Bowel obstruction caused by an internal hernia that developed after laparoscopic subtotal colectomy: a case report
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Laparoscopic surgery is a minimally invasive approach with good treatment outcomes and is currently the standard surgery for colorectal cancer in Japan. Mesenteric closure is considered unnecessary in laparoscopic colorectal surgery because it can damage the bowel and blood vessels. However, an internal hernia may develop if the mesentery is not repaired.
We report a case of internal hernia in a 61-year-old male of Japanese ethnicity. The patient had advanced sigmoid colon cancer, early-stage transverse colon cancer, and multiple adenomatous polyposis, and underwent laparoscopically-assisted subtotal colectomy. Bowel obstruction developed six days postoperatively and did not improve with conservative treatment. Abdominal computed tomography detected an internal hernia, prompting emergency surgery in which the ileum protruding into the mesenteric defect and an anastomotic stricture were detected. Reanastomosis, mesentery closure, and ileostomy were performed after hernia repair.
In this case, open surgery was necessary due to bowel obstruction after laparoscopic colectomy. This outcome indicated that mesenteric closure should have been performed. Thus, the benefits of mesenteric closure require assessment in future cases.
KeywordsLaparoscopic surgery Subtotal colectomy Bowel strangulation Internal hernia Mesenteric closure
Body mass index
Laparoscopic surgery for colon cancer yields treatment outcomes equivalent to those in open surgery, and thus this approach has been rapidly adopted . Laparoscopic surgery also benefits patients because it leaves a smaller scar than open surgery and is minimally invasive . However, some negative effects can arise as a result of conditions unique to laparoscopic surgery, including rising intraperitoneal pressure due to pneumoperitoneum and steep head-up or head-down positions, and there have been reports of development of internal hernias if the mesentery is not repaired [3, 4, 5, 6, 7, 8]. The mesenteric defect is typically closed after open surgery, but this is generally not considered to be necessary after laparoscopic surgery . Here, we report a case of bowel obstruction caused by an internal hernia that developed after laparoscopic subtotal colectomy without mesenteric repair.
Blood test findings before emergency surgery at 6 days after subtotal colectomy
White blood cells WBC (/μL)
Red blood cells RBC (104/μL)
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Platelets (Plt) (104/μL)
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Aspartate aminotransferase (AST) (U/L)
Alanine aminotransferase (ALT) (U/L)
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Alkaline phosphatase (ALP) (U/L)
γ-Glutamyltranspeptidase (γ-GTP) (U/L)
Blood urea nitrogen (BUN) (mg/dL)
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Amylase (Amy) (U/L)
C-reactive protein test (CRP) (mg/dL)
Prothrombin time (PT) (%)
Activated partial thromboplastin time (APTT) (sec)
Fibrin and fibrinogen degradation product (FDP) (μg/mL)
In recent years, there has been an increase in the number of laparoscopic surgeries for colorectal cancer in Japan, as shown by the results of a survey conducted by the Japan Society for Endoscopic Surgery . Laparoscopic surgery has been proven to be comparable with open surgery and is becoming the standard method for colorectal cancer surgery [1, 2]. Aggregate data in Japan indicates that 82,291 patients with benign or malignant conditions of the small or large bowel underwent laparoscopic surgery from 2008 to 2011, of which 4,912 (6%) experienced a procedural accident, including 1,172 cases (1%) of bowel obstruction . Bowel obstruction caused by an internal hernia after laparoscopic surgery has been reported in Roux-en-Y reconstruction [10, 11, 12], Nissen fundoplication , and various types of laparoscopic urogenital surgeries .
There are also several reports of internal hernia after laparoscopic colorectal cancer surgery [3, 4, 5, 6, 7, 8]. Among these, Cabot et al. observed 4 cases of internal hernia in 530 laparoscopic right colon surgeries (0.8%) and Trabaldo et al. observed 5 cases in 436 laparoscopic left colon surgeries (1.14%). Only 2 deaths were reported in these studies [6, 7], but the individual risk is uncertain. A narrow defect hole (2–5cm) caused by incomplete closure may increase the risk of a symptomatic internal hernia . Internal hernia in our patient might have developed due to the long duration of surgery; or may have been caused by protrusion of the bowel into the mesenteric defect due to the higher intraperitoneal pressure during postoperative bowel paresis or intraperitoneal infection. Given the low incidence of internal hernias, mesenteric closure may not be necessary for every patient. However, closure should be considered in bowel damage during surgery if postoperative bowel paresis is likely or if the patient has a thin physique, as for our patient. Masubuchi et al. proposed that the mesenteric defect should be closed in thin patients because they are at risk for developing an internal hernia.
The current case shows that both frontal and transverse CT images are useful for diagnosis of internal hernias. Trabaldo et al. also used CT scans for diagnosis. In our case, bowel obstruction arose from an internal hernia caused by the absence of repair of the mesentery after laparoscopic subtotal colectomy. Diagnosis with CT permitted subsequent performance of emergency surgery.
We have reported a case of internal hernia that developed after laparoscopic surgery for colon cancer. This case suggests that the benefits of mesenteric closure after laparoscopic colorectal surgery should be examined further in patients with risk factors for development of internal hernia. In such patients, postoperative abdominal computed tomography may be useful for detection of a potential hernia.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors would like to thank Emeritus Professor Kazuo Shirouzu for his continued support and constant encouragement.
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