A Rare Complication After Laparoscopic Lateral Lymph Node Dissection for Rectal Cancer: Two Case Reports of Internal Hernia Below the Superior Vesical Artery

Abstract

Total mesorectal excision or mesorectal excision with lateral lymph node dissection (LLND) is a standard treatment for locally advanced lower rectal cancer in Japan. Although laparoscopic LLND for rectal cancer is technically complex and challenging, previous studies have demonstrated its feasibility, and the procedure is gradually becoming more common. With this increased use, the incidence of new complications specific to laparoscopic LLND is likely to increase, and a greater awareness of these complications is required.Here we report two cases of internal hernia of the small bowel through an orifice of the vesicohypogastric fascia below the superior vesical artery after laparoscopic LLND. There are six previous reports of internal hernia underneath the pelvic blood vessel after pelvic lymph node dissection for urological or gynecological malignancies, but our cases are the first two that occurred after LLND for rectal cancer. Almost all cases, including our two cases, occurred after laparoscopic surgery and required resection of an incarcerated small bowel. Therefore, the incidence of this complication is likely to increase as the number of cases treated with laparoscopic LLND increases. Our cases show that it is important to perform an emergency operation promptly instead of conservative treatment.

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

“…It is particularly interesting that about half of reports have originated from the gynecologic field, in which all the initial gynecologic surgeries were done laparoscopically [ 13 , 17 – 23 ]; moreover, approximately one-third of those reports were from the urologic area, in which the primary operations, except for the first case reported, were laparoscopic or robot-assisted surgeries [ 12 , 24 – 28 ]. Recently, two reports described three cases after rectal cancer surgeries [ 29 , 30 ]. In general, PL performed in gynecologic and urological fields can dissect lymph nodes around an external iliac artery or common iliac artery [ 1 , 2 , 4 ].…”

“…According to past papers, vessels or nerves constructing the internal hernia orifice were right common iliac artery (3 cases) [ 12 , 18 , 24 ], left external iliac artery and/or vein (4 cases) [ 17 , 22 , 25 , 27 ], right external iliac artery and/or vein (4 cases) [ 13 , 20 , 23 , 26 ], right superior vesical artery (3 cases) [ 21 , 29 ] and right umbilical artery and/or obturator nerve (5 cases) [ 19 , 28 , 30 ]. In fact, PL-related SBO is more common on the right side than on the left side (Table 1 ), which might be attributable to the fact that the left side is covered with the sigmoid colon.…”

Internal hernia beneath superior vesical artery after pelvic lymphadenectomy for cervical cancer: a case report and literature review

“…To the best of our knowledge, Guba et al first reported an iatrogenic internal hernia beneath the right iliac artery after lymphadenectomy in testicular cancer in 1978 and up to till now, only eight cases were reported in English literatures. The previous reports are shown in Table 1 [4][5][6][7][8][9][10][11]. Except for one laparotomy [4], the remaining 7 documents (8 cases) were all laparoscopic or robotic surgery.…”

“…reported the adhesion after laparoscopic or robotic surgery was obviously better than that of open surgery [ 12 ]. According to the Japanese literature, 200 (laparotomy) versus 276 (laparoscopy) cases of lateral lymph node dissection, there are only 2 cases of internal hernia occurred and all of them are in the laparoscopy group [ 11 ]. Minami [ 10 ] conjectures the incidence of strangulated bowel obstruction may rise with the increasing number of laparoscopic or robot-assisted pelvic lymphadenectomies, although they have less postoperative adhesion formation than open surgery.…”

“…Although clinical symptoms can not effectively differentiate the two conditions because they are nonspecific, computed tomography (CT) is usually useful for this situation. The characteristic CT finding is the caliber change of the small bowel in the lateral pelvic cavity or the caudal dorsal side of pelvic vessels or nerves [ 11 ].…”