Monday, July 7, 2008

Internal hernia

During my early training, my attendings always hammered home the notion of closing mesenteric defects after open bowel resection cases. The mesentery is a fan-like sheet of peritonealized fat that suspends the bowels and carries the feeding blood vessels. When you do a bowel resection and an anastomosis, there's always a gap in the mesentery that results. Generally, we close these to prevent internal hernias.

Toward the latter years of my training, with the rise of laparoscopic colectomies, I noticed that more often than not, the mesenteric defect would be left alone after a right colectomy. Too much of a pain in the ass to close it laparoscopically. Besides, I was told, the defect was so big, that even if the bowel herniated through it, there was little chance of strangulation.

Well, I saw a lady last week with a classic SBO on initial imaging. A year and a half ago, she had undergone a laparoscopic right hemicolectomy for a villous adenoma at a "major midwestern university program". I put an NG in but she didn't get better. By day #3, her films still looked lousy so I booked her for an exploration. The point of obstruction involved a loop of ileum that had slipped through the mesenteric defect down into the pelvis and, for whatever reason, formed a weird adhesion to the bowel on the other side of the mesentery, thus completely occluding the lumen at that point. The case itself took 5 minutes, snip snip. I also closed the defect with a running suture. I think it will be interesting to see if we start to see more internal hernias from mesenteric defects as we move deeper into the laparoscopic era of bowel surgery.....

6 comments:

rlbates said...

This and the last post go well together. It will be interesting to see if this becomes more common. Do you think anyone is keeping track of them? Other than just individual docs like you.

Theresa said...

I had a similar case on my hospitalist service. He was in and out several times with SBO, until finally our general surgeon explored him and--internal hernia. Interesting to hear about the underlying technique. Thanks!

Buckeye Surgeon said...

Ramona-
I haven't any long term studies in the literature. It will definitely be interesting to see if we see more of it in the future.

rlbates said...

Would it be appropriate to write a case report for a journal?

Buckeye Surgeon said...

I ought to Ramona.....as soon as this procrastination phase wears off...

Resident Anesthesiologist Guy (RAG) said...

Interesting. I recently saw a pt in the ED for almost the exact same thing. I bet we see an increase - if someone's taking tabs.