A case of extraperitoneal stoma-associated internal hernia after abdominoperineal resection

Abstract

Published reports concerning internal hernias after extraperitoneal stoma construction are scarce. In our present report, we describe the case of a 56-year-old man who was referred to our hospital for the treatment of rectal cancer. He underwent abdominoperineal resection of the rectum with sigmoidostomy using an extraperitoneal route. On the ninth postoperative day, the patient experienced sudden and intense abdominal pain and was diagnosed with strangulation of the small intestine due to a stoma-associated internal hernia. Therefore, an emergency laparotomy was performed. The surgical findings showed that the small intestine protruded through the space between the sigmoid colon loop and the abdominal wall in a cranial-to-caudal direction. The strangulated portion of the small intestine was recovered, and the orifice of herniation was closed. No recurrence of internal herniation was observed during the follow-up period.

Figure 1

Preoperative computed tomography, barium enema and gross appearance of the resected tumor specimen. Preoperative computed tomography scan (A) and barium enema (B) showing the presence of rectal cancer at the anterior wall of the lower rectum, close to the anal canal. (C) The resected cancer specimen had a diameter of 35 mm.

Figure 2

Emergency computed tomography and laparotomy findings after reduction of the herniated intestine. (A) and (B) After the onset of acute abdominal pain, the emergency computed tomography scan shows a loop of small intestine obstructed by the abdominal wall and sigmoid colon that resulted in sigmoidostomy (white arrows). The wall of the obstructed intestine is edematous and less enhanced. (C) The left side of the photograph is indicative of the cranial direction, and the right side shows the caudal direction. Sigmoidostomy is indicated by the black arrow marked A, and the route of herniation through the space lateral to the sigmoid colon is indicated by the black arrows marked B.

Figure 3

Schemes illustrating the internal hernia. (A) This illustration shows reperitonealization after abdominoperineal resection of the rectum by sigmoidostomy through an extraperitoneal route. (B) This drawing shows the route of internal herniation.