small bowel. Fortunately, during 6-month follow-up, she showed only slight difficulty in walking as a postoperative complication. Case 2: A 62-year-old woman with cervical cancer underwent laparoscopic radical hysterectomy with PL. Six months after the operation, she visited our hospital emergently because of sudden onset of abdominal pain and vomiting. CT showed strangulated SBO. Urgent laparoscopic surgery exhibited the incarcerated small bowel at the right pelvis. Consequently, we converted to open surgery. The terminal ileum was detained into the space constructed by the right umbilical artery. We cut the umbilical artery and performed ileocecal resection. After the surgery, she was discharged with no complication or sequela.

Conclusion

When examining a patient after PL who complains of severe pain or symptoms, one should consider the possibility of PL-related SBO, even if the pain is apparently atypical for SBO.