559 One Mesenteric Defect, Two Segments of Colon, A Number of Surgical Strategies! A Rare Case of An Internal Hernia Causing Bowel Ischemia

Internal hernias due to mesenteric defects are a rare cause of bowel obstruction, but once present their complications are associated with a high morbidity and mortality. We present the case of a 24-year-old patient who presented to the emergency department with signs and symptoms of an acute abdomen. Following surgical review, taking into consideration the patient’s clinical, biochemical, and radiological findings, the patient was taken for immediate emergency surgical exploration. A laparoscopic approach was initially taken, which revealed dilated and ischemic colon, and therefore an open approach was then adopted. Operative findings included a very mobile caecum and proximal ascending colon which had herniated through a defect in the small bowel mesentery, the sigmoid colon had subsequently become incarcerated by the caecum and small bowel too. Both the ascending and sigmoid colon had become ischemic. A number of surgical strategies were considered, and given the patients age it was decided to preserve as much normal bowel as possible. Thus, a right hemi- and sigmoid colectomy were performed with an ileo-transverse anastomosis and formation of an end colostomy. In this case, radiological diagnosis pointed to a suspicion of an internal hernia, and operative diagnosis highlighted a rare mesenteric defect causing herniation and subsequent ischemia. Relying on the patient’s clinical condition and an early decision for surgical intervention resulted in a positive outcome for outpatient. The patient made a good recovery following the bowel preserving surgery.

Internal Hernia in Pregnant Woman due to Congenital Transmesenteric Defect

Congenital transmesenteric hernias are uncommon and are a rare cause of bowel obstruction, which is even rarer in pregnant woman. Because of the lack of specific symptoms or reliable sensitive markers, it is difficult to diagnose internal hernia at early stage, therefore resulting in the delay of surgical intervention and a high mortality rate, especially in pregnant woman. We report a case in which a woman presenting at 16 weeks gestation was admitted with symptoms of nausea, vomiting and left upper abdominal pain similar to her first-trimester morning sickness. Nephrolithiasis of the left kidney detected by ultrasound may lead to early incorrect diagnosis. Due to the patient`s concern about known adverse effects of ionizing radiation on the fetus, computed tomography was postponed until abdominal pain worsened, coffee color gastric contents vomited and anus stopped exhaust and defecation 12 hours later. Low dose CT plain scan showed features of small bowel obstruction by an internal hernia. Emergency exploratory laparotomy revealed a mesenteric defect of the left colon with a 30 cm long jejunal herniating distal to 10 cm of the ligament of Treitz. The involved small bowel was strangulated and gangrened, necrotic segmental resection and end to end anastomosis were performed subsequently, and the mesenteric defect was then successfully repaired with sutures. doi: https://doi.org/10.12669/pjms.37.5.4116 How to cite this:Yuansheng X, Yi W, Jinyan F. Internal Hernia in Pregnant Woman due to Congenital Transmesenteric Defect. Pak J Med Sci. 2021;37(5):---------. doi: https://doi.org/10.12669/pjms.37.5.4116 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Does the non-absorbable suture closure of the jejunal mesenteric defect reduce the incidence and severity of internal hernias after laparoscopic Roux-en-Y gastric bypass?

Purpose Internal hernias (IH) are frequent complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Closure of the jejunal mesenteric and the Petersen defect reduces IH incidence in prospective and retrospective trials. This study investigates whether closing the jejunal mesenteric space alone by non-absorbable suture and splitting the omentum can be beneficial to prevent IH after LRYGB. Methods Observational cohort study of 785 patients undergoing linear LRYGB including omental split at a single institution, with 493 patients without jejunal mesenteric defect closure and 292 patients with closure by non-absorbable suture, and a minimal follow-up of 2 years. Patients were assessed for appearance and severity of IH. Additionally, open mesenteric gaps without herniated bowel as well as early obstructions due to kinking of the entero-enterostomy (EE) were explored. Results Through primary mesenteric defect closure, the rate of manifest jejunal mesenteric and Petersen IH could be reduced from 6.5 to 3.8%, but without reaching statistical significance. The most common location for an IH was the jejunal mesenteric space, where defect closure during primary surgery reduced the rate of IH from 5.3 to 2.4%. Higher weight loss seemed to increase the risk of developing an IH. Conclusion The closure of the jejunal mesenteric defect by non-absorbable suture may reduce the rate of IH at the jejunal mesenteric space after LRYGB. However, the beneficial effect in our collective is smaller than expected, particularly in patients with good weight loss. The Petersen IH rate remained low by consequent T-shape split of the omentum without suturing of the defect.

Does the non-absorbable suture closure of the jejunal mesenteric defect reduce the incidence and severity of internal hernias after laparoscopic Roux-en-Y gastric bypass?

Objective Internal hernias (IH) are frequent complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Closure of the jejunal mesenteric and the Petersen defect reduces IH incidence in prospective and retrospective trials. This study investigates whether closing the jejunal mesenteric space alone by non-absorbable suture and splitting the omentum can be beneficial to prevent IH after LRYGB. Methods Observational cohort study of 785 patients undergoing linear LRYGB including omental split at a single institution, 493 without jejunal mesenteric defect closure, 292 with closure by non-absorbable suture with a minimal follow-up of 2 years. Patients were assessed for appearance and severity of IH. Additionally, open mesenteric gaps without herniated bowel, as well as early obstructions due to kinking of the entero-enterostomy (EE) were explored. Results By primary mesenteric defect closure, the rate of manifest jejunal mesenteric and Petersen IH could be reduced from 6.5% to 3.8%, but without reaching statistical significance. The most common location for an IH was the jejunal mesenteric space, where defect closure during primary surgery could reduce the rate of IH from 5.3% to 2.4%. Higher weight loss seemed to increase the risk of developing an IH. Conclusion The closure of the jejunal mesenteric defect by non-absorbable suture can reduce the rate of IH at the jejunal mesenteric space after LRYGB. However, the beneficial effect in our collective is smaller than expected, especially in patients with excellent weight loss. Petersen IH rate remained low by consequent T-shape split of the omentum without suturing of the defect.

The effect of mesenteric defect closure on internal hernias and small bowel obstruction in patients undergoing colorectal surgery: A systematic review and meta-analysis

Objective Internal hernias (IH) are potentially severe complications after colorectal surgery and may lead to small bowel obstruction (SBO). However, the impact of mesenteric defect closure (MDC) on IH and SBO is currently unclear. The aim of this systematic review and meta-analysis was, therefore, to investigate the effect of MDC on IH and SBO in patients undergoing laparoscopic and open colorectal surgery. Methods Ovid Medline, PubMed, and Embase databases were searched. Studies reporting MDC in colorectal surgery were enclosed in the systematic review. Meta-analysis included studies that assessed the effect of MDC vs. non-closure (non-MDC) on IH and SBO. Meta-analysis was performed using a random effect model. Results of individual studies were summarized as ranges. Effect sizes were described as odds ratios (OR) with 95% confidence intervals (CI). Results Literature search revealed a total of 344 abstracts. Of these, 16 studies met the inclusion criteria. Included studies comprised a total of 10,068 patients and were published between 2009 and 2019. The incidence of IH and SBO as a composite outcome ranged from 0.0 to 3.5%, whereas the incidence of IH and SBO as single outcomes ranged from 0.0 to 2.7% and 0.0 to 1.7%, respectively. If IH occurred, reoperation was required in 66-100% with additional bowel resections in 20-100% and stoma-formation in 17-50%. The complication rate after reoperations was 25-100% and mortality 0-25%. Meta-analysis including four studies revealed no statistically significant effect of MDC on the composite outcome of IH and SBO (OR 0.25, 95% CI 0.04-1.77) and SBO as a single outcome (three studies, OR 0.48, 95% CI 0.04-5.49). The risk for IH as a single outcome was significantly lower in the MDC group (three studies, OR 0.15, 95% CI 0.02-0.92). Heterogeneity of the studies included was low to moderate for the composite outcome, as well as for IH and SBO as single outcomes (I2 40.3%, 0.0%, and 45.7%, respectively). Conclusion In current meta-analysis, MDC was not significantly associated with the composite outcome of IH and SBO in patients undergoing colorectal surgery. However, MDC significantly reduced the risk for IH. Based on these results, the benefit of MDC in colorectal surgery remains unclear and needs to be addressed in further studies.

Case Report: 7-Year-Old Boy with Incarcerated Internal Hernia Leading to Extensive Intestinal Necrosis Due to a Large Congenital Mesenteric Defect

We present a case of a 7-year-old boy with acute abdominal symptoms initially misdiagnosed as constipation. Delayed imaging diagnostics revealed an ileus with contorted small intestine, so laparotomy was indicated. An acute bowel obstruction was found based on an incarcerated internal hernia. Small and large bowel segments were incarcerated into a large mesenteric defect leading to extended intestinal necrosis. About 30 cm of necrotic small bowel and 15 cm of large intestine were resected, two primary anastomoses were performed. The mesenteric defect was closed with two running sutures. The boy’s clinical outcome was very good. Two aspects are discussed: the initial clinical misdiagnosis of acute bowel obstruction in a child leading to a delay of diagnostics and therapy on the one hand and the origin of mesenteric defects on the other. In children with abdominal pain, ultrasound must be performed as soon as possible and pediatric surgeons have to be involved early. There should be an awareness of the fact, that mesenteric defects and other congenital malformations can occur more often than we suspect it. In the case of an internal hernia, a misjudgement of the clinical condition may be very harmful for the patient and can lead to a short bowel syndrome or even death.

Absorbable suture can be effectively and safely used to close the mesenteric defect in a gastric bypass Sprague-Dawley rat model

Background To observe if closing the mesenteric defect with absorbable sutures creates a safe adhesion compared to non-absorbable suture after Roux-en-Y gastric bypass. Methods Rats were randomly assigned to 5 experimental groups according to the different suture materials used in closing the mesenteric defects (Peterson’s space) after Roux-en-Y gastric bypass. Group A (control group), Group B (non-absorbable suture, Prolene suture), Group C (biological glue), Group D (non-absorbable suture, polyester suture) and Group E (absorbable suture). All rats were followed up for 8 weeks postoperatively and underwent laparotomy to observe the degree of adhesion and closure of the mesenteric defect. Results No significant difference was found in the decrease in food intake and body weight among all groups. No internal hernia (IH) occurred in any group. The mesenteric defects of Group A remained completely visible without any closure or adhesion. Multiple gaps were found between the Prolene suture and the mesentery along the suture line in Group B. The mesenteric defects of Group C were complete closed with multiple adhesions of the small intestine and the greater omentum. The mesenteric defects in both Group D and Group E closed completely. The average adhesion scores in Group A and Group B were 0 and 0.33 ± 0.52 respectively. The average adhesion score in group C (3.83 ± 0.41) was higher than the other groups (p<0.05). The average adhesion scores in Group D and E were similar (3.17 ± 0.41 and 3.00 ± 0.00 respectively). Conclusion Absorbable suture created a safe adhesion score between the mesentery which was not inferior to non-absorbable sutures.