Jejunal obstruction due to rare internal hernia between skeletonized external iliac artery and vein as late complication of laparoscopic hysterectomy with pelvic lymphadenectomy—case report and review of literature

Abstract

Background Internal herniation of small intestine in the lesser pelvis alongside iliac vasculature is a rare occurrence. Skeletonization of iliac vessels during pelvic lymph node dissection (LND), as part of surgical staging or treatment of patients with uterine, ovarian or urogenital cancer, is a strict prerequisite for orifice formation. Case presentation A 68-year-old woman presented at the emergency department with complaints of constipation for the last 3 days and acute-onset abdominal pain, nausea and vomiting since few hours. She had a history of laparoscopic hysterectomy, bilateral salpingo-oophorectomy and para-aortic and pelvic LND 7 years ago. A distended abdomen with diffuse tenderness on palpation was noted. A CT scan demonstrated bowel obstruction secondary to an incarcerated hernia underneath an elongated right external iliac artery. During an emergency exploratory laparotomy, the incarcerated bowel was reduced and the hernial orifice closed with a running suture. The patient had an uneventful postoperative period and was discharged on the fifth postoperative day. Discussion This rare internal hernia can manifest with non-specific symptoms of small bowel obstruction at any given point after index surgery, sometimes even after several years free of complaints. Contrast-enhanced computed tomography is the method of choice for fast and reliable diagnosis and helps in planning the necessary emergency laparotomy. Conclusion This life-threatening complication adds to the current controversy of pelvic and para-aortic lymphadenectomy in patients with endometrial cancer. Primary closure of peritoneal defects should be considered to potentially prevent internal hernias, especially when elongated iliac vessels are present.

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

“…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.…”

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

“…There have only been a few reports of bowel herniating under the external iliac arteries, and all of them have occurred following lymphadenectomies for pelvic organ malignancies [1,[4][5][6][7][8][9]. The patients in these reports have presented with features of bowel obstruction between two months and seven years following their lymphadenectomies and invariably have had the operations performed by minimally invasive surgical techniques -laparoscopically or using a robot.…”

“…The scan of our patient revealed features of SBO with no clear point of transition. Some authors have diagnosed this condition by identifying a closed loop of the bowel at the level of the artery [4,5,7,8].…”

“…In less than 24 hours, this was complicated by a pre-gangrenous change of the right lower limb, necessitating a left to right femoro-femoral by-pass using a Dacron graft. Frenzel et al [5] managed the hernial orifice by closing it using continuous 5-0 PDS sutures. Other options discussed in the literature are fixation of the artery to the lateral abdominal wall using a fibrin sealant patch [7], using an omentum to repair the defect, placing a mesh [4] or re-positioning the artery in the retroperitoneum by closing the parietal peritoneum over it [1,8].…”

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

“…Small bowel occlusion due to adhesions can present after years and is the most common long-term complication. Uncommonly, adhesions may also cause an internal hernia, a condition where the small bowel is strangulated through a peritoneal tear [2] . Typically, patients present severe abdominal pain with sudden onset, nausea and vomiting, abdominal distension; and even sign of sepsis due to bacterial translocation or bowel perforation, these signs are the clinicopathological result of bowel incarceration or strangulation.…”