A strangulated internal hernia beneath the left external iliac artery after radical hysterectomy with laparoscopic pelvic lymphadenectomy: a case report and literature review

Abstract

Background Ileum obstruction due to internal hernia beneath external iliac artery after pelvic lymph node dissection (PLND) is extremely rare. We reported a case of acute strangulated internal hernia between the left external iliac artery and psoas major as late complication of laparoscopic hysterectomy with pelvic lymphadenectomy. Case presentation A 46-year-old woman, who with histories of laparoscopic hysterectomy, bilateral salpingo-oophorectomy and PLND 9 years ago for the cervical malignant tumor, open appendectomy 18 years ago, visited our hospital complaining of aggravated left lower abdominal pain, bloating, nausea and vomiting from few hours ago. Left abdomen distention, tympanitic with rebound tenderness and muscular tension was detected during physical examinations. Accompanying with elevated inflammatory markers and mild intestinal dilatation showed in lab results and contrast-enhanced computed tomography (CT) respectively. After carefully reading the CT images, a small bowel was found between the left external iliac artery (EIA) and the psoas major, combined with the patient's surgical history, we suspected it might be internal hernia. Eventually, the emergency laparoscopic laparotomy confirmed our conjecture, the gap between the iliac vessels and the psoas major was closed with an absorbable suture, the patient was discharged on the fourth postoperative day. Conclusion Primary closure of peritoneal fissue maybe an effective measure to potentially prevent internal hernia. The choice of surgical approach for pelvic tumors still needs further exploration but faster diagnosis and immediate laparotomy might promise a better prognosis.

Strangulated small bowel obstruction caused by isolated obturator nerve and pelvic vessels after pelvic lymphadenectomy in gynecologic surgery: two case reports

“…According to past papers, vessels or nerves constructing the internal hernia orifice were right common iliac artery (3 cases) [ 12 , 18 , 24 ], left external iliac artery and/or vein (4 cases) [ 17 , 22 , 25 , 27 ], right external iliac artery and/or vein (4 cases) [ 13 , 20 , 23 , 26 ], right superior vesical artery (3 cases) [ 21 , 29 ] and right umbilical artery and/or obturator nerve (5 cases) [ 19 , 28 , 30 ]. In fact, PL-related SBO is more common on the right side than on the left side (Table 1 ), which might be attributable to the fact that the left side is covered with the sigmoid colon.…”

“…The median time to onset from PL was 6 months, but its distribution was from 2 to 108 months, underscoring the point that PL-related SBO can occur anytime in patients with a history of PL. Three of four cases in which the incarcerated small bowel was preserved were of laparoscopic techniques [ 17 , 19 , 22 , 23 ], whereas open surgeries were performed in 13 of 15 cases in which the incarcerated small bowel was removed, including five cases converted from laparoscopic surgeries. Those findings might reflect the difficulty, in many cases, of providing the patients with an accurate diagnosis rapidly.…”

Ileal Obstruction Secondary to Internal Hernia Under the External Iliac Artery: A Case Report and Literature Review

“…Considering the pathology, it is unlikely that a wait and watch policy would be successful and may end up causing more harm than good since the herniated bowel might progress from a stage of incarceration to strangulation and gangrene. Barring Dumont et al [4], who noted no evidence of bowel necrosis on laparoscopy, all other authors have performed a laparotomy in this situation, and all but two patients [4,8] have required resection of dead bowel and anastomosis. In our case, we also wanted to ensure that the ileal conduit was not a part of this pathology or damaged during the procedure.…”

“…There have only been a few reports of bowel herniating under the external iliac arteries, and all of them have occurred following lymphadenectomies for pelvic organ malignancies [1,[4][5][6][7][8][9]. The patients in these reports have presented with features of bowel obstruction between two months and seven years following their lymphadenectomies and invariably have had the operations performed by minimally invasive surgical techniques -laparoscopically or using a robot.…”

“…The scan of our patient revealed features of SBO with no clear point of transition. Some authors have diagnosed this condition by identifying a closed loop of the bowel at the level of the artery [4,5,7,8].…”