Small bowel strangulation due to internal hernia after left colectomy

Internal small bowel herniation through a mesenteric defect is a rare but severe complication. The purpose of the video is to demonstrate the closure of a mesenteric defect following a full left colectomy. This closure is controversial, and when performed, the closure must be perfect. This is the case of a patient who underwent a left colectomy with defect closure, the latter had not been efficient and caused an obstruction syndrome postoperatively, which was well identified by the CT-scan. It identified a small bowel passage behind the lower colon. The patient is re-operated on the second postoperative day.

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Small bowel strangulation due to internal hernia after left colectomy

Authors

J Leroy, F Costantino, J Marescaux

Abstract

Internal small bowel herniation through a mesenteric defect is a rare but severe complication. The purpose of the video is to demonstrate the closure of a mesenteric defect following a full left colectomy. This closure is controversial, and when performed, the closure must be perfect. This is the case of a patient who underwent a left colectomy with defect closure, the latter had not been efficient and caused an obstruction syndrome postoperatively, which was well identified by the CT-scan. It identified a small bowel passage behind the lower colon. The patient is re-operated on the second postoperative day.

Classification

tips and tricks

Keywords

Small bowel strangulation, internal hernia after left colectomy

Media type

Surgical video

Duration

12'45''

Publication

2010-04

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E-publication

WeBSurg.com, Apr 2010;10(04).
URL: http://www.websurg.com/doi-vd01en2830.htm

Small bowel strangulation due to internal hernia after left colectomy

1. Introduction 00'08''

The purpose of the video is to demonstrate the closure of a mesenteric defect following a full left colectomy. This closure is controversial, and when performed, the closure must be perfect. This is the case of a patient who underwent a left colectomy with defect closure, the latter had not been efficient and caused an obstruction syndrome postoperatively, which was well identified by the CT-scan. It identified a small bowel passage behind the lower colon. The patient is re-operated on the second postoperative day.

2. Intraoperative view 00'45''

We notice that the small bowel is distended, with one segment situated laterally to the left colon and another segment medially. Normally, the entire small bowel should have been located at the lower colon’s right.

3. Anastomosis control 01'01''

We check the anastomotic area, which appears to be healthy. We identify the ileocaecum and gradually go up the small bowel through gentle traction from the distal small bowel to the proximal small bowel. The small bowel that is currently manipulated is not dilated as situated after the hernia. A few adherent areas are found, but these are not recent.

4. Hernia reduction 01'37''

With gentle traction and while avoiding any trauma on the small bowel through manipulation, we move towards the proximal bowel. We can check our progression by looking at the posterior and lateral section of the lowered colon, and we see that there is still a lot of proximal small bowel behind and out of the left lowered colon. We continue exerting gradual and gentle traction, although with some difficulty, proving that there is a narrow passage area. Therefore, there is occasionally a risk of rupturing the small bowel or even the meso; this rupture could be dangerous, and the small bowel therefore needs to be manipulated with extreme caution. We continue to pull the small bowel medially and we finally see the proximal section of the small bowel following its difficult retraction, especially as the bowel is becoming increasingly dilated. The proximal area contains the orifice, but also quite surprisingly, a hernia related to a fixation of the peritoneum at the first jejunal loop, beyond the duodenojejunal flexure, explaining the migration of the duodenojejunal flexure that brought along the small bowel.

5. Defect closure 03'38''

In order to avoid a recurrence, it is essential to close the defect. We complete the surgical procedure after having reduced all the small bowel medially by freeing the duodenojejunal flexure and a closure through stapling. This time, the stapling only takes the peritoneum to avoid injuring the small bowel, but also to avoid another recurrence with sliding of the small bowel from the duodenojejunal flexure that was poorly mobilized. We see the complete closure of the defect and a check of the distal defect is necessary to avoid another mesenteric defect. We can of course complete this closure with sutures. The postoperative period was uneventful.