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

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.

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

“…The small intestine strangulated by internal hernia is seen in the pelvis, and the starting point of the intestinal obstruction is located in the lateral pelvic wall in both cases. Similar CT findings have been seen in several previous reports [ 15 , 16 , 24 ]. If a patient with a history of PL presents with symptoms of SBO, physical findings, or HR sign, and we find characteristic CT findings in the pelvis, we need to consider this disease as a SBO formed by an internal hernia with exposed vessels and nerves in the pelvis.…”

“…We searched the PubMed database using the key words “internal hernia”, “pelvic lymphadenectomy (or lymph node dissection)” between 1978 and 2022. 21 cases have been described in 18 reports, including ours (Table 1 ) [ 8 – 24 ]. Strangulated internal hernia involving the right common iliac artery after PL in a patient with testicular cancer was first reported in 1978 [ 8 ].…”

“…In previous reports, most of the patients complained of abdominal symptoms, but when the obturator nerve forms an internal hernia and caused intestinal obstruction, some patients, including the case 1, complained of inguinal or thigh pain. [ 18 , 24 ]. Therefore, it is necessary to be very careful when examining the patient with a history of PL.…”

Strangulated internal hernia caused by an iatrogenic peritoneal band after total laparoscopic hysterectomy—A caveat to consider retroperitoneum closure

“…As for gynecologic surgery, strangulated small bowel obstruction cases caused by isolated obturator nerve and pelvic vessels after pelvic lymphadenectomy were reported. 11 These reported cases seem to be a similar mechanism to our case.…”

“…In contrast, acquired hernia orifices are caused by inflammation, trauma, or previous surgery such as gastric bypass for bariatric treatment and liver transplantation. As for gynecologic surgery, strangulated small bowel obstruction cases caused by isolated obturator nerve and pelvic vessels after pelvic lymphadenectomy were reported 11 . These reported cases seem to be a similar mechanism to our case.…”