Internal Hernia Research Articles

Changing patterns and surgical outcomes of small bowel obstruction in the era of minimally invasive surgery for colorectal cancer.

This study aimed to investigate whether the incidence, patterns, and surgical outcomes of small bowel obstruction (SBO) have changed in the era of minimally invasive surgery (MIS) for primary colorectal cancer (CRC). Consecutive patients who underwent laparotomy for SBO were divided into MIS and traditional open surgery (TOS) groups based on the previous colorectal cancer operation technique used. The MIS group was selected from 1544 consecutive patients who underwent MIS as a treatment for primary CRCs between 2014 and 2022, while the TOS group was selected from 1604 consecutive patients who underwent TOS as a treatment for primary CRCs between 2004 and 2013. The demographics, clinicopathological features, and surgical outcomes were compared between the two groups. The SBO incidence in patients who underwent MIS for primary CRC was significantly lower than that in patients who underwent TOS (4.4%, n =68/1544 vs. 9.7%, n =156/1604, P <0.0001). Compared with the TOS group, the MIS group had significantly different ( P <0.0001) SBO patterns: adhesion (48.5 vs. 91.7%), internal herniation (23.5 vs. 2.6%), external herniation (11.8 vs. 1.9%), twisted bowel limbs (4.4 vs. 0.6%), ileal volvulus with pelvic floor adhesion (5.9 vs. 1.9%), and nonspecific external compression (5.9 vs. 1.3%). A subset analysis of patients with adhesive SBO (ASBO) showed that the MIS group tended to ( P <0.0001) have bands or simple adhesions (75.8%), whereas the TOS group predominantly had matted-type adhesions (59.4%). Furthermore, SBO in the MIS group had an acute (<3 months) or early (3-12 months) onset (64.7%), while that in the TOS group ( P <0.0001) had an intermediate or a late onset. When the surgical outcomes of SBO were evaluated, the TOS group had significantly more ( P <0.0001) blood loss and longer operation time; however, no significant difference was observed in the surgical morbidity/mortality (Clavien-Dindo classification ≧3, 11.8 vs. 14.1%, P =0.6367), hospitalization, and readmission rates between the two groups. Postoperative follow-up showed that the estimated 3-year (11.37 vs. 18.8%) and 6-year (25.54 vs. 67.4%) recurrence rates of SBO were significantly lower ( P =0.016) in the MIS group than in the TOS group. The wide adoption of MIS to treat primary CRC has led to a lower incidence, altered patterns, and reduced recurrence rates of SBO. Awareness of this new trend will help develop surgical techniques to prevent incomplete restoration of anatomical defects and bowel malalignments specifically associated with MIS for CRC, as well as facilitate timely and appropriate management of SBO complications whenever they occur.

IBC-Oxford University2023_BJSPoster_6Management of Gastrointestinal Obstruction due to Internal Hernia after Bariatric Metabolic Surgery

Abstract Background Gastrointestinal obstructions after bariatric metabolic surgery are uncommon. They could occur in the form of internal hernias, and port site hernia as we will present in this presentation. Objectives This work aims to introduce novel techniques for managing gastrointestinal obstructions after bariatric metabolic surgery. Methods This case-series study presents 3 cases with different types of gastrointestinal obstructions after bariatric surgery and the management plan. Results The postoperative results in 3 patients were uneventful, with excellent recovery. Conclusion All types of gastrointestinal obstructions which frequently occur in general surgery could also happen after bariatric surgery. So, we must respect patient complaints even if the investigations are not conclusive, and we have to respect also rare cases of obstruction related to bariatric surgery.

IBC-Oxford University2023_BJSPoster_14Short-Term Outcomes of Single-Anastomosis Sleeve-Ileal Bypass (SASI)

Abstract Background The SASI bypass, which is a simplified version of sleeve gastrectomy with transit bipartition, is based on the same metabolic principles, particularly the early postprandial ileal brake. Compared to SASI bypass, sleeve gastrectomy offers advantages such as shorter operation time and lower incidence of internal herniation. The aim of this study was to assess the safety and outcomes of SASI bypass over a 3-year follow-up period. Methods A retrospective study was conducted on all patients who underwent SASI bypass between January 2018 and June 2023. The primary endpoints were weight loss and diabetic remission. Results A total of 54 patients, with a mean age of 39,4 ± 15 years and a mean body mass index of 38,5 ± 6,8 kg/m2, underwent SASI bypass. There was no significant early postoperative complications. At the end of the first year, the average percentage of excess weight loss (%EWL) was 82,6 ± 7,4, and the rate of diabetic remission was 96,1 %. After 3 years, the %EWL was 97,4 ± 4,1, and the diabetic remission rate was 98,8%. Severe protein-energy malnutrition occurred in 4 patients(7,4%), and reversal of the bypass were made in 3 of 4 patients. Technical variations did not significantly affect %EWL or diabetic remission. Conclusion SASI bypass demonstrated promising outcomes in terms of 3-year %EWL and diabetic remission. While the double-outlet for gastric content allows access to the duodenum, it may hinder the standardization of postoperative care. Furthermore, the presence of a double-outlet does not guarantee the absence of malnutrition.

Lessons learnt in the management of paraduodenal hernias: a case series.

Paraduodenal hernias (PDH) are rare congenital internal hernias with non- specific symptoms. Left-sided paraduodenal hernia is three times more common than right-sided paraduodenal hernia with similar clinical presentation but different embryological origins. We report a series of eight cases of paraduodenal hernia who presented with varied clinical presentation ranging from vague abdominal pain to complete intestinal obstruction. Six cases had left-sided paraduodenal hernia, while two cases had right-sided paraduodenal hernia. Seven cases based on their presentation underwent surgery either electively or on emergent basis. Three cases underwent laparoscopic repair. One case had a recurrence and was re-operated four months later. There was no mortality among any of the cases. A pre-operative diagnosis of paraduodenal hernia is essential. Laparoscopic surgery is safe in select cases and is found to be beneficial.

EGS P23 A rare case of gallstone ileus post Roux-en-Y Gastric Bypass: Stone migration from large duodenal diverticulum

Abstract Background Small bowel obstruction following Roux-en-Y gastric bypass is common and is mainly attributed to adhesions or internal herniation. Intraluminal formation of stones, usually in areas of stasis due to the anatomical changes post-RYGB, and migration to the distal ileum to cause acute bowel obstruction is rare. Impacted stones at the duodenal diverticulum can trigger diverticular inflammation, back pressure to the common bile duct and pancreas resulting in abdominal pain, nausea and vomiting, intermittent derangement of liver enzymes and episodes of cholangitis and pancreatitis. The impaction at the distal ileum is an emergency requiring prompt diagnosis and intervention to prevent complications. Methods This is a case report of a 56-year-old female who presented at East Surrey Hospital in February 2023 with recurrent upper abdominal pain, nausea and vomiting. She previously underwent an open cholecystectomy for cholelithiasis and cholecystoduodenal fistula (2003) and a Roux-en-Y gastric bypass (2018). Her symptoms were initially thought to be secondary to inflammation and periduodenal abscess managed with antibiotics, but as time and scans (CT, MRCP, water-soluble contrast, gastroscopy) progressed without resolution of her symptoms it became evident that she had developed mechanical bowel obstruction. We described her case and the diagnostic challenges leading to the final surgical management. Results To investigate the patient’s symptoms, her intermittently raised inflammatory markers, deranged liver enzymes and amylase a series of radiological examinations was rperformed. Initial CT scan showed an inflamed large duodenal (D3) diverticulum and fluid filled proximal duodenum. Subsequent MRCP demonstrated dilated common bile duct and intrahepatic ducts without any ductal stone. Repeat CT scan two weeks later, confirmed small bowel obstruction due to a heterogenous bolus at the ileocecal valve with resolution of the duodenal inflammation and dilatation. The patient underwent a laparoscopic extraction of a stone impacted at the ileocecal valve causing small bowel obstruction and recovered well. Conclusions Even though small bowel obstruction due to stone aggregation is uncommon post-RYGB, a high index of suspicion for the diagnosis and a low threshold for early laparoscopic intervention can prevent further serious complications. Reporting these cases in literature offers a guidance for the workup and management of these unusual scenarios amongst surgical teams and improves patients’ outcomes.

Ultrasound as the first line investigation for midgut malrotation: a UK tertiary centre experience

To present the first 22-months experience of transitioning to an ultrasound-first pathway for suspected midgut malrotation. An "ultrasound-first" imaging pathway was initiated in October 2021. Twenty-two-months later, a search was undertaken of all <1-year-old patients with "bilious", "malrotation," or "volvulus" as the imaging indication. Reports and images from upper gastrointestinal fluoroscopy (UGI) and ultrasound were reviewed, and diagnoses and outcomes were documented. The search yielded 101 eligible cases between October 2021 and July 2023. Of the patients, 63/101 (62%) had both ultrasound and UGI: 47/63 (75%) ultrasound first, 16/63 (25%) UGI first. Thirty-one per cent (31/101) had ultrasound only and 7/70 (10%) UGI only. The pathway diagnosed 7/8 (88%) infants with midgut malrotation with or without volvulus and one infant who had an inconclusive ultrasound examination with a suspected an internal hernia and who was found to have malrotation volvulus at surgery. Twenty-one infants who had confidently normal ultrasound examinations and who also had UGI all had a normal duodenojejunal flexure position. Ultrasound detected alternative pathology in eight children. Duodenal visualisation improved with time: 6/15 (40%) in the first 6 months to 23/34 (68%) after the first year. The transition to ultrasound as the first diagnostic test for midgut malrotation can be done safely and effectively in a UK centre, which previously relied solely on UGI.

Acute Intestinal Occlusion: Think About Supra Bladder Internal Hernia

Internal hernia of the supravesical fossa is a rare cause of intestinal obstruction [1]. This pathology arouses great interest among radiologists and surgeons due to its diagnostic difficulty, even with the advancement of different imaging techniques, particularly computed tomography [2]. We present the case of a patient without a history of laparotomy who presented with acute intestinal obstruction. Computed tomography examination revealed a strangulated left supravesical internal hernia. Diagnostic confirmation was obtained by laparoscopic exploration.

Very low risk of short bowel after Roux-en-Y gastric bypass – a large nationwide Swedish cohort study

BackgroundRoux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedures. Internal herniation may lead to small bowel ischemia requiring small bowel resection, resulting in short bowel syndrome. ObjectiveTo determine the incidence of extensive small bowel resection in patients operated with RYGB. We also aimed to look for early clinical warning signs among patients requiring extensive small bowel resection. SettingCohort from national quality registers. MethodsAll patients having undergone RYGB between January 2007 to June 2019 were analyzed in the Scandinavian Obesity Surgery Registry (SOReg). We identified patients with small bowel obstruction (SBO) for whom small bowel resection was necessary. Additionally, we assessed clinical signs in these patients. ResultsThe study included 57,255 patients having undergone RYGB. Closure of the mesenteric openings was performed in 78%. Surgery for SBO was required in 3659 (6%) of patients, and small bowel resection in 188 (.3%). Extensive small bowel resection, resulting in less than 1.5 meters of remaining small bowel, was required in 7 patients (.01%). All patients with extensive small bowel resection presented with abdominal pain and had confirmed internal herniation as the cause of the small bowel resection, and 2 of 7 patients died. Closure of mesenteric defects was not associated with a reduction in overall small bowel resection rates (P = .89) ConclusionSurgery for SBO after RYGB was common (6%). The risk of extensive small bowel resection leading to short bowel was low (.01%). Patients with abdominal pain after RYGB should be assessed for internal hernia, as it can be devastating.

A Rare Case of Internal Hernia of Partial Volvulus Right Colon through Foramen of Winslow &amp; Its Management by Laparoscopic Approach

Introduction: Foramen of Winslow hernias is a rare and critical form of internal hernia that can present in individuals with signs and symptoms of bowel obstruction. This case report entails the operative management of a right-side colon herniation through the foramen of Winslow in an elderly female with a previous history of Hysterectomy. The patient presented with worsening abdominal pain, nausea, and multiple episodes of vomiting. Delay in diagnosis often results in higher morbidity and mortality. Case Presentation: A 46 years old female, presented with acute upper abdominal pain, constipation, and loss of appetite for 24 hrs. Computed tomography showed foramen of Winslow hernia with partial volvulus right colon as content with incomplete rotation of gut which was managed laparoscopically without the need for bowel resection. The patient recovered well with no postoperative complications and no immediate technical failure of repair confirmed by a cross-sectional study. The patient is doing well on follow-up. Discussion: Herniation of the bowel through the foramen of Winslow is very rare, comprising only 8% of all internal herniations. Historically, the majority of cases were diagnosed intra-operatively during laparotomy. Bowel resection was often done in cases of ischemia. In recent times, early diagnosis &amp; increasing expertise in minimal access surgery that is resulting in a lower morbidity and mortality rate along with other added benefits of minimal access surgery. Conclusion: Herniation contents through the foramen of Winslow is a rare condition. Patients will present with sudden onset abdominal pain. Early imaging helps to recognise the diagnosis and could prevent bowel ischemia &amp; its management with minimal access surgery leads to early recovery, shorter hospital stay, less pain &amp; early return to work.

A case of internal hernia in the pararectal fossa

BackgroundInternal hernias are relatively rare and difficult to diagnose. Diagnostic delays lead to the progression of strangulation. In particular, pararectal fossa hernias are extremely rare. We encountered a case in which internal hernia occurred in the pararectal fossa.Case presentationAn 87-year-old woman was referred to our hospital because of persistent lower abdominal pain and vomiting. Contrast-enhanced computed tomography revealed findings of intestinal ischemia, such as closed loop formation with reduced contrast effect on the left side of the rectum in the pelvis. Strangulation small bowel obstruction was diagnosed, and emergency laparotomy was performed. The small intestine was found to invade the peritoneal reflection on the left side of the rectum. The patient was finally diagnosed with pararectal fossa hernia. The incarcerated small intestine was released with no bowel resection. The 4-cm hernia phylum was observed and closed by simple suture. The patient had a good postoperative course without recurrence.ConclusionsWe encountered a very rare case of internal hernia in the left pararectal fossa. Preoperative diagnosis of this disease is difficult, but it should nevertheless be considered in cases in which the cause of the intestinal obstruction is unknown.

S4008 The Complicated Rule of Two’s in an Adult: Meckel’s Diverticulum Incarcerated in a Volvulus Internal Hernia

S4008 The Complicated Rule of Two’s in an Adult: Meckel’s Diverticulum Incarcerated in a Volvulus Internal Hernia

Management of Early Postoperative Bleeding After OAGB: A Single-center Experience.

One anastomosis gastric bypass (OAGB) has gained popularity among bariatric surgeons due to the shorter operative time, fewer sites for anastomotic leaks and internal herniation, shorter learning curve, ease of reversibility and revision with equivalent results to Roux en Y gastric bypass in terms of weight loss and co-morbidity resolution. We present our experience in managing early postoperative bleeding after OAGB. Patients who underwent OAGB in Bariatric Surgery Unit, Ain Shams University Hospitals between January 2016 and January 2023 were followed up for 30 days for early postoperative complications. Patients were 210 females (70%) and 90 males, with a mean age of 41.3±7.1 years, and mean preoperative body mass index of 45.2±6.1kg/m². The incidence of early postoperative bleeding, the sites of the bleeding and management strategy were reported. Fourteen of 300 patients (4.67%) developed early postoperative bleeding after OAGB. Intraluminal bleeding occurred in 4 patients, 3 of which were controlled by endoscopy and one by laparoscopic suturing. Intra-abdominal bleeding occurred in 10 patients, 7 of which were successfully managed conservatively, and 3 required laparoscopic management. Two cases had both intra-abdominal bleeding and intraluminal bleeding in the distal stomach, confirmed by intraoperative endoscopy, and controlled by laparoscopic suturing. Early postoperative bleeding after OAGB is a rare complication (4.67%). Conservative treatment is more successful in controlling intra-abdominal bleeding. In case of failed conservative treatment, laparoscopy is the method of choice. Most cases of intra-luminal bleeding need early endoscopic intervention.

Comparison of Single Versus Double Anastomosis Bariatric Metabolic Surgery in Obesity: a Systematic Review and Meta-analysis.

Major BMS are modified through loop rather than Roux-en-Y type reconstruction recently, and this study systematically reviews the BMS from the perspective of SA(single anastomosis) and DA(double anastomosis) procedures, aiming to research the differences among bariatric procedures. A total of 39 studies compared SA- and DA-BMS were finally eligible for analysis after searching in PubMed, Web of Science, and Cochrane Library. Compared with DA, SA shortens operative time and decreases complications especially obstruction, internal hernia, and reoperation. SA-GB(gastric bypass) has significantly higher %TWL and T2DM remission rate than DA-GB 1- and 5-year postoperatively. SA-DS(duodenal switch) has similar 1-year %TWL and lower 5-year %TWL, and comparable 1- and 5-year T2DM remission with DA-DS. SA provides significant advantages about simplicity and safety. This, together with the shorter learning curve, makes SA a promising choice.

Barbed vs. Conventional Sutures in Bariatric Surgery: Early and Late Outcomes

The implementation of barbed sutures appears to enhance the process of suturing and knot tying, particularly in the field of bariatric surgery, where they can offer significant advantages. The objective of this study is to evaluate the safety and effectiveness of utilising barbed sutures for gastric pouch-jejunal anastomosis (GPJA) and jejuno-jejunal anastomosis (JJA) anastomosis in Roux-en-Y Gastric Bypass (RYGB). Data from patients who underwent primary RYGB between January 2012 and October 2018 were retrospectively collected using Propensity Score Matching (PSM) to randomise groups (barbed sutures—BS-G and conventional sutures—CS-G). The primary outcome was postoperative early complications. The secondary outcomes were late complications (internal hernias and small bowel obstructions), operative time and postoperative hospital stay. A total of 969 patients were included. After PSM, 322 (161 in BS-G vs. 161 in CS-G) patients were compared (chi-square 0.287, p = 0.862). Postoperative early and late complications were comparable between the two groups. BS-G had a significantly shorter median operative time (65 vs. 95 min p &lt; 0.001). Median postoperative hospital stay was significantly shorter for BS-G (2 vs. 5 days, p &lt; 0.001). Barbed sutures effectively reduce the operation duration and are as safe as conventional sutures for closing anastomotic defects during RYGB.

1148 A Rare Case of Loose Right Medial Umbilical Ligament Found During Laparoscopic Appendectomy

Abstract Aim We report this extremely rare variation of loose medial umbilical ligament discovered incidentally during laparoscopic appendectomy. This can be a potential cause of bowel obstruction and internal herniation or cause technical difficulty during laparoscopic surgery. Method A 29-year-old man presented to the emergency department with one day history of central abdominal pain that shifted to right iliac fossa associated with nausea and vomiting. He has no significant past medical history. His abdominal examination revealed tenderness and guarding in the right iliac fossa and his inflammatory markers were elevated. A clinical diagnosis of acute appendicitis was made. Results The patient was brought to the operating theatre for laparoscopic appendectomy. Laparoscopy revealed acutely inflamed appendix and also a completely redundant rounded structure extending from the anterior abdominal wall just to the right side of the umbilicus to the small bowel mesentery consistent with right medial umbilical ligament. The left medial umbilical ligament was entirely normal. Excision of right medial umbilical ligament was done using LigaSure laparoscopic instrument and was sent for histology. Laparoscopic appendectomy was also performed. The patient recovered well with no complications. Conclusions The medial umbilical ligament is the obliterated umbilical artery. This anatomical variation of the medial umbilical ligament is extremely rare. Surgeons should be aware of anatomical variations of medial umbilical ligament especially during laparoscopic surgeries at it may affect the surgeon’s preference for trocar locations.

60 Mesenteric defect closure and the rate of internal hernia in laparoscopic Roux-en-Y gastric bypass: A systematic review and meta-analysis

Abstract Introduction Laparoscopic Roux-en-Y gastric bypass (LRGB) is an increasingly popular operation as rates of obesity rise. Internal hernias pose a worrying complication. This meta-analysis aimed to determine if internal hernia rates were reduced by closure of the mesenteric defects at primary operation. Method A systematic review was performed identifying all observational and randomised studies comparing internal hernia rates in patients whose mesenteric defects were closed vs not closed during LRGB. Results 14 studies were included, totalling 20,553 patients undergoing LRGB. There was a significant reduction in internal hernia rate at both Petersen’s and the Jejunojejunostomy (J-J) defect when closed at operation. The rate of re-operation for suspected small bowel obstruction was also lower in the closure cohort. There was no difference in anastomotic leak or perioperative bleeding between closure and non-closure patients. Similar efficiency was observed when sutures were used to close the defects compared to clips and staples. Conclusion Mesenteric defect closure is reducing internal hernia rate as well as re-operation for suspected small bowel obstruction. The closure method of choice remains debatable, and further studies are required to determine this.

113 Exploratory laparoscopy in suspected bowel obstruction secondary to a transmesenteric hernia

Abstract Background Transmesenteric hernias (TH) in adults are an uncommon subtype of internal hernia that can be life-threatening because of the risk of bowel ischemia if not correctly diagnosed. Case report A 79-year-old man came to the emergency department with abdominal pain associated with vomiting and constipation for 24 hours. Physical examination showed no alarm signs. However, due to the presence of leukocytosis with neutrophilia and an abdominal X-ray with suspected obstruction, an abdominal CT scan was requested. Given the radiological finding of a defect in the mesentery through which a portion of the mesentery and several loops of bowel were introduced, an exploratory laparoscopy was indicated on suspicion of TH. Intraoperatively, 150 cm from the ileocecal valve, a 30 cm congestive segment of jejunum was observed, which was inserted in a 4 cm long eyelet in the omentum. Reduction of the herniated small bowel loops through the eyelet was performed without difficulty, observing good viability of the loops, and the eyelet was opened with scissors leaving the omentum open at the distal end. The patient was discharged on the 5th postoperative day tolerating oral diet, with transit and the surgical wound without signs of infection. Conclusion Although CT is the best diagnostic test for TH its preoperative diagnosis remains difficult. In the case of suspected TH, early exploratory laparoscopy is a correct technique that can preserve the viability of the bowel.

A Prospective Study on the Diagnoses for Abdominal Pain After Bariatric Surgery: The OPERATE Study

PurposeLong-term follow-up after bariatric surgery (BS) reveals high numbers of patients with abdominal pain that often remains unexplained. The aim of this prospective study was to give an overview of diagnoses for abdominal pain, percentage of unexplained complaints, number and yield of follow-up visits, and time to establish a diagnosis.Materials and MethodsPatients who visited the Spaarne Gasthuis Hospital, The Netherlands, between December 2020 and December 2021 for abdominal pain after BS, were eligible and followed throughout the entire episode of abdominal pain. Distinction was made between presumed and definitive diagnoses.ResultsThe study comprised 441 patients with abdominal pain; 401 (90.9%) females, 380 (87.7%) had Roux-en-Y gastric bypass, mean (SD) % total weight loss was 31.4 (10.5), and median (IQR) time after BS was 37.0 (11.0–66.0) months. Most patients had 1–5 follow-up visits. Readmissions and reoperations were present in 212 (48.1%) and 164 (37.2%) patients. At the end of the episode, 88 (20.0%) patients had a presumed diagnosis, 183 (41.5%) a definitive diagnosis, and 170 (38.5%) unexplained complaints. Most common definitive diagnoses were cholelithiasis, ulcers, internal herniations, and presumed diagnoses irritable bowel syndrome (IBS), anterior cutaneous nerve entrapment syndrome, and constipation. Median (IQR) time to presumed diagnoses, definitive diagnoses, or unexplained complaints was 16.0 (3.8–44.5), 2.0 (0.0–31.5), and 13.5 (1.0–53.8) days (p < 0.001). Patients with IBS more often had unexplained complaints (OR 95%CI: 4.457 [1.455–13.654], p = 0.009). At the end, 71 patients (16.1%) still experienced abdominal pain.ConclusionOver a third of abdominal complaints after BS remains unexplained. Most common diagnoses were cholelithiasis, ulcers, and internal herniations.Graphical

Transanal Minimally Invasive Surgical Approach to Total Pelvic Exenteration.

Total pelvic exenteration, a surgical procedure for patients with highly advanced primary and recurrent rectal cancer, is technically demanding. We report the utility of a transanal minimally invasive surgical approach to total pelvic exenteration. A 2-team approach with a laparoscopic transabdominal approach and transanal minimally invasive surgery was adopted. During the transabdominal approach in the pelvis, dissection was performed to remove the pelvic organs and visceral branches of the internal iliac vessels. The dissection goal via the transabdominal approach is the levator ani. During the transperineal approach, dissection is performed along the levator ani, and the tendinous arch of the levator ani is penetrated at the lateral side to achieve rendezvous between the 2 approaches. The levator ani is then dissected circumferentially, with identification of the internal pudendal vessels passing through the levator ani at the 4 o'clock and 8 o'clock positions, known as Alcock's canal. The anterior wall of Alcock's canal is formed by the coccygeus muscle and sacrospinous ligament, which are dissected by the transperineal approach to open Alcock's canal, thus obtaining a clear view of the internal pudendal vessels. On the anterior side, the urethra is divided with a laparoscopic linear stapler via the transperineal approach. Eight patients with rectal cancer underwent this procedure. The median (range) blood loss was 200 (120-1520) mL and operating time was 467 (321-833) minutes. Reoperation was performed in 1 internal hernia case; however, there were no mortalities, and there were no cases with severe complications or conversion to open surgery. When performing total pelvic exenteration, transanal minimally invasive surgery offers direct visualization behind the tumor from the anal side and shows the deep pelvic structures, including the retroperitoneal space of the pelvic sidewall.

Internal Herniation of Small Bowel Underneath Iliac Vascular Axis After Pelvic Surgery: A Systematic Review.

Internal abdominal hernias are rare entities that most commonly present with acute small bowel obstruction. These hernias can be congenital or acquired. While congenital hernias are considered the most common type, acquired hernias are becoming more common. Recently, a rare type of internal herniation has been reported underneath iliac vasculature in patients who have undergone pelvic lymph node dissection in the past. This study was carried out to assess the prevalence of this rare type of internal hernia. Two reviewers searched the literature in three online databases using the Cochrane methodology for systematic reviews. The search of databases yielded 70 articles. The studies which reported internal herniation underneath iliac vasculature were included. Studies that reported herniation underneath other pelvic organs or vasculature were excluded. After screening, 17 articles were deemed suitable and selected. All 17 cases reviewed underwent pelvic lymph node dissection in the past. The median latency period between index surgery and clinical presentation with the incarcerated hernia was 20 months. All 17 cases were managed surgically with small bowel resection carried out in 13 cases. Eleven authors reported closing the hernia defect with various techniques, while five decided not the close it. All 17 cases were alive at the time of discharge from the hospital, with a mean hospital stay of 12.7 days. Given our findings, there should be a high index of suspicion of internal hernia in patients presenting with small bowel obstruction with a history of pelvic lymph node dissection. In our review, internal herniation was always preceded by pelvic lymph node dissection, so the closure of the peritoneum should be considered while pelvic lymph node dissection is carried out.