Internal Hernia Following Robotic Assisted Pancreaticoduodenectomy

Abstract

BACKGROUND Robotic assisted pancreaticoduodenectomy (RPD) is reported to be safe and feasible. Internal hernia (IH) after RPD is a serious but rarely reported complication. MATERIAL AND METHODS We retrospectively reviewed data of 231 patients who underwent RPD from October 2010 to December 2016. The incidence, symptoms, time of presentation, and outcome were investigated. RESULTS Five patients (2.6%) were diagnosed with IH. Significant correlation (P<0.001) between IH and transverse mesocolon defect was confirmed. In patients without defect closure, the incidence of IH was 62.5%, while patients who received defect closure experienced no IH. The median time between initial surgery and occurrence of IH was 76 days. The main symptoms were abdominal pain, nausea, and vomiting. All patients received abdominal computed tomography (CT) and were suspected to have IH according to imaging and symptoms. All patients underwent reoperation (2 laparoscopic and 3 open surgery). The median length of hospital stay was 13 days. No patient experienced a relapse after treatment. CONCLUSIONS Abdominal pain, nausea, and vomiting were common symptoms in our study patients who underwent RPD. IH should be suspected if there is a positive finding on CT. Timely reoperation is necaAbdominal pain, nausea, and vomiting were common symptoms in our study patients who underwent RPD. IH should be suspected if there is a positive finding on CT. Timely reoperation is necessary because IH may cause intestinal ischemia. Meticulous closure of the mesenteric defect is vital to avoid IH.essary because IH may cause intestinal ischemia. Meticulous closure of the mesenteric defect is vital to avoid IH.

Figure 1

The diagram of patients included in the study.

Figure 2

Computed tomography image of an internal hernia case. The left arrow shows the expanded intestine. The smaller arrow shows the hernia ring

Figure 3

Laparoscopic exploration of internal hernia case. (A) Expanded jejunal loop caused by herniation through the mesenteric defect. (B) The jejunal loop was returned back through the defect of transverse mesocolon. (C) The mesenteric defect was closed by 3-0 V-Loc after the returning of herniation.

Figure 4

Schematic diagrams. (A) The mesenteric defect left in first operation has induced parts of the small bowels to slide into the mesenteric opening. (B) In open surgery, the jejunal loop is brought through the right side of the transverse mesocolon before hepaticojejunostomy and pancreatojejunostomy. (C) In robotic assisted pancreaticoduodenectomy, the jejunal loop is retracted from the hole, where the Treitz ligament was located, to the right upper quadrant. P – pancreas; G – gastric area; J – jejunal loop; T – transverse mesocolon; L – liver.

Figure 5

Mesenteric defect and closure during robotic assisted pancreaticoduodenectomy. (A, B) Mesenteric defect. (C) Closure of the mesenteric defect with suture. D – duodenum; J – jejunum.