[Quiz] Abdominal pain after laparoscopic nephrectomy

A 46-year-old male underwent a left laparoscopic radical nephrectomy for a cT1b renal cell carcinoma. Intra-operatively, a rent in the descending mesocolon was made during bowel mobilization but was not closed. The remainder of the procedure was uneventful and the patient was discharged home on post-operative day 1 after passing flatus. Subsequently, the patient presented to the emergency room 4 days later with complaints of sudden onset sharp abdominal pain and nausea. A non-contrast CT scan was obtained (figure 1, below).

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Answer:

B. Internal hernia

Discussion:

Internal hernias are a rare cause of obstruction following laparoscopic nephrectomy. These hernias usually occur through mesocolic defects made inadvertently during the procedure and not subsequently closed. Furthermore, removal of the kidney leads to a potential retroperitoneal space that may make these patients more susceptible to bowel obstruction. Thus, when mobilizing the colon, mesenteric defects should be recognized and repaired.

Management of most of these cases is usually by surgical exploration if small bowl obstruction persists. In the current era, laparoscopy can be the modality of management if there is no suggestion of bowel necrosis or gangrene. The entrapped bowel can be reduced laparoscopically and the mesenteric rent repaired with suture.

Dr. Sorokin, endourology fellow at the University of Texas Southwestern Medical Center, Dallas, is section editor for Urology Times Clinical Quiz.

Suggested reading:

Systematic review of internal hernia formation following laparoscopic left nephrectomy. Ann R Coll Surg Engl 2009; 91:667-9

Small bowel obstruction after laparoscopic donor nephrectomy. Surg Endosc. 2003; 17:108-10

Management of intestinal obstruction following laparoscopic donor nephrectomy. J Minim Access Surg. 2012; 8:149-51

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