Mesenteric defect after laparoscopic left hemicolectomy: to close or not to close?

Abstract

Dear Editor: Laparoscopic surgery for colorectal cancer is being performed in increasing frequency over the last decades. Studies have shown the advantages and safety of laparoscopic colorectal surgery, such as decreased pain, improved cosmesis and early return to normal activities, thus making it the preferred method in the treatment of colorectal diseases. With laparoscopic colorectal surgeries becoming commonplace nowadays, surgeons are encountering complications related to laparoscopic work more frequently than before. Of interest, small bowel obstruction arising from internal herniation of the small bowel through a colon mesenteric defect may be occurring more frequently than we thought, potentially misleading one to overlook the possibility of such event when it arises. This would then lead to a delayed diagnosis and the catastrophic consequence of bowel ischemia and inevitable loss of unhealthy bowels. Traditionally, mesenteric defects created during laparoscopic colorectal surgery are not routinely closed. This is attributable to various reasons. These include technical difficulty due to limited surgical space, prolonging operative times in closing the defect, potential injury to mesentery blood supply jeopardizing bowel anastomosis healing, and even injury to underlying structure such as the ureters. Here, we would like to report a case of internal herniation following laparoscopic colonic surgery and review of literatures of its occurrence and management. An 80-year-old man was admitted for elective surgery for distal transverse colon tumor. Preoperative colonoscopy examination showed a 3×3 cm ulcerative tumor. The patient underwent laparoscopic left hemicolectomy with intracorporeal ligation of tumor feeding vessels (left colic and left branch of middle colic vessels) at their origins. Resection of the colon with functional end-to-end anastomosis was performed extra-corporeally using linear staplers via a 4-cm midline abdominal incision. Anastomosis and position of the small bowel was checked laparoscopically to ensure no trapping of the small bowel at the colonic mesenteric opening. Postoperative recovery was uneventful, and he was discharged from the hospital on day 7. Final histology showed a T2N0M0 stage I tumor. However, on postoperative day 12, the patient presented to the emergency department with 1-day history of abdominal pain associated with nausea and vomiting. Physical examination revealed a distended abdomen with generalized tenderness. Computed tomographic scanwas performed and showed dilated small bowel loops with a transitional point in the left side of the abdomen, associated with edema and poor enhancement of the bowel wall. There was also mild mesenteric engorgement and ascites suspicious for vascular compromise. Patient was immediately prepared for emergency laparotomy. On entry of the abdomen, there was a moderate amount of clear ascitic fluid. Congested small bowel loops from the proximal jejunum to the terminal ileum were found to have herniated through the colonic mesenteric window defect. The extent of the original mesenteric window was greatly narrowed by adhesion formation between the mesentery and retroperitoneum, resulting in a 3-cm mesenteric defect. These small bowel loops were reduced from the mesenteric defect and examined for viability. The small bowel returned to normal color within minutes after reduction, and no resection was required. The mesenteric defect was then closed with * Wen Hui Sim wenhui.sim@mohh.com.sg