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Laparoscopic-assisted surgery has been applied for a variety of colonie surgery. The objective of this paper is to demonstrate a possible and avoidable complication of laparoscopic colonie surgery.
A 47-year-old woman underwent gasless laparoscopic-assisted sigmoid colectomy. On the 20th postoperative day, she developed bowel obstruction. Decompression with a long tube failed to resolve the bowel obstruction. Open laparotomy was performed. Abdominal exploration revealed a loop of the small bowel incarcerated in the mesenteric defect caused by the previous operation. Adhesiolysis was performed, and the post-operative course was uneventful.
Despite technical difficulty, complete closure of the mesentery after bowel resection is strongly recommended for prevention of transmesenteric incarcerated hernia after laparoscopic surgery.
Bowel obstruction is a complication which is not uncommon after laparoscopic colectomy. Previous studies have reported incidences of 0.8-2.5%.1–3 In most cases, the cause of the bowel obstruction is an incarcerated Richter's hernia in the trocar site. Here we report a case with a transmesenteric hernia after laparoscopic sigmoid colectomy in which a loop of small bowel was incarcerated in a surgery-related mesenteric defect.
A 47-year-old woman was admitted to our hospital for surgical treatment of sigmoid colon cancer. Barium enema and colonoscopic study demonstrated a 1.5 cm × 1.8 cm polypoid lesion in the sigmoid colon (Figure 1). Biopsy revealed well-differentiated adenocarcinoma. Based on a diagnosis of submucosal cancer, laparoscopic-assisted sigmoid colectomy was selected for the optimal treatment. The operation was performed with curative intent using a gasless technique (Figure 2) previously described.4 Anastomosis was undertaken using the double stapling method. Lymph node dissection with low ligation of the inferior mesenteric artery was per-formed simultaneously. The mesenteric defect resulting from bowel resection was not completely closed because of technical difficulty. Figure 3 shows the resected specimen. Pathological examination revealed submucosally invasive cancer without lymph node involvement.
On the 20th postoperative day, the patient developed abdominal distension, nausea and vomiting. Plain abdominal X-ray films demonstrated a small bowel obstruction. A decompression tube (long tube) was inserted, and, on the 26th postoperative day, the bowel obstruction showed improvement. However, after initiating liquid meals, the patient again developed bowel obstruction. Abdominal X-rays after ingestion of contrast medium showed a severely dilated small bowel (Figure 4). The anal edge of the dilated loop was located near the anastomosis, and laparotomy was performed. Abdominal exploration revealed a dilated loop of small bowel incarcerated within the mesenteric defect. Adhesiolysis was performed. The postoperative course was uneventful, and the patient was discharged on day 21 after the second procedure.
Laparoscopic approaches to colonie malignancies have gained acceptance for selected patients as a new, minimally invasive therapeutic modalities. The incidence of bowel obstruction after laparoscopic colectomy is reported to be 0.8-2.5%.1–3 The most frequent cause of the bowel obstruction is Richter's hernia at the trocar site. Such conditions have been reported after gastroentero-logical as well as urologie and gynecological laparoscopic operations.5–12 To prevent Richter's hernia, fascial closure has been recommended, even for 5 mm trocar sites.7
Vanclooster13 and Tsang14 reported cases developing hernia after laparoscopic herniorrhaphy in which a loop of small bowel became incarcerated in the incompletely closed peritoneum. In this case, which to our knowledge is the first case in the literature, a loop of small bowel became incarcerated in the incompletely closed mesentery. Closure of the mesentery after bowel resection is sometimes very difficult due to the limited operative field, especially at the most proximal portion of the mesentery. However, this case strongly suggests the need for complete closure of the mesentery to prevent bowel incarceration. Meticulous suturing or clipping should be performed to avoid transmesenteric hernia after laparoscopic colectomy.