Closed loop small bowel obstruction - internal hernia

Case contributed by Dr Michael P Hartung

Presentation

Worsening abdominal pain. History of remote liver transplantation.

Patient Data

Age: 65
Gender: Male

Isolated loop of dilated and obstructed proximal small bowel with closed loop configuration. Two adjacent transition points entering and exiting the closed loop, best seen on coronal reformats. The clustering of the small bowel loops suggests internal hernia. Mesenteric edema. 

Liver transplant. SMV jump graft to the transplant portal vein appears compressed, twisted, and distorted. 

CT

Annotated image

Circle indicates the site of the small bowel ENTERING and EXITING the closed loop into the internal hernia sac. 

Findings: Internal hernia through mesenteric defect created by jump graft

Description of Procedure:  

A 10 blade was used to make a midline incisison . The soft tissues were divided using electrocautery, being careful to maintain hemostasis as the dissection proceeded. We inmediatedly identified upon reaching the abdomen a distended proximal small bowel that was herniating through a defect created between the SMV jump graft that provide a portal vein inflow to the transplanted liver and her mesentery. We Carefully release the incarcetrated bowel and untwisted to correct its natural curvature. 

We were able to improve flow to the bowel . No evidence of discoloration or lack of perfusion were noticed.  Since there was no need to performed a bowel resection at this point, We irrigated profusely the abdominal cavity. 

The wound was irrigated. The fascia was closed using a number 1 PDS suture following with internal retention sutures.  The skin was closed with a staples . A sterile island bandage was applied.  The sterile drapes were removed and the patient remained intubated and transferred to the Intensive Care Units unit in stable condition for further monitoring.

Case Discussion

Closed loop obstruction due to internal hernia from a defect created from her SMV jump graft to the transplant portal vein (remote history of liver transplantation). Notice how the graft is hard to see because it is twisted and compressed, further supporting internal hernia. 

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Case information

rID: 65402
Published: 8th Jan 2019
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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