Strangulated small bowel obstruction complicating totally extra-peritoneal laparoscopic inguinal hernia repair

Abstract

Totally extraperitoneal (TEP) laparoscopic inguinal hernia repair is a surgical method of inguinal hernia repair that avoids entry into the peritoneum, thus significantly reducing likelihood of intra-peritoneal complications. Herein, we describe a rare case in which a 42-year-old man presented with acutely strangulated small bowel in an internal hernia through the peritoneum and posterior rectus sheath 6 days postelective TEP laparoscopic inguinal hernia repair. He presented with acute onset severe abdominal pain and intractable vomiting. After CT diagnosis, emergent laparotomy was performed, and 20 cm of non-viable small bowel required resection, with enteric anastomosis. The peritoneal defect was identified and repaired. The patient was discharged 4 days postoperatively with an uneventful postoperative course.

Background

Laparoscopic operations offer an advantage of rapid postoperative recovery¹ and reduce the inpatient hospital stay. However a rapid expansion in the volume and complexity of laparoscopic surgery and laparoscopic approach in most surgical scenarios has been accompanied by complications. It follows that early identification of complications plays a major role in preventing serious outcomes. Peritoneal injury in preperitoneal approach for laparoscopic inguinal hernia repair is a rare complication, and it can be overlooked or missed due to its rarity. However, it can have serious implications. This unusual complication highlights the importance of identifying peritoneal defects during preperitoneal approach as a big pocket has been already made through CO2 inflation in the pre-peritoneal plane. Repairing of that defect is crucial in preventing hernia evolvement.

Case presentation

A 42-year-old man underwent an elective total extraperitoneal (TEP) laparoscopic right inguinal hernia repair for a fat containing right indirect inguinal hernia by an experienced surgeon with great laparoscopic hernia repair experience. The surgery had uneventful immediate postoperative period. The operation was performed electively through three ports, a 10 mm camera port was inserted 2 cm to the left and parallel to the umbilicus, preperitoneal space was made with CO₂ insufflation, 30 degrees scope used and the two other ports were inserted under direct vision, 5 mm ports at the suprapubic region and 5 mm port at the left iliac fossa, no immediate complications were noted. The right inguinal defect was identified, fat was reduced and mesh fixed in place with no complications. Ports were removed under vision and camera trocar reduced after deflation of the preperitoneal space, then layers were closed. Patient discharged home on the following day uneventfully. On the sixth postoperative day, he presented to the emergency department with severe abdominal pain, most prominent over the peri-umbilical port site, nauseated with recurrent vomiting and profuse sweating. The pain commenced at 11:00 and last bowel motion was early morning which was normal. He started vomiting 1 hour later which mandated his presentation to the emergency department. Clinically he was in severe distress with localised periumbilical tenderness. The abdomen was mildly distended with absent bowel sounds. The surgical wounds were unremarkable aside from bruising was noted at the periumbilical camera port site.

The patient was taken urgently for CT abdomen which demonstrated multiple dilated small bowel loops that had breached the parietal peritoneum and lie within the pre-peritoneal space, although a definitive plane between the posterior rectus sheath and rectus muscle was not evident (figures 1–3). There was a discrete transition point located at the neck of the peritoneal breach port site hernia, with small bowel obstruction. Routine blood investigations showed a white cell count of 12.5×10⁹/L, C-reactive protein of 4.8 mg/L and lactate of 1.8 mmol/L. He was transferred urgently to theatre for exploratory laparotomy.

Figure 1.

Axial CT image demonstrating extraperitoneal incarcerated small bowel obstruction, deep to the abdominal musculature. There is a discrete transition point located at the neck of the peritoneal breach (arrow) with proximal dilated jejunal loops consistent with a small bowel obstruction, although there is no differential bowel wall enhancement or pneumatosis to suggest strangulation.

Figure 2.

Axial CT image demonstrating obstructed loop of small bowel enclosed within compartment superficial to posterior rectus sheath.

Figure 3.

Sagittal CT image demonstrating the site of the Port and the resultant hernia developed postoperatively.

Approach to the hernia was achieved though the periumbilical port wound after removal of the sutures and extension of the wound cephalocaudally. The rectus sheath was divided. A peritoneal defect leading into an enclosed space anterior to the posterior layer of the rectus sheath was identified (figure 4). A loop of small bowel was tightly adherent to the neck with no sac (as the hernia was developed through the peritoneal defect), and gentle manipulation of the neck freed the bowel. The small bowel had an ischaemic segment of 20 cm which failed to re-perfuse (figure 5). The peritoneal defect was closed with 2–0 Ethibond. Then the decision was made to resect the infarcted segment of small bowel, with enteric anastomosis. Peristaltic movements were noted before closure of the abdomen. The abdomen was then closed primarily in layers. The patient transferred to high dependency unit for observation and close monitoring. The postoperative course was unremarkable and he was discharged home on day 4.

Figure 4.

Peritoneal/posterior rectus sheath defect demonstrated to right of artery forceps.

Figure 5.

The ischaemic bowel segment before resection.

Outcome and follow-up

The patient was followed up 6 weeks postoperatively. The wound was completely healed and he returned back to his normal job with full duties.

Discussion

Laparoscopic hernia repair can be associated with a number of unique complications. These include immediate complications associated with the creation of a pneumoperitoneum, the use of general anaesthesia and injuries from trocar insertion. Long-term complications of small bowel obstruction can be related to trocar site fascial defects, intra-abdominal adhesions and reaction with the synthetic mesh. In an effort to decrease these possible complications, a technique involving a totally extraperitoneal preperitoneal endoscopic hernia repair has evolved. This approach does not violate the peritoneal cavity, can be performed under regional anaesthesia, and allows trocars to be placed that do not penetrate the posterior rectus fascia. By not entering the peritoneal space, the risk for small bowel obstruction secondary to adhesions or superficial bowel injury should be eliminated.² This approach is considered to be more difficult than transabdominal preperitoneal but may have fewer complications.³

In our case, a small bowel obstruction and strangulation occurred in the setting of a totally extraperitoneal approach to endoscopic hernia repair, which, in theory, should not occur. The hernia was through a breached peritoneum, the latter was happened during the preperitoneal approach for the right inguinal hernia repair, probably from the blunt instrument or during trocar insertion and gas insufflation. After camera trocar removal and gas deflation, the peritoneal defect was missed. As the incidence of developing peritoneal defects during totally extraperitoneal approach is low, that makes the peritoneal injury overlooked or missed during surgery and before trocar removal. This has been similarly documented in other cases. However, they differ in in the time of presentation and the acuity and severity of the condition. It was previously documented that intestinal obstruction or strangulation was reported frequently following transperitoneal laparoscopic procedures, but most have been Richter-type port site hernias,^{4 5} but in our case there was 20 cm of bowel within the preperitoneal space, herniated and strangulated thought the narrow posterior rectus sheath and peritoneal defect (figure 4). This case has been compared with the previously reported similar cases, it has been noted the bowel strangulation happened at sixth day while in the case reported by Azurin et al,² the bowel was strangulated for 48 hours postoperatively. The other cases reported by Rink et al ⁶ and Lodha et al ⁷ showed small bowel obstruction with no strangulation. Delayed presentation with strangulation suggesting that the bowel had been herniating slowly through the peritoneal defect into the preperitoneal space over the first few subsequent days, probable big preperitoneal space was accommodating the bowels efficiently until a reasonably long segment of the bowel had herniated and incarcerated and eventually strangulated due to narrow peritoneal defect. Early identification of the posterior rectus sheath and/or peritoneal damage prior to trocars removal and suturing it will prevent the development of hernias, in addition, active preperitoneal space gas deflation after thorough inspection of the space for peritoneal defect will further reduce the risk of herniation.

Learning points.

• Total extraperitoneal laparoscopic inguinal hernia repair carries a risk of inadvertent injury to the posterior rectus sheath and peritoneum, with potential for serious intraperitoneal complications.

• The preperitoneal space should be examined thoroughly prior to camera trocar removal.

• Full gas deflation from the preperitoneal space under direct vision may reduce preperitoneal space formation for any potential hernias.