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

Abstract

Introduction and importance

The occurrence of an internal hernia beneath the external iliac artery is rare but may occur after pelvic lymphadenectomy. The challenging treatment of this rare condition should be tailored to the patient's clinical and anatomical characteristics.

Case presentation

We present the case of a 77-year-old woman with previous history of laparoscopic hysterectomy and adnexectomy with extended pelvic lymphadenectomy for endometrial cancer. The patient was admitted in the emergency department because of severe abdominal pain and a computed tomography scan showed signs of internal hernia. The laparoscopy confirmed such a finding below the right external iliac artery. A small bowel resection was deemed necessary and the defect was closed with an absorbable mesh. The post-operative course was uneventful.

Clinical discussion

Internal hernia beneath the iliac artery is a rare condition after pelvic lymphadenectomy. The first challenge is the hernia reduction, which can be safely carried out laparoscopically. Secondly, a patch or a mesh should be used to close the defect if a primary peritoneal suture is not feasible, but it requires to be fixed in the small pelvis. The use of absorbable material is a valuable option and should leave a fibrotic area that covers the hernia defect.

Conclusion

A strangulated internal hernia beneath the external iliac artery is a possible complication after extensive pelvic lymph node dissection. The laparoscopic approach to treat bowel ischemia and to close the peritoneal defect with a mesh, should reduce as much as possible the risk of internal hernia recurrence.

Highlights

• •Internal hernia beneath the external iliac artery is a rare complication after pelvic lymphadenectomy.
• •The closure of peritoneal defect with a mesh reduce the risk of internal hernia recurrence.
• •The absorbable mesh is a valuable option and should leave a fibrotic area that covers the hernia defect.

1. Introduction

Yearly, hundreds of thousands of operations for urological and gynecological cancers are carried out worldwide [1]. Pelvic lymphadenectomy is key to achieving complete tumor resection and obtaining the pathological staging, which determines further oncological treatment [1]. However, extensive pelvic lymphnode dissection brings the risk of early and late complications. 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. In such life-threatening cases, an emergent surgical approach is necessary.

The aim of our study was to report a rare case that was treated in our surgery department, with particular attention to surgical treatment. This work has been reported in line with the SCARE and PROCESS criteria [3]^, [4].

2. Presentation of case

A 77-year-old woman with a previous history of laparoscopic hysterectomy and adnexectomy with extended pelvic lymphadenectomy for endometrial cancer 20 months earlier. In addition, the patient underwent a laparoscopic cholecystectomy 10 years earlier and an open appendicectomy in young age. The patient had no relevant comorbidity, body mass index was 23.3 Kg/m² and the oncological follow-up ruled out any tumor recurrence. The patient presented in the emergency department because of severe sudden-onset abdominal pain, nausea, and vomiting over the past 24 h. The physical examination showed a rebound tenderness on the right lower abdomen. The blood test showed only a slight leucocytosis (11.2x10E9/L), while C-reactive protein and lactate were normal. We performed a contrast-enhanced computer tomography (CT scan) that showed a small bowel occlusion, a close loop sign, bowel wall thickening, mesenteric fat stranding and peritoneal fluid; which were highly suggestive of an internal hernia near the right external iliac artery with intestinal ischemia. Fig. 1.

Fig. 1.

CT scan images (a, b) showing signs of internal hernia beneath the external iliac artery. Arrows indicate the ischemic small bowel. Arrowheads indicate the presence of fluid in the mesentery, a sign of internal hernia and bowel viability threat.

An emergent surgical exploration was deemed necessary. We decided to carry out the operation laparoscopically and the patient was placed supine with the operating table at 12° Trendelenburg and 5° left tilt position. We confirmed the presence of an internal hernia localized beneath the right external iliac artery. Fig. 2. The small bowel was necrotic over an area of the 70 cm in length and resection was necessary. Despite many attempts, the reduction of the herniated small bowels was unsuccessful. Therefore, we decided to perform the resection of the herniated small bowel without prior reduction. Two laparoscopic 60-mm linear staplers were used to transect the small bowel and the mesentery was dissected with the Harmonic® scalpel. A side-to-side mechanical isoperistaltic anastomosis was performed laparoscopically and the resected bowel was retrieved through a 4 cm mini-laparotomy incision.

Fig. 2.

Intraoperative images (a, b) confirming the internal hernia beneath the external iliac artery and the necrosis of the small bowel. Arrows indicate the ischemic small bowel. Arrowheads indicate the site of the internal hernia.

Finally, we approached the 4 cm large hernia defect. As a direct peritoneal closure was not feasible, to prevent any internal hernia recurrence we decided to cover the defect with a shaped absorbable mesh (polyglactin 910) fixed with absorbable sutures (polyglactin 910 braided suture) Fig. 3. We shaped a rectangular mesh in a way to round the corners and the superior part. The goal is to fit the mesh around the artery and create a minimum contact of 180° between them, in order to cover perfectly the space between the artery and the inguinal wall. The microscopic pathological examination has shown ischemic changes affecting mucosa-submucosa in the ileal wall and acute perivisceritis. The postoperative course was uneventful, and the patient was discharged on the 8th postoperative day. One year after the operation no recurrence or small bowel occlusion episodes were shown in the clinical follow-up.

Fig. 3.

Intraoperative images (a, b) showing the mesh placement and fixation which closes the peritoneal tear and does not allow any early recurrence. Arrowheads indicate the mesh placement.

3. Discussion

The sudden onset of severe abdominal pain in previously operated patients should always lead to prompt diagnosis, if necessary with an abdominal CT scan, and emergency surgery if small bowel ischemia cannot be ruled out. Internal hernia is a rare cause of small bowel obstruction after surgery in comparison with adhesions, which holds 5.8 % accountability. More than 90 % of all internal hernias are caused by natural or artificial orifices built by the intestine [5]. Small bowel ischemia due to internal hernia beneath iliac arteries is a rare occurrence after extensive pelvic lymphnode dissection for cancer. Only a few cases are reported in the literature [1]^, [2]^, [6]^, [7]^, [8]^, [9]^, [10]^, [11]^, [12]. Table 1. The first one was described in 1978 by Guba AM Jr. et al. who reported the case of a 52-year-old male with previous radical retroperitoneal lymphadenectomy for testicular cancer who, due to an internal hernia beneath the right common iliac artery, underwent a laparotomy and a bowel resection. The authors closed the hernia defect with a peritoneum suture. Among the reported cases, all operations with one exception were carried out with an open approach [8]. We decided to operate laparoscopically as the small bowel was not massively dilated and no severe adhesions were expected. However, such an approach is technically challenging and requires advanced laparoscopic skills to reduce the hernia and perform bowel resection and anastomosis. Therefore, the operation was performed by an experimented surgeon with advanced laparoscopic background, as his skills are necessary to avoid injuries of the iliac arteries during traction maneuvers. In our case, a primary hernia reduction was not feasible and, firstly, we carried out the resection of the ischemic and dilated bowel.

Table 1.

Cases reported in the literature of internal hernia beneath the iliac artery.

Study	Patient	Previous operation	Hernia localization	Latency	Treatment approach	Repair method
Zhang Z et al. 2021 [1]	56-year-old female, cervix cancer	Hysterectomy and pelvic lymphadenectomy	Left external iliac artery	9 years	Open, no bowel resection	With peritoneum
Frenzel F et al. 2020 [2]	68-year-old female, endometrial adenocarcinoma	Hysterectomy and pelvic lymphadenectomy	Between right external iliac artery and vein	7 years	Open, with bowel resection	With peritoneum
Guba AM Jr. et al. 1978 [3]	52-year-old male, testicular cancer	Radical retroperitoneal lymphadenectomy	Right common iliac artery	4 months	Open, with bowel resection	With peritoneum
Ninomiya S et al. 2019 [4]	72-year-old male, prostate cancer	Radical prostatectomy and lymphadenectomy	Left external iliac artery	2 months	Open, with bowel resection	Unrepaired
Dumont KA et al. 2013 [5]	56-year-old female, gynecological cancer	Hysterectomy, omentectomy,radical retroperitoneal lymphadenectomy	Left external iliac artery	4 years	Laparoscopic, no bowel resection	Unrepaired
Kambiz K et al. 2018 [6]	64-year-old male, prostate cancer	Radical prostatectomy	Right external iliac artery	1 years	Open, with bowel resection	Unrepaired
Viktorin-Baier P et al. 2016 [7]	50-year-old male, prostate cancer	Radical prostatectomy and lymphadenectomy	Left external iliac artery	1 years	Open, with bowel resection	Arteriotomy, collagen patch and peritoneum
Kim KM et al. 2008 [8]	67-year-old female, cervix cancer	Hysterectomy with lymphadenectomy	Right external iliac artery	3 months	Open, with bowel resection	With peritoneum
Ardelt M et al. 2014 [9]	39-year-old female, cervix cancer	Trachelectomy with pelvic lymphadenectomy	Right common iliac artery	2 years	Open, with bowel resection	With collagen patch

Among the published report in the literature, in four cases the hernia defect was closed with the peritoneum [1]^, [4]^, [6]^, [11], in two cases with a collagen patch [10]^, [12] and in three cases no closure was carried out [7]^, [8]^, [9]. Ninomiya S et al. [7], Dumont KA et al. [8], and Kambiz K et al. [9] reduced the hernia but decided to not close the hernial orifice. Guba AM Jr. et al. [6], Kim KM et al. [11], Frenzel F et al. [4], and Zhang Z et al. [1] closed the hernia defect with a direct peritoneal closure. Viktorin-Baier P et al. [10] performed an arteriotomy, an end-to-end anastomosis, and closed the defect with a collagen patch and peritoneum. Finally, Ardelt M et al. [12] closed the defect with a collagen patch. The peritoneum should be considered the best option, because it is the natural way to repair the defect and avoid the problem of contamination of non-absorbable mesh. In our case, due to anatomical reasons, it was not feasible. The use of a patch or a mesh could be used in case of large defects, but it is technically more demanding and requires to be fixed in the small pelvis. Although no gross contamination occurred during the operation, we decided not to use a non-adsorbable mesh to avoid direct contact with the small bowel and because a bowel resection was deemed necessary. In accordance with Zhang Z [1], we consider not safe the use of non-absorbable mesh due also to a lack of experience with permanent mesh directly on an artery. The use of absorbable material is a valuable option and, once adsorbed, should leave a fibrotic area that covers the hernia defect.

In our institution, we perform a clinical follow-up after one month from the operation. However, in this particular case, we have also done a clinical follow-up after one year, related to the endometrial cancer, where we did not notice any recurrence of the hernia. We are likely to think that the peritoneal closure with mesh reduces the risk of hernia recurrence. However, our follow-up period is not long enough to make conclusions; further accumulation of cases and longer follow-up of our patient are necessary to confirm this assumption. To our best knowledge, this is the first report describing a laparoscopic approach to treat bowel ischemia due to an internal hernia beneath the external iliac artery with mesh closure of the orifice.

4. Conclusion

A strangulated internal hernia beneath the external iliac artery is a possible complication after extensive pelvic lymph node dissection. The laparoscopic approach to treat bowel ischemia and to close the peritoneal defect with a mesh is safe and feasible, and should reduce as much as possible the risk of internal hernia recurrence, in a short-term period. Finally, we recommend this approach on patients with a large peritoneal defect without a possibility of primary peritoneum repair, with a risk of contamination of the mesh. Furthermore, laparoscopy approach must be reserved for experimented surgeon, due to risk of artery lesion during the reducing procedure.

Patient consent

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 on request.

Ethical approval

Ethical approval was waived at our institution.

Funding

Nothing to declare.

Author contribution

Kostas Mario Zanca: Conceptualization; Investigation; Roles/Writing - original draft. Maria Marcantonio: Roles/Writing - original draft; Data curation. Ramon Pini: Investigation; Roles/Writing - original draft. Francesco Mongelli: Supervision; Writing - review & editing. Davide La Regina: Supervision; Writing - review & editing, Supervision. Agnese Cianfarani: Investigation; Writing - original draft; Writing - review & editing.

Guarantor

Kostas M Zanca (corresponding author)

Bellinzona e Valli Regional Hospital

6500 Bellinzona

Switzerland

Conflict of interest statement

Nothing to declare.