Laparoscopic Assessment of Bowel Viability After Reduction En Masse

BACKGROUND

Strangulated inguinal herniae are common in the emergency setting and are associated with significant morbidity and mortality.^1,2 Reduction en masse may occur in the initial stages of the operation and visualisation of the viability of the bowel is essential before the hernia repair. This usually involves an extension of the original incision and/or a laparotomy resulting in a longer hospital stay, morbidity, mortality² and, in a significant number of cases, bowel resection is not required. We, therefore, describe a laparoscopic technique that allows an adequate assessment of bowel viability without increasing the size or nature of the initial incision.

TECHNIQUE

Should a reduction en masse occur in the early stages of the operation, a 10-mm laparoscopic port is inserted through the hernia sac into the peritoneal cavity. A purse string is then secured around the port, a pneumoperitoneum is established and a 30° laparoscope is passed to assess the intraperitoneal cavity. A further 5-mm port is inserted superiorly, allowing insertion of a non-traumatic instrument. This will allow an adequate assessment of bowel viability, thereby allowing the surgeon to decide whether a bowel resection is required.

DISCUSSION

This unique application of laparoscopy allows the surgeon to assess bowel viability after reduction en masse during the early stages of strangulated hernia repair and, in some cases, will prevent a larger abdominal incision. We have only recently started using this technique; of the three cases managed in this way, one had ischaemic-looking bowel which, after laparoscopic assessment over 20 min, was deemed viable. In the other two cases, there was no evidence of bowel ischaemia. All three patients had uneventful recoveries. A possible false negative rate is a concern and larger study to assess this is warranted.