Internal hernia following laparoendoscopic single site surgery: a case report

Abstract

Laparoscopic donor nephrectomy was introduced in 1995 as a means of minimally invasive surgeries that entail kidney extraction from healthy individuals. Since then, it has widely overtaken the traditional open surgical approaches, especially in live donor nephrectomy procedures worldwide. Laparoendoscopic single-site surgery is considered a more optimized surgical approach utilizing a single incision instead of four. Various studies have scrutinized many of the risk factors related to such surgeries, most commonly: vascular problems, intraoperative organ injury, and postoperative ileus. Other rare complications have not been thoroughly explored due to their decreased prevalence. Internal hernias are considered a rare complication of laparoendoscopic single-site surgery with dangerous repercussions ranging from bowel obstruction to ischemia, and necrosis. Our study presents a rare case of a trans-mesenteric internal hernia following laparoendoscopic single-site surgery. The patient was relatively healthy with no serious medical conditions. However, the past medical history did record a diagnosis of irritable bowel syndrome a few years back. Knowing that the occurrence of internal hernias is infrequent, we recommend that mesenteric defects be taken seriously to avoid the risk of internal hernias and their complications.

Introduction

Laparoscopic donor nephrectomy (LDN) is a minimally invasive surgical procedure, involving kidney extraction from healthy individuals. Since its introduction in 1995, LDN has widely replaced the traditional surgical approach of open surgery, hence, becoming more commonly used in left kidney donor nephrectomy procedures globally [1]. The typical LDN procedure involves multiple ports and a small lower abdominal incision to deliver the kidney [2]. Compared to open nephrectomies, the laparoscopic technique has a lower association with pulmonary complications and wound infections [1, 3]. The procedure prioritizes patient safety while still achieving equivalent results to the traditional open surgery method. Laparoendoscopic single-site surgery, (LESS) is a minimally invasive surgical technique that uses a single incision instead of the four found in LDN. This procedure was developed to make the process less invasive while decreasing hospital stay and recovery time [4]. Common complications of LDN include vascular problems (endovascular stapler malfunction and Veress needle injury), intraoperative organ injury, and postoperative ileus [5, 6]. Rare but significant complications include rhabdomyolysis, chylous ascites, and gastrointestinal partial obstruction [5, 6]. Although internal hernias (IH) are not considered to be one of the well-known complications of LESS, here we will be presenting a rare case of trans mesenteric IH following the procedure. IH is a class of hernias involving the protrusion of internal organs through a defect within the abdominal cavity, more specifically through the peritoneum or mesentery. There are 8 main types of IH, one of which is trans mesenteric hernias that occur through a defect in the large or small bowel mesentery [7]. In our case, we will present a trans mesenteric internal hernia as a complication of LESS.

Case

A 32-year-old male weighing 59 Kg with a height of 167 cm presented to the outpatient clinic as a case of an unrelated renal kidney donor. He had a history of irritable bowel syndrome (IBS) and was taking medication only when flair-ups occurred. He had no surgical or blood transfusion procedures, no history of allergies, and no record of active infectious disease. The patient’s clinical and laboratory parameters were normal.

At the time of admission, the patient had a soft and lax abdomen with no scars. The Laparoscoendoscopic single site (LESS) donor nephrectomy procedure took place the next morning. The operation went well; however, a minor complication arose, which was a mesenteric defect that occurred while mobilizing the left colic flexure and was left un-closed. It was left un-closed due to its size being considered too large for a hernia to occur.

The patient had an uneventful postoperative (post-op) course. The day after the surgery upon inspection, the abdomen was soft and lax, able to tolerate oral feeding, and was passing flatus. The patient was discharged on that day, with no complaints and in good condition.

One day after discharge (day 2 post-op), the patient presented to the emergency room (ER) complaining of abdominal pain and thus received intravenous (IV) hydration and analgesia. After a slight improvement in symptoms, he decided to go home against medical advice. He returned to the ER a few hours later with the same complaint and was managed conservatively and discharged.

The next day (day 3 post-op), the patient presented to the ER with abdominal pain, nausea, and vomiting for 1 h. Upon examination, his abdomen was distended with mild tenderness all over his abdomen. Laboratory reports presented; Hb 14.3 g/dL, WBC 24.83 × 10⁹/L, and CRE 107 µmol/L. CT was also done, showing dilated jejunal and proximal ileal loops reaching up to 3.5 cm with focal abrupt transition points seen in the distal jejunum with collapsed distal small bowel loops. Based on CT scans, lab results, and examination, the patient was diagnosed with small bowel obstruction (SBO).

The patient was admitted and kept on nothing by mouth (NPO). Anesthesia was consulted and the patient was prepared for a laparoscopic exploration using the same incision and the same technique as the previous LESS.

Intraoperatively, dilated bowel loops with herniated small bowel through a mesenteric defect were found as shown in Fig. 1. It is believed that even though the defect was too large to cause herniation it was split into two smaller openings via a crossing artery. A transitional zone was identified, and the bowel was taken out of the mesenteric defect and found to be healthy with no necrosis. The mesenteric defect was closed using V- Lock monofilament (Glycolide, dioxanone, and trimethylene carbonate. 710 Medtronic Parkway Minneapolis, MN55432-5604USA) stitch, and hemlock, suction of fluids and then closure was done as seen in Fig. 2. The decision to use V- Lock monofilament was due to it not requiring any ties which are difficult to do during LESS, saving time. The hemlock was used as a precautionary step to minimize the chance of the stitch slipping backward due to any stretch or pressure.

Fig. 1.

Left colon mesenteric defect with small bowel going through the hernia site

Fig. 2.

The use of hemlock and V- Lock monofilament (Glycolide, dioxanone, and trimethylene carbonate. 710 Medtronic ParkwayMinneapolis, MN55432-5604USA) to close the mesenteric defect. The use of hemlock was avoided in parts where a significant mesenteric vessel was at the edge of the defect

Postoperatively, the patient was sent to recovery after extubating and all vitals were stable.

The patient stayed for 2 days and was discharged in good condition after he tolerated oral intake, passed normal bowel movements, and all parameters were found to be within normal ranges. He later came to the outpatient clinic for a follow-up and was doing fine.

Discussion

Our study presents a rare case of an internal trans mesenteric hernia transpiring within the first 2 days following a LESS donor nephrectomy procedure. IH is considered a rare complication with dangerous repercussions including bowel obstruction, ischemia, and necrosis [8]. When looking at common complications of our procedure, internal hernias were not on that list. Nevertheless, umbilical hernias were viewed as the most common type of hernia [8]. IH has been reported in cases of radical nephrectomy with renal cancer, where it can be attributed to extensive dissection and mesenteric rents [2, 3].

Various studies report donors with hypertension, smoking, and obesity have an increased tendency to develop complications following the LDN procedure [6]. Nevertheless, our patient did not present with any of these risk factors. Moreover, studies with higher rates of complications had a higher proportion of donors with non-white races [6]. Possible risk factors for the development of an IH include anything that causes a congenital or acquired defect of the abdominal viscera, in our case an iatrogenic defect of the mesentery. An acquired cause of IH is considered a post-surgical complication with a mesenteric defect; nevertheless, surgical experience does not appear to play a role in the occurrence of IH as a complication [8]. Our case presents a patient who is relatively healthy with no serious medical conditions. His only recorded condition was IBS which may have contributed to the occurrence of IH due to irregular bowel motility. In the study by Regan JP et al., a possible relationship between low body mass index (BMI) (< 18.5) and instances of IH was highlighted; however, our patient has a normal BMI of (21.2). Another explanation could be an increase in abdominal pressure which could be caused by increased physical activity after surgery due to poor medical compliance, or straining during defecation. This was seen in our patient as they were not compliant with prescribed laxatives, ambulation, and were straining to pass stool.

We identified two case reports which discussed the occurrence of internal hernias after LDN. In a 1999 published report presented by Knoepp et al., a case was presented of a 25-year-old male who underwent the procedure and presented with an internal hernia 6 weeks postoperatively [9]. The only similarity between both cases was the patients’ demographic, where both were relatively young at presentation. Contrary to our case, the Knoepp et al. case presented with symptoms of internal hernia 6 weeks after the surgery, while in our case it was within the first 2 days after the procedure. Another difference would be the procedure used in the Knoepp et al. case was a traditional laparoscopic donor nephrectomy, whereas in our case LESS procedure was done. The second case was back in 2002 when Regan JP et al. looked at a total of 635 patients who underwent LDN between the years of 1996 (March) and 2001 (August). The study showcases three separate patients who developed internal hernias due to the procedure (0.47% of cases) [10]. Similar to our case, all three patients who had internal hernias were male, however, there was variability in patient age (23, 46, and 59 years). Additionally, in the occurrence of signs and symptoms of internal hernia in the Regan JP et al. case, the documented cases all occurred within the first postoperative week with one case occurring as soon as the 3rd postoperative day [10].

This study presents a rare complication of LESS procedures, which has only been documented in two other studies. The grey area regarding the occurrence of such an event could be attributed to various ill-defined responsive measures taken to investigate this issue. Hence, various limitations were identified: (1) Lack of information on the activities undertaken by the patient following the LESS procedure. This information is critical in identifying if other factors played a role in the occurrence of IH. (2) Inherent recall bias during initial data collection from the patient, which is prone to happen in studies involving human subjects. Furthermore, our study’s outcomes cannot be generalized as a common complication to all patients undergoing LESS; however, it remains a critical issue to investigate.

We also wanted to shed light on the safety and feasibility of using laparoscopy in the management of bowel obstruction. It was decided to use this approach with this specific patient because of the very recent previous operation– less than one week- thus the previous incisions were reused for the laparoscopy. Previous literature has also proved the advantages of the procedure such as in Szeliga J et al. review where it is mentioned how in cases where laparoscopy was used to treat obstructed bowel they presented with reduced complication rates, shorter hospitalization time, and lower use of analgesics [11].

Conclusion

Although hernias in general might be a common complication of laparoscopic donor nephrectomy, internal hernias have been rarely reported in previous studies especially post LESS. Our study presents a scarce event of the IH occurrence in LESS. The incidence of mesenteric defects during the procedure is probably under-reported and most of the time under-estimated. However, knowing that IH is unpredictable, we recommend that mesenteric defects are closed to avoid the risk of IH. We also demonstrated that using the minimally invasive technique (LESS) when re-exploring IH for treating such complications, is safe and helps in early recovery.

Abbreviations

LDN

Laparoscopic donor nephrectomy

LESS

Laparoendoscopic single-site surgery

IH

Internal hernias

IBS

Irritable bowel syndrome

post-op

Postoperative

ER

Emergency room

IV

Intravenous

SBO

Small bowel obstruction

NPO

Nothing by mouth

Author contributions

A.A., Y.B. & R.H. wrote the main manuscript and collected data. G.A., performed the surgery and provided the data. G.A., A.A., Y.B., R.H., T.J., M.J., and N.K. reviewed the manuscript.

Funding

No funding has been provided.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Ethical approval was provided by King Faisal Specialist Hospital and Research Centre under the IRB approval number IRB 2023-CR-32. Written consent was provided by the patient to document and publish his procedures.

Consent for publication

The patient has provided written consent agreeing to the documentation and publishing of the case.

Competing interests

The authors declare no competing interests.