Jejunal obstruction due to rare internal hernia between skeletonized external iliac artery and vein as late complication of laparoscopic hysterectomy with pelvic lymphadenectomy-case report and review of literature

Abstract

Background: Internal herniation of small intestine in the lesser pelvis alongside iliac vasculature is a rare occurrence. Skeletonization of iliac vessels during pelvic lymph node dissection (LND), as part of surgical staging or treatment of patients with uterine, ovarian or urogenital cancer, is a strict prerequisite for orifice formation.

Case presentation: A 68-year-old woman presented at the emergency department with complaints of constipation for the last 3 days and acute-onset abdominal pain, nausea and vomiting since few hours. She had a history of laparoscopic hysterectomy, bilateral salpingo-oophorectomy and para-aortic and pelvic LND 7 years ago. A distended abdomen with diffuse tenderness on palpation was noted. A CT scan demonstrated bowel obstruction secondary to an incarcerated hernia underneath an elongated right external iliac artery. During an emergency exploratory laparotomy, the incarcerated bowel was reduced and the hernial orifice closed with a running suture. The patient had an uneventful postoperative period and was discharged on the fifth postoperative day.

Discussion: This rare internal hernia can manifest with non-specific symptoms of small bowel obstruction at any given point after index surgery, sometimes even after several years free of complaints. Contrast-enhanced computed tomography is the method of choice for fast and reliable diagnosis and helps in planning the necessary emergency laparotomy.

Conclusion: This life-threatening complication adds to the current controversy of pelvic and para-aortic lymphadenectomy in patients with endometrial cancer. Primary closure of peritoneal defects should be considered to potentially prevent internal hernias, especially when elongated iliac vessels are present.

Keywords: Case report; Iliac vessels; Internal hernia; Lymphadenectomy; Small bowel obstruction.

Fig. 1

CT scan. a Axial view showing herniation of ileum with abrupt reduction of caliber (arrowheads) between external iliac artery ( +) and external iliac vein (*). b Coronal view, showing the site of herniation (arrowheads). Distension of proximal jejunal loops due to small bowel obstruction. Perihepatic and inter-enteric ascites in the right hemiabdomen as secondary finding

Fig. 2

Intraoperative sight. a Ileum proximal ( <) to herniation between the external iliac artery ( +) and external iliac vein (*). The herniated ileum loop ( >) presents clear signs of incarceration. b Demonstration of the hernial orifice between the external iliac artery ( +) and external iliac vein (*) after reposition and resection of the incarcerated ileum loop