Fujiwara Ryota, Yano Masaaki, Matsumoto Makoto, Higashihara Tomoaki, Tsudaka Shimpei, Hashida Shinsuke, Ichihara Shuji, Otani Hiroki
Department of Gastroenterology and General Surgery, Kagawa Prefectural Central Hospital, 1-2-1 Asahimachi, Takamatsu, Kagawa, 760-8557, Japan.
Surg Case Rep. 2024 Apr 15;10(1):85. doi: 10.1186/s40792-024-01889-8.
The majority of small bowel obstructions (SBO) are caused by adhesion due to abdominal surgery. Internal hernias, a very rare cause of SBO, can arise from exposed blood vessels and nerves during pelvic lymphadenectomy (PL). In this report, we present two cases of SBO following laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer, one case each, of which obstructions were attributed to the exposure of blood vessels and nerves during the procedures.
Case 1: A 68-year-old man underwent laparoscopic perineal rectal amputation and LLND for rectal cancer. Four years and three months after surgery, he visited to the emergency room with a chief complaint of left groin pain. Computed tomography (CT) revealed a closed-loop in the left pelvic cavity. We performed an open surgery to find that the small intestine was fitted into the gap between the left obturator nerve and the left pelvic wall, which was exposed by LLND. The intestine was not resected because coloration and peristalsis of the intestine improved after the hernia was released. The obturator nerve was preserved. Case 2: A 57-year-old man underwent a robot-assisted rectal amputation with LLND for rectal cancer. Eight months after surgery, he presented to the emergency room with a complaint of abdominal pain. CT revealed a closed-loop in the right pelvic cavity, and he underwent a laparoscopic surgery with a diagnosis of strangulated SBO. The small intestine was strangulated by an internal hernia caused by the right umbilical arterial cord, which was exposed by LLND. The incarcerated small intestine was released from the gap between the umbilical arterial cord and the pelvic wall. No bowel resection was performed. The umbilical arterial cord causing the internal hernia was resected.
Although strangulated SBO due to an exposed intestinal cord after PL has been a rare condition to date, it is crucial for surgeons to keep this condition in mind.
大多数小肠梗阻（SBO）由腹部手术引起的粘连所致。内疝是SBO的一种非常罕见的病因，可源于盆腔淋巴结清扫术（PL）期间暴露的血管和神经。在本报告中，我们呈现了两例直肠癌腹腔镜和机器人辅助侧方淋巴结清扫术（LLND）后发生SBO的病例，各1例，梗阻均归因于手术过程中血管和神经的暴露。
病例1：一名68岁男性因直肠癌接受腹腔镜会阴直肠切除术和LLND。术后4年3个月，他因左腹股沟疼痛为主诉就诊于急诊室。计算机断层扫描（CT）显示左盆腔有一个闭袢。我们进行了开放手术，发现小肠嵌入了LLND暴露的左闭孔神经与左盆腔壁之间的间隙。由于疝松解后肠管颜色和蠕动改善，未切除肠管。保留了闭孔神经。病例2：一名57岁男性因直肠癌接受机器人辅助直肠切除术及LLND。术后8个月，他因腹痛就诊于急诊室。CT显示右盆腔有一个闭袢，他接受了腹腔镜手术，诊断为绞窄性SBO。小肠被LLND暴露的右脐动脉索引起的内疝绞窄。将嵌顿的小肠从脐动脉索与盆腔壁之间的间隙中松解出来。未进行肠切除。切除了导致内疝的脐动脉索。
尽管PL后因暴露的肠索导致绞窄性SBO迄今为止一直是一种罕见情况，但外科医生牢记这种情况至关重要。
