Closed loop obstruction - internal hernia into nephrectomy bed
Severe abdominal pain. History of VHL and right nephrectomy for clear cell carcinoma.
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Right nephrectomy. Cluster of abnormal loops of small bowel within the nephrectomy bed which are fluid-filled, have thickened walls with slightly diminished enhancement, and are associated with mesenteric edema. The afferent and efferent loops of this cluster converge centrally at a single point, consistent with passing through an internal hernia defect or tight adhesive band. Proximally, the small bowel is mildly dilated with gradual transition of enteric contrast into fluid-filled loops of bowel. Distally, the small bowel is decompressed.
PREOPERATIVE DIAGNOSIS: Closed loop small bowel obstruction.
POSTOPERATIVE DIAGNOSIS: Closed loop small bowel obstruction, secondary to an internal hernia in the right dorsal peritoneum.
Exploratory laparotomy with lysis of adhesions and release of bowel obstruction, with reduction of internal hernia.
...An approximately 10 cm incision was made along the linea alba. The peritoneal cavity was sharply entered. He had markedly dilated proximal small bowel loops. The diameter of the bowel approached 6 cm. The bowel was run and he was found to have a roughly round internal hernia measuring approximately 5 cm in diameter in the right retroperitoneum. An approximately 25 cm segment of incarcerated, strangulated small bowel was reduced from that. The surface of the small bowel was erythematous and hemorrhagic, but the bowel was clearly viable and did peristalse normally. Its color became less and less congested and more and more normal with time. The obstruction was in the mid small bowel. The remainder of the small bowel was unobstructed. That was followed down to the cecum. The neck of the retroperitoneal defect was then oversewn with 2-0 Vicryl sutures so that no further herniation would be possible. Palpation of the remainder of the peritoneal cavity demonstrated very hard, rock-like fragments of stool. The stool was especially hard in the sigmoid colon. The transverse colon was adherent to the upper abdomen along the old Chevron scar. There was ascites due to his obstruction, which was aspirated away. His gallbladder was known to be surgically absent. The incision was in the upper abdomen and the appendix was not visualized. The fascia was closed with 0 PDS, beginning 1 suture at either end and tying those in the middle. Local anesthetic was infiltrated. The subdermal tissues were approximated with interrupted 4-0 Vicryl. The skin was closed with a running 4-0 subcuticular Vicryl suture. He tolerated the procedure well.
The cluster of abnormal small bowel loops in the right nephrectomy bed is impressive. On a single coronal image, you might even think it looks like XGP on first glance!
Both afferent (going in) and efferent (going out) limbs of the closed loop are narrowed and obstructed at the same location, and can be difficult to distinguish from each other (best followed on the axial and sagittal images). Given the history of nephrectomy and the tight, focal narrowing resulting in closed loop obstruction, internal hernia cannot be favored over adhesion as the cause, although it would be appropriate to provide both in the differential diagnosis. Either way, this case is a surgical emergency as the vascular supply of the bowel has been compromised and concerning for ischemia (see operative note).
Companion cases of closed-loop obstructions: