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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

SMALL BOWEL OBSTRUCTION STATUS POST-TAPP

M Vix, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Summary


This case reports a small bowel obstruction status post a laparoscopic hernia repair (TAPP). Five questions allow surgeons to perform a self-evaluation of their knowledge of the complications after laparoscopic hernia repair.

2. Patient


43-year-old man

3. Past history


Previous repair of left inguinal hernia 23 years ago and redo herniorrhaphy via laparoscopic approach (TAPP) 1 year ago.

4. History of present illness


The patient presents with acute onset of severe periumbilical abdominal pain followed, within 24 hours, by onset of cramping, nausea, vomiting and lack of passage of gas and feces.

5. Physical examination


The patient is afebrile.
- normal vital signs;
- abdomen: minimally distended with borborygmi;
- soft with mild tenderness around umbilicus;
- no peritoneal signs.

6. Laboratory values


WBC: 12,500CRP: 20 (N<10)
Liver function tests, Amylase, Lipase: WNL

7. Sonography


Routine ultrasonography of the abdomen was performed. The following images are not of major diagnostic value and were not able to identify the cause of the occlusion.

8. Abdominal X-ray


Abdominal X-ray reveals air-fluid levels consistent with a small bowel obstruction.

9. CT scans


9.1. CT scan 1

This CT scan image confirms the presence of a small bowel obstruction. The small bowel is distended and full of liquid. The images were not able to find the source of the obstruction but did confirm the diagnosis.

9.2. CT scan 2

This CT scan image reveals the presence of an adhesion in the area of the previous operation. One can see the evidence of the fixation staples on the mesh in the first 2.

9.3. CT scan 3

The third scanner image strongly suggests an area of strangulation with non-dilated and dilated small bowel. This transition zone shows a point of contact between the fixation staples and the bowel. This image gives the indication for an open surgical exploration.

9.4. CT scan 4

This image shows a suspicion of a hernia tract with a strangulated loop of bowel in contact with the peritoneum.

10. Clinical progression


Due to the patient's clinical presentation with worsening abdominal cramping and pain, a diagnostic laparoscopy is performed. Small bowel obstruction secondary to adhesions to the peritoneum overlying the mesh is identified, and these adhesions are divided laparoscopically.

11. Quizzes


11.1. Quiz 1

The next set of investigations should include the following imaging:
1) Plain abdominal XR
2) Colonoscopy
3) Abdominal CT
4) Ultrasound
5) Laparoscopy
Correct answers:
1) Plain abdominal XR
3) Abdominal CT

The plain abdominal XR is still the baseline investigation for the surgical abdomen.
Endoscopy is not a first-line investigation for the surgical abdomen.
CT scanning provides excellent diagnostic yield in the surgical abdomen, and can often delineate the cause and site of a bowel obstruction.
Although ultrasound is an excellent modality for solid organ imaging and in suspected appendicitis, it has limited application in cases of suspected bowel obstruction, except in pediatric intussusception as the picture is usually obscured by the gas-filled bowel loops.
Laparoscopy is very rarely a first-line investigation for the surgical abdomen.

11.2. Quiz 2

The incidence of small bowel obstruction secondary to laparoscopic hernia repair is:
1) 2-4%
2) 1-2%
3) <1%
Correct answer:
3) <1%

The incidence of small bowel obstruction is <1% in all the large series. The incidence of small bowel obstruction is <1% in all the large series. The incidence of small bowel obstruction after laparoscopic hernia repair is low, usually much less than 1%.

11.3. Quiz 3

Please choose the correct statement(s):
1) Late small bowel obstruction is invariably due to port-site herniation.
2) Small bowel obstruction is a complication of the trans-abdominal approach, and is not seen after the totally extraperitoneal repair.
3) Most of early small bowel obstruction after TAPP repair is due to surgical error.
4) The sheath should be closed in all 10 mm port sites.
5) Bowel obstruction occurs commonly with the intraperitoneal onlay mesh technique (IPOM).
Correct answers:
3) Most of early small bowel obstruction after TAPP repair is due to surgical error.
4) The sheath should be closed in all 10 mm port sites.
5) Bowel obstruction occurs commonly with the intraperitoneal onlay mesh technique (IPOM).

Late small bowel obstruction does occur secondary to port site hernia, but some cases are probably due to adhesion formation to the peritoneum over the mesh or to the mesh itself. Although bowel obstruction occurs almost exclusively in the TAPP group, there has been case reports of obstruction after TEP. Early obstruction is largely a complication of herniation of bowel into either a port site or an incompletely closed peritoneum over the mesh. However, it does occur secondary to early fibrin adhesions as well. All authorities agree that 10 mm port sites should be closed routinely. Although herniation through 5 mm port sites are well described, this is sufficiently rare to exclude their routine closure. A high complication rate due to bowel adhesion is seen with the IPOM technique.

11.4. Quiz 4

What is the next step in management?
1) Lower gastrointestinal endoscopy to exclude large bowel obstruction or ischemia
2) Laparotomy to identify the cause of obstruction
3) Laparoscopy to identify the cause of obstruction
4) Mesenteric arteriography to exclude bowel ischemia
Correct answers:
2) Laparotomy to identify the cause of obstruction
3) Laparoscopy to identify the cause of obstruction

Endoscopy has limited application in the management of small bowel obstruction, and is never a first-line management unless there is specific reason to believe that there is large bowel obstruction. Laparotomy is a viable alternative and probably safe, but a large percentage of these cases can be managed by re-laparoscopy. Laparoscopy is indeed safe and effective in the diagnosis of causes of obstruction, and should probably be the first-line invasion in cases of small bowel obstruction after laparoscopic hernia repair. This is not the classical picture of mesenteric ischemia, which usually presents with forceful bowel evacuation and severe abdominal pain, coupled to a featureless abdominal XR.

11.5. Quiz 5

Anatomy (please choose the correct item):
1) The inferior epigastric vessels course superiorly directly posterior to the abdominal wall muscles, on the lateral edge of the rectus abdominus muscles.
2) The inferior epigastric vessels should be dissected away from the abdominal wall to ensure proper mesh placement.
3) The spermatic cord should be encircled by the mesh to prevent recurrence.
4) Bleeding from the inferior epigastric vessels is very rarely a problem during laparoscopic hernia repair, as they can be easily visualized and avoided.
5) The inferior epigastric vessels constitute the lateral border of Hesselbach’s triangle, therefore a direct will always be medial to these.
Correct answers:
1) The inferior epigastric vessels course superiorly directly posterior to the abdominal wall muscles, on the lateral edge of the rectus abdominus muscles.
5) The inferior epigastric vessels constitute the lateral border of Hesselbach’s triangle, therefore a direct will always be medial to these.

The vessels originate from the external iliac vessels, proximal to the inguinal ligament, and course superiorly on the posterior surface of the lateral edge of the rectus muscle. The vessels should stay on the "roof" of the preperitoneal space and will be covered by a well-placed mesh. Occasionally, the balloon dissects the vessels down during initial inflation, which can make further dissection difficult. A slit mesh does not increase the strength of the repair, can be more difficult to insert with a greater chance of injury to cord structures, and leads to an increased incidence of seroma. The problem is well described in the literature, injury to inferior epigastric vessels constituted the majority of minor complications in the laparoscopic group (British MRC trial - Lancet, 1999). The surgeons in this trial were inexperienced with laparoscopic hernia repair and had a low surgical volume of these procedures. It is not stated in the article whether this occurred mainly in the TEP or TAPP cohort.

12. Discussion


As demonstrated in this clinical observation, small bowel obstruction after laparoscopic surgery for inguinal hernias is a rare but real occurrence. Postoperative small bowel obstructions can be acute, which indicates a surgical management. A laparoscopic approach may be the first-line approach if performed by an experienced team. For cases when there is doubt or the dissection is difficult, it is imperative to convert to an open laparotomy due to the risk of perforation while dissecting. The laparoscopic exploration in our experience allows complete dissection of the adhesions and alleviation of the rapid transit.

13. References


  1. Aeberhard P, Klaiber C, Meyenberg A, Osterwalder A, Tschudi J. Prospective audit of laparoscopic totally extraperitoneal inguinal hernia repair: a multicenter study of the Swiss Association for Laparoscopic Thoracoscopic Surgery (SALTC). Surg Endosc 1999;13:1115-20.
  2. Leibl BJ, Schmedt CG, Schwarz J et al. A single institution’s experience with transperitoneal laparoscopic hernia repair. Am J Surg 1998;175:44651; discussion 452.
  3. Liem MS, van der Graaf Y, van Steensel CJ et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal hernia repair. N Engl J Med 1997;336:1541-7.
  4. Stark E, Oestreich K, Wendl K, Rumstadt B, Hagmuller E. Nerve irritation after laparoscopic hernia repair. Surg Endosc 1999; 13:878-81.
  5. The MRC Laparoscopic Groin Hernia Trial Group. Laparoscopic versus open repair of groin hernia: a randomised comparison. Lancet 1999;354:185-90.