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Fujiwara R, Yano M, Matsumoto M, Higashihara T, Tsudaka S, Hashida S, Ichihara S, Otani H. 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. Surg Case Rep 2024; 10:85. [PMID: 38619675 PMCID: PMC11018568 DOI: 10.1186/s40792-024-01889-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 04/05/2024] [Indexed: 04/16/2024] Open
Abstract
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.
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Affiliation(s)
- Ryota Fujiwara
- Department of Gastroenterology and General Surgery, Kagawa Prefectural Central Hospital, 1-2-1 Asahimachi, Takamatsu, Kagawa, 760-8557, Japan.
| | - Masaaki Yano
- Department of Gastroenterology and General Surgery, Kagawa Prefectural Central Hospital, 1-2-1 Asahimachi, Takamatsu, Kagawa, 760-8557, Japan
| | - Makoto Matsumoto
- Department of Gastroenterology and General Surgery, Kagawa Prefectural Central Hospital, 1-2-1 Asahimachi, Takamatsu, Kagawa, 760-8557, Japan
| | - Tomoaki Higashihara
- Department of Gastroenterology and General Surgery, Kagawa Prefectural Central Hospital, 1-2-1 Asahimachi, Takamatsu, Kagawa, 760-8557, Japan
| | - Shimpei Tsudaka
- Department of Gastroenterology and General Surgery, Kagawa Prefectural Central Hospital, 1-2-1 Asahimachi, Takamatsu, Kagawa, 760-8557, Japan
| | - Shinsuke Hashida
- Department of Gastroenterology and General Surgery, Kagawa Prefectural Central Hospital, 1-2-1 Asahimachi, Takamatsu, Kagawa, 760-8557, Japan
| | - Shuji Ichihara
- Department of Gastroenterology and General Surgery, Kagawa Prefectural Central Hospital, 1-2-1 Asahimachi, Takamatsu, Kagawa, 760-8557, Japan
| | - Hiroki Otani
- Department of Gastroenterology and General Surgery, Kagawa Prefectural Central Hospital, 1-2-1 Asahimachi, Takamatsu, Kagawa, 760-8557, Japan
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Sakamoto S, Inada R, Kuroda E, Kumon K, Toshima T, Okabayashi T. Internal hernia caused by exposed structures after laparoscopic lateral lymph node dissection for rectal cancer: A case report. Asian J Endosc Surg 2023; 16:591-594. [PMID: 37088466 DOI: 10.1111/ases.13194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/11/2023] [Indexed: 04/25/2023]
Abstract
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.
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Affiliation(s)
- Shinya Sakamoto
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, India
| | - Ryo Inada
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, India
| | - Eri Kuroda
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, India
| | - Kento Kumon
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, India
| | - Toshiaki Toshima
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, India
| | - Takehiro Okabayashi
- Department of Gastroenterological Surgery, Kochi Health Sciences Center, Kochi, India
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Uehara K, Ogura A, Murata Y, Sando M, Mukai T, Aiba T, Yamamura T, Nakamura M. Current status of transanal total mesorectal excision for rectal cancer and the expanding indications of the transanal approach for extended pelvic surgeries. Dig Endosc 2023; 35:243-254. [PMID: 36342054 DOI: 10.1111/den.14464] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022]
Abstract
Transanal total mesorectal excision (taTME) has been rapidly accepted as a promising surgical approach to the distal rectum. The benefits include ease of access to the bottom of the deep pelvis linearly over a short distance in order to easily visualize the important anatomy. Furthermore, the distal resection margins can be secured under direct vision. Additionally, a two-team approach combining taTME with a transabdominal approach could decrease the operative time and conversion rate. Although taTME was expected to become more rapidly popularized worldwide, enthusiasm for it has stalled due to unfamiliar intraoperative complications, a lack of oncologic evidence from randomized trials, and the widespread use of robotic surgery. While international registries have reported favorable short- and medium-term outcomes from taTME, a Norwegian national study reported a high local recurrence rate of 9.5%. The characteristics of the recurrences included rapid, multifocal growth in the pelvis, which was quite different from recurrences following traditional transabdominal TME; thus, the Norwegian Colorectal Cancer Group reached a consensus for a temporary moratorium on the performance of taTME. To ensure acceptable baseline quality and patient safety, taTME should be performed by well-trained colorectal surgeons. Although the appropriate indications for taTME remain controversial, the transanal approach is extremely important as a means of goal setting in difficult TME cases and as an aid to the transabdominal approach in various types of extended pelvic surgeries. The benefits in transanal lateral lymph node dissection and pelvic exenteration are presented herein.
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Affiliation(s)
- Kay Uehara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Atsushi Ogura
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yuki Murata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masanori Sando
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Toshiki Mukai
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Toshisada Aiba
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masanao Nakamura
- Department of Gastroenterology, Nagoya University Graduate School of Medicine, Aichi, Japan
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Strangulated small bowel obstruction caused by isolated obturator nerve and pelvic vessels after pelvic lymphadenectomy in gynecologic surgery: two case reports. Surg Case Rep 2022; 8:104. [PMID: 35644816 PMCID: PMC9148868 DOI: 10.1186/s40792-022-01459-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/24/2022] [Indexed: 01/06/2023] Open
Abstract
Abstract
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.
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A retrospective study of internal small bowel herniation following pelvic lymphadenectomy for gynecologic carcinomas. Sci Rep 2021; 11:1441. [PMID: 33446912 PMCID: PMC7809471 DOI: 10.1038/s41598-021-81160-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 01/04/2021] [Indexed: 11/12/2022] Open
Abstract
After pelvic lymphadenectomy (PLA), pelvic vessels, nerve, and ureter are skeletonized. Internal hernias beneath the skeletonized pelvic structure following pelvic lymphadenectomy (IBSPP) are a rare complication following PLA. To the best of our knowledge, only 12 IBSPP cases have been reported and clinical details on such hernias remain unknown.
The aim of the study was to investigate the incident and etiology of IBSPP. 1313 patients who underwent open or laparoscopic pelvic lymphadenectomy were identified from our database. A retrospective review was performed. Mean follow-up period was 33.9 months. A total of 12 patients had IBSPP. Multivariate analysis of laparoscopic surgeries group as compared to open surgeries group, para-aortic lymphadenectomy rate, number of dissected lymph nodes by PLA, antiadhesive material use rate, and blood loss were lower in laparoscopic surgeries group: odd ratio (OR) = 0.13 [95% confidence interval (CI) 0.08–0.19], and OR = 0.70 [95% CI 0.50–0.99], OR = 0.17 [95% CI 0.10–0.28], OR = 0.93 [95% CI 0.92–0.94]. However, no significant difference was observed in the incidence of IBSPP between laparoscopic surgery (1.0%) and open surgery (0.8%). All IBSPP occurred in the right pelvic space. These findings may contribute to the development of prevention methods for this disease.
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Ai W, Liang Z, Li F, Yu H. Internal hernia beneath superior vesical artery after pelvic lymphadenectomy for cervical cancer: a case report and literature review. BMC Surg 2020; 20:312. [PMID: 33267803 PMCID: PMC7709390 DOI: 10.1186/s12893-020-00985-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 11/25/2020] [Indexed: 12/17/2022] Open
Abstract
Background The common complications of radical hysterectomy and pelvic lymphadenectomy usually include wound infection, hemorrhage or hematomas, lymphocele, uretheral injury, ileus and incisional hernias. However, internal hernia secondary to the orifice associated with the uncovered vessels after pelvic lymphadenectomy is very rare. Case presentation We report a case of internal hernia with intestinal perforation beneath the superior vesical artery that occurred one month after laparoscopic pelvic lymphadenectomy for cervical cancer. A partial ileum resection was performed and the right superior vesical artery was transected to prevent recurrence of the internal hernia. Conclusions Retroperitonealization after the pelvic lymphadenectomy should be considered in patients with tortuous, elongated arteries which could be causal lesions of an internal hernia.
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Affiliation(s)
- Wen Ai
- The First Affiliated Hospital of Shandong First Medical University, Jinan, 250014, Shandong, China
| | - Zhihua Liang
- The First Affiliated Hospital of Shandong First Medical University, Jinan, 250014, Shandong, China
| | - Feng Li
- The First Affiliated Hospital of Shandong First Medical University, Jinan, 250014, Shandong, China
| | - Haihua Yu
- The First Affiliated Hospital of Shandong First Medical University, Jinan, 250014, Shandong, China.
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