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Strangulated Internal Hernia as a Complication of Uretero-Intestinal Anastomosis
THE JOURNAL OF UROLOGY
Vol. 66, No. 4, October, 1951 Printed in U.S.A.
STRANGULATED INTERNAL HERNIA AS A COMPLICATION OF URETERO-INTESTINAL ANASTOMOSIS T. H. SWEETSER
The incident which focused my interest on this subject nearly ended disastrously. My earlier experience and training in general surgery should have kept me out of trouble, but it was that earlier training that led me to recognize the need for prompt surgical relief. It was consoling to find, in discussing the matter orally recently and tonight at dinner, that several of my eminent colleagues have had similar trying experiences, but I have failed to find any such reports in the recent numerous articles on uretero-intestinal anastomosis, or any description of appropriate prophylaxis. My patient, a 66 year old farmer, had had intermittent hematuria for about 10 months before consulting his doctor. Excretory urograms demonstrated an extensive filling defect of the left half of his bladder. Cystoscopy and biopsies proved a widespread papillary carcinoma, grade 2, with extension to and into the bladder outlet. After the usual preparation, abdominal exploration showed no extensions or metastases. Therefore the ureters were anastomosed to the sigmoid, and the bladder, prostate and vesicles were removed at the time of the exploration. "\Ve used the technique of anastomosis described by Reed Nesbit. 1 Implantations were well up in the sigmoid as described in most recent reports. It has seemed to me, since the discussions by Flocks2, that the blood supply of the ureters is less likely to be inadequate near the pelvic brim than lower down. The patient made an excellent recovery and went home in good condition 14 days after the cystectomy. Six days later he suffered severe low abdominal pain with nausea but without vomiting or intermittent cramps or borborygmi. A mass could be felt suprapubically. Abdominal exploration done promptly on his return to the hospital discovered free serosanguinous fluid in the peritoneal cavity and a loop of small intestine three and a half feet long in the pelvis, about 3 feet of it being gangrenous. The aperture through which the loop had passed was about 3 cm. in diameter, behind the sigmoid and between the mesosigmoid and the site of implantation of the right ureter into the sigmoid. In reducing the hernia, with much difficulty, I caused a small leak at the anastomosis, but was able to repair it satisfactorily. The strangulated loop was resected by the method of Dennis. 3 The hernial aperture was closed with two rows of fine catgut sutures between the posterior parietal peritoneum and the peritoneum of the mesosigmoid, avoiding the blood vessels. Aureomycin solution was injected high in the left lateral peritoneal gutter before completing closure of the abdomen. The patient made an entirely uneventful recovery and went home again on the fourteenth day after operation. Read at meeting of the Chicago Urological Society, April 27, 1950. 1 Nesbit, R. M.: J. Urol., 61: 728, 1949. 2 Flocks, R.H.: J. Urol., 59: 21, 1948. 3 Dennis, C.: Surgery, 5: 548, 1939; and Surg. Gynec. & Obst., 77: 225, 1943. 571
572
T. H. SWEETSER
A few instances of intestinal obstruction after uretero-intestinal anastomosis have been reported 4 • 5 • 6 • 7, but this particular source of the trouble was not found, or at least not recognized in the reported cases, and I find no description of appropriate prophylactic measures in the various reported operative techniques. Faldform lig,1nwnt ,f
F\\1::i::: Duodenum.
nf Hver.
~-c---1-
1~::!1-----
Hgament
ofliver. Duodenum.
r
Duote~~~ ::::::::::::_:::::_ behind
peritoneum...
Commence~ mentof colon.
r
Fm. 1. Diagram to show lines along which peritoneum leaves wall of abdomen to invest viscera. (Cunningham.) (From Morris, H.: Human Anatomy. Philadelphia: P. Blakiston & Co., 1893, p. 1015.)
Within the last few years many descriptions have been written of techniques for and results of uretero-intestinal anastomosis. Few reports have been made of intestinal obstruction following such operations and none that come within the field of this report, unless the true cause of difficulty in some of these cases was unrecognized. In one case, there was obstruction of the rectum by carcinomatous •Hepler, A. B.: J. Urol., 44: 794, 1940. 5 Schnittman, M.: N. Y. State J. Med., 48: 882, 1948. 6 Marshall, V. F.: J. Urol., 68: 244, 1947. 7 Strom, G. W.: Personal communication.
ST'RA:1\GULATED INTERNAJ, HERNIA
tissue filling the after cystectomy. In one case reported to me orally hy Dr. (lordon Strom7 (a Veterans' Hospital case), there ,ms obstruction a pelvic abscess due to perforation of the rectosigmoid after cystectomy. Hepler 4 reported I case (patient died from fecal fistula 3 years later). Two cases reported were due to adhesions between the sigmoid and posterior peritoneum. One case was reported by . F. 1Vlarshall 6 as small intestinal obstruction at the site of the operation, but no cause was given. Schnittman 5 reported 1 case (may have been the same case). Cordonnier8 reported that he does not extraperitonealize the site8 of implantation for fear of intestinal obstruction, but the inference is that the obstruction would be due to kinking at those points.* Charles Mayo and Dixon, 9 recognizing the possibility of intestinal obstruction after colostomy, advised in 1927 that the peritoneal pocket or opening (fig. I,
Fm. 2. Bilateral trnnsperitoncal uretcrosigmoidostomy. Both anastomoses are through right, longitudinal band of colon. (From Ferris and Priestley: J. Urol., 60: 98, 1D48.)
X 10 ) between the 8igmoid mesentery and the left lateral abdominal ,vall be obliterated by means of a pursestring suture to avoid the danger of herniation of a loop of small intestine into this space with subsequent ob8truction. In figure 1, the hernial aperture artificially produced in our patient is indicated by XX and was c:losed in a similar manner. The original description of Coffey 11 and those of Schinagel1z and some others depict the implantations as being made into the rectosigmoid or rectum, where the bowel is in the midline and has no mesosigmoid or very little. In such procedures there would be no chance of internal herniation or it could easily be prevented. 8
Cordonnier, J. J.: Surg. Gyrwc. & Obst., 88: 441, 1949.
* From his motion pictnre film, seen since presenting this paper, I understand that he
does now extraperitonealize the sites of implantation, but there is no indication that any at.tempt is made to close the spaces behind the sigmoid. 0 Mayo, C.H. and Dixon, C. F.: Ann. Surg., 87: 711, 1928. 10 Morris, Henry: Human Anatomy. Philadelphia: P. Blakiston & Co., 1893, 1st ed., p. 1015. 11 Coffey, R. C.: Surg. Gynec. & Obst., 47: 593, 1928. 12 Schinagel, G.: .J. Urol., 59: 1101, 1948.
574
T. H. SWEETSER
However, in many reports, and especially in most recent ones, the implantations are intentionally placed higher in the sigmoid and the sites of right and left implantations are farther apart, the left being shown as at or near the distal part of the descending colon. Cordonnier8 reports that after implanting both ureters, he rolls the sigmoid downward to produce a straightening of the ureter (left) and closing the posterior parietal peritoneum; it is not clear that he prevents the herniation here described. The illustrations in Dr. Flocks' report 2 of January 1948, do not show any mesosigmoid, but in watching him doing his operation I do not remember that he obliterated the opening behind the sigmoid. Illustrations and descriptions from other reports by Jewett 13 , Jacobs, 14 Priestley and Strom, 15 Higgins, 16 Dreiling and Hyman, 17 Ferris and Priestley,1 8 Schnittman, 19 Nesbit, 19 and Melick, 20 show that an internal herniation might well occur behind the sigmoid at either side of the mesosigmoid but more probably to the right, between the mesosigmoid and the point of right ureterosigmoid anastomosis (fig. 2) _is Of course, the best treatment of intestinal obstruction is its prevention. Prevention in these cases is by closure of the artificially made aperture by suturing. One must avoid kinking of the sigmoid and also avoid any interference with its blood supply. Closure of the peritoneal surfaces only with two rows of fine chronic catgut should suffice. The actual occurrence of intestinal obstruction due to any internal herniation demands prompt recognition and treatment; any delay is fatal. I remember one patient some twenty years ago in whom it was necessary to resect about three feet of gangrenous bowel, although the operation was performed as soon as he reached the hospital and within 10 hours after onset of symptoms. I was recently told of a patient whose gangrenous bowel was found at autopsy, the diagnosis of mechanical intestinal obstruction due to internal herniation after a gastroenterostomy having been missed entirely; another exactly similar case recovered after prompt operation. In our case we found that reduction of the herniated bowel could easily cause tearing at the site of the recent ureteral implantation. It has been suggested that such a hazard may be avoided by emptying the strangulated bowel by trochar and suction, closing the perforation with a pursestring suture at once.
1553 Medical Arts Bldg., Minneapolis 2, Minn. Jewett, H.J.: Brit. J. Urol., 15: 121, 1943; J. Urol., 48: 489, 1942. Jacobs, A.: Brit. J. Urol., 18: 4, 1946. 16 Priestley, J. T. and Strom, G. W.: J. Urol., 50: 210, 1943. 16 Higgins, C. C.: J. Urol., 57: 693, 1947. 17 Dreiling, D. A. and Hyman, A.: J. Urol., 58: 435, 1947. 18 Ferris, D. 0. and Priestley, J. T.: J. Urol., 60: 98, 1948. 19 Schnittman, M.: J. Urol., 60: 421, 1948. 20 Melick, W. F.: J. Urol., 62: 454, 1949. 13
14
Vol. 66, No. 4, October, 1951 Printed in U.S.A.
STRANGULATED INTERNAL HERNIA AS A COMPLICATION OF URETERO-INTESTINAL ANASTOMOSIS T. H. SWEETSER
The incident which focused my interest on this subject nearly ended disastrously. My earlier experience and training in general surgery should have kept me out of trouble, but it was that earlier training that led me to recognize the need for prompt surgical relief. It was consoling to find, in discussing the matter orally recently and tonight at dinner, that several of my eminent colleagues have had similar trying experiences, but I have failed to find any such reports in the recent numerous articles on uretero-intestinal anastomosis, or any description of appropriate prophylaxis. My patient, a 66 year old farmer, had had intermittent hematuria for about 10 months before consulting his doctor. Excretory urograms demonstrated an extensive filling defect of the left half of his bladder. Cystoscopy and biopsies proved a widespread papillary carcinoma, grade 2, with extension to and into the bladder outlet. After the usual preparation, abdominal exploration showed no extensions or metastases. Therefore the ureters were anastomosed to the sigmoid, and the bladder, prostate and vesicles were removed at the time of the exploration. "\Ve used the technique of anastomosis described by Reed Nesbit. 1 Implantations were well up in the sigmoid as described in most recent reports. It has seemed to me, since the discussions by Flocks2, that the blood supply of the ureters is less likely to be inadequate near the pelvic brim than lower down. The patient made an excellent recovery and went home in good condition 14 days after the cystectomy. Six days later he suffered severe low abdominal pain with nausea but without vomiting or intermittent cramps or borborygmi. A mass could be felt suprapubically. Abdominal exploration done promptly on his return to the hospital discovered free serosanguinous fluid in the peritoneal cavity and a loop of small intestine three and a half feet long in the pelvis, about 3 feet of it being gangrenous. The aperture through which the loop had passed was about 3 cm. in diameter, behind the sigmoid and between the mesosigmoid and the site of implantation of the right ureter into the sigmoid. In reducing the hernia, with much difficulty, I caused a small leak at the anastomosis, but was able to repair it satisfactorily. The strangulated loop was resected by the method of Dennis. 3 The hernial aperture was closed with two rows of fine catgut sutures between the posterior parietal peritoneum and the peritoneum of the mesosigmoid, avoiding the blood vessels. Aureomycin solution was injected high in the left lateral peritoneal gutter before completing closure of the abdomen. The patient made an entirely uneventful recovery and went home again on the fourteenth day after operation. Read at meeting of the Chicago Urological Society, April 27, 1950. 1 Nesbit, R. M.: J. Urol., 61: 728, 1949. 2 Flocks, R.H.: J. Urol., 59: 21, 1948. 3 Dennis, C.: Surgery, 5: 548, 1939; and Surg. Gynec. & Obst., 77: 225, 1943. 571
572
T. H. SWEETSER
A few instances of intestinal obstruction after uretero-intestinal anastomosis have been reported 4 • 5 • 6 • 7, but this particular source of the trouble was not found, or at least not recognized in the reported cases, and I find no description of appropriate prophylactic measures in the various reported operative techniques. Faldform lig,1nwnt ,f
F\\1::i::: Duodenum.
nf Hver.
~-c---1-
1~::!1-----
Hgament
ofliver. Duodenum.
r
Duote~~~ ::::::::::::_:::::_ behind
peritoneum...
Commence~ mentof colon.
r
Fm. 1. Diagram to show lines along which peritoneum leaves wall of abdomen to invest viscera. (Cunningham.) (From Morris, H.: Human Anatomy. Philadelphia: P. Blakiston & Co., 1893, p. 1015.)
Within the last few years many descriptions have been written of techniques for and results of uretero-intestinal anastomosis. Few reports have been made of intestinal obstruction following such operations and none that come within the field of this report, unless the true cause of difficulty in some of these cases was unrecognized. In one case, there was obstruction of the rectum by carcinomatous •Hepler, A. B.: J. Urol., 44: 794, 1940. 5 Schnittman, M.: N. Y. State J. Med., 48: 882, 1948. 6 Marshall, V. F.: J. Urol., 68: 244, 1947. 7 Strom, G. W.: Personal communication.
ST'RA:1\GULATED INTERNAJ, HERNIA
tissue filling the after cystectomy. In one case reported to me orally hy Dr. (lordon Strom7 (a Veterans' Hospital case), there ,ms obstruction a pelvic abscess due to perforation of the rectosigmoid after cystectomy. Hepler 4 reported I case (patient died from fecal fistula 3 years later). Two cases reported were due to adhesions between the sigmoid and posterior peritoneum. One case was reported by . F. 1Vlarshall 6 as small intestinal obstruction at the site of the operation, but no cause was given. Schnittman 5 reported 1 case (may have been the same case). Cordonnier8 reported that he does not extraperitonealize the site8 of implantation for fear of intestinal obstruction, but the inference is that the obstruction would be due to kinking at those points.* Charles Mayo and Dixon, 9 recognizing the possibility of intestinal obstruction after colostomy, advised in 1927 that the peritoneal pocket or opening (fig. I,
Fm. 2. Bilateral trnnsperitoncal uretcrosigmoidostomy. Both anastomoses are through right, longitudinal band of colon. (From Ferris and Priestley: J. Urol., 60: 98, 1D48.)
X 10 ) between the 8igmoid mesentery and the left lateral abdominal ,vall be obliterated by means of a pursestring suture to avoid the danger of herniation of a loop of small intestine into this space with subsequent ob8truction. In figure 1, the hernial aperture artificially produced in our patient is indicated by XX and was c:losed in a similar manner. The original description of Coffey 11 and those of Schinagel1z and some others depict the implantations as being made into the rectosigmoid or rectum, where the bowel is in the midline and has no mesosigmoid or very little. In such procedures there would be no chance of internal herniation or it could easily be prevented. 8
Cordonnier, J. J.: Surg. Gyrwc. & Obst., 88: 441, 1949.
* From his motion pictnre film, seen since presenting this paper, I understand that he
does now extraperitonealize the sites of implantation, but there is no indication that any at.tempt is made to close the spaces behind the sigmoid. 0 Mayo, C.H. and Dixon, C. F.: Ann. Surg., 87: 711, 1928. 10 Morris, Henry: Human Anatomy. Philadelphia: P. Blakiston & Co., 1893, 1st ed., p. 1015. 11 Coffey, R. C.: Surg. Gynec. & Obst., 47: 593, 1928. 12 Schinagel, G.: .J. Urol., 59: 1101, 1948.
574
T. H. SWEETSER
However, in many reports, and especially in most recent ones, the implantations are intentionally placed higher in the sigmoid and the sites of right and left implantations are farther apart, the left being shown as at or near the distal part of the descending colon. Cordonnier8 reports that after implanting both ureters, he rolls the sigmoid downward to produce a straightening of the ureter (left) and closing the posterior parietal peritoneum; it is not clear that he prevents the herniation here described. The illustrations in Dr. Flocks' report 2 of January 1948, do not show any mesosigmoid, but in watching him doing his operation I do not remember that he obliterated the opening behind the sigmoid. Illustrations and descriptions from other reports by Jewett 13 , Jacobs, 14 Priestley and Strom, 15 Higgins, 16 Dreiling and Hyman, 17 Ferris and Priestley,1 8 Schnittman, 19 Nesbit, 19 and Melick, 20 show that an internal herniation might well occur behind the sigmoid at either side of the mesosigmoid but more probably to the right, between the mesosigmoid and the point of right ureterosigmoid anastomosis (fig. 2) _is Of course, the best treatment of intestinal obstruction is its prevention. Prevention in these cases is by closure of the artificially made aperture by suturing. One must avoid kinking of the sigmoid and also avoid any interference with its blood supply. Closure of the peritoneal surfaces only with two rows of fine chronic catgut should suffice. The actual occurrence of intestinal obstruction due to any internal herniation demands prompt recognition and treatment; any delay is fatal. I remember one patient some twenty years ago in whom it was necessary to resect about three feet of gangrenous bowel, although the operation was performed as soon as he reached the hospital and within 10 hours after onset of symptoms. I was recently told of a patient whose gangrenous bowel was found at autopsy, the diagnosis of mechanical intestinal obstruction due to internal herniation after a gastroenterostomy having been missed entirely; another exactly similar case recovered after prompt operation. In our case we found that reduction of the herniated bowel could easily cause tearing at the site of the recent ureteral implantation. It has been suggested that such a hazard may be avoided by emptying the strangulated bowel by trochar and suction, closing the perforation with a pursestring suture at once.
1553 Medical Arts Bldg., Minneapolis 2, Minn. Jewett, H.J.: Brit. J. Urol., 15: 121, 1943; J. Urol., 48: 489, 1942. Jacobs, A.: Brit. J. Urol., 18: 4, 1946. 16 Priestley, J. T. and Strom, G. W.: J. Urol., 50: 210, 1943. 16 Higgins, C. C.: J. Urol., 57: 693, 1947. 17 Dreiling, D. A. and Hyman, A.: J. Urol., 58: 435, 1947. 18 Ferris, D. 0. and Priestley, J. T.: J. Urol., 60: 98, 1948. 19 Schnittman, M.: J. Urol., 60: 421, 1948. 20 Melick, W. F.: J. Urol., 62: 454, 1949. 13
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