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Strangulated Internal Hernia Behind the Common Iliac Artery Following Pelvic Lymph Node Dissection
Images in Clinical Urology Strangulated Internal Hernia Behind the Common Iliac Artery Following Pelvic Lymph Node Dissection Andrew Pridjian, Steven Myrick, and Ilia Zeltser We report a rare case of a strangulated internal hernia behind the common iliac artery after robot-assisted pelvic lymph node dissection. Internal hernias involving the retroperitoneal vascular axis have been reported four times in medical literature. This is the first time it has been seen after robotic surgery. UROLOGY 86: e23ee24, 2015. 2015 Elsevier Inc.
Figure 1. Axial computerized tomography. (A) Anteriorly displaced right common iliac artery (arrow) with mesenteric vessels and fat seen herniating between the right common iliac artery and vein. Strangulated loops of ileum (*). Note anatomic left common iliac artery (arrow). (B) Compromised ileum within hernia sac (arrow).
A
50-year old male who underwent robot-assisted partial cystectomy and extended pelvic lymphadenectomy for poorly differentiated squamous cell carcinoma within a bladder diverticulum (T3aN0) presented 5 months after with nausea, vomiting, and abdominal pain. Computerized tomography scan demonstrated multiple loops of thickened, edematous ileum and an anteriorly displaced right common iliac artery (Fig. 1). A clear transition point was seen on coronal images (Fig. 2). Given the concern for closed-loop bowel obstruction, an emergent exploratory laparotomy was performed (Fig. 3). The necrotic ileum was resected, and the iliac artery was covered with peritoneal flaps. Financial Disclosure: The authors declare that they have no relevant financial interests. From the Urology Department, Thomas Jefferson University, Philadelphia, PA Address correspondence to: Andrew Pridjian, M.D., 440 S. Broad St, #1207, Philadelphia, PA 19106. E-mail: [email protected] Submitted: July 22, 2015, accepted (with revisions): August 4, 2015
ª 2015 Elsevier Inc. All Rights Reserved
Figure 2. Coronal computerized tomography. Two limbs of right common iliac artery (arrows) with transition point in proximal ileum (*). http://dx.doi.org/10.1016/j.urology.2015.08.001 0090-4295/15
e23
Extended pelvic lymph node dissection is the accepted standard in patients undergoing cystectomy for bladder cancer. Once the lymphatic tissue is removed, a significant free space is frequently created between the arching retroperitoneal vessels. There are no established guidelines regarding prevention of internal hernias following retroperitoneal lymphadenectomy. Reperitonealization although logical, has not been shown to change outcomes.3 Filling the free space beneath the vessels with surgical cellulose or closing the posterior peritoneum by raising peritoneal flaps adds minimal operative time and may decrease the risk of this rare complication.
References Figure 3. Right common iliac artery with herniated ileum underneath.
Internal hernias involving the retroperitoneal vascular axis have been reported 4 times in medical literature, and always following retroperitoneal lymphadenectomy.1,2
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1. Dumont K, Wexels JC. Laparoscopic management of a strangulated internal hernia underneath the left external iliac artery. Int J Surg Case Rep. 2013;4:1041. 2. Ardelt M, Dittmar Y, Scheuerlein H, et al. Post-operative internal hernia through an orifice underneath the right common iliac artery after Dargent’s operation. Hernia. 2014;18:907. 3. Bamigbote AA, Hofmeyr GJ. Closure versus non-closure of the peritoneum at caesarean section: short- and long-term outcomes. Cochrane Database Syst Rev. 2014;8:CD000163.
UROLOGY 86 (5), 2015
Figure 1. Axial computerized tomography. (A) Anteriorly displaced right common iliac artery (arrow) with mesenteric vessels and fat seen herniating between the right common iliac artery and vein. Strangulated loops of ileum (*). Note anatomic left common iliac artery (arrow). (B) Compromised ileum within hernia sac (arrow).
A
50-year old male who underwent robot-assisted partial cystectomy and extended pelvic lymphadenectomy for poorly differentiated squamous cell carcinoma within a bladder diverticulum (T3aN0) presented 5 months after with nausea, vomiting, and abdominal pain. Computerized tomography scan demonstrated multiple loops of thickened, edematous ileum and an anteriorly displaced right common iliac artery (Fig. 1). A clear transition point was seen on coronal images (Fig. 2). Given the concern for closed-loop bowel obstruction, an emergent exploratory laparotomy was performed (Fig. 3). The necrotic ileum was resected, and the iliac artery was covered with peritoneal flaps. Financial Disclosure: The authors declare that they have no relevant financial interests. From the Urology Department, Thomas Jefferson University, Philadelphia, PA Address correspondence to: Andrew Pridjian, M.D., 440 S. Broad St, #1207, Philadelphia, PA 19106. E-mail: [email protected] Submitted: July 22, 2015, accepted (with revisions): August 4, 2015
ª 2015 Elsevier Inc. All Rights Reserved
Figure 2. Coronal computerized tomography. Two limbs of right common iliac artery (arrows) with transition point in proximal ileum (*). http://dx.doi.org/10.1016/j.urology.2015.08.001 0090-4295/15
e23
Extended pelvic lymph node dissection is the accepted standard in patients undergoing cystectomy for bladder cancer. Once the lymphatic tissue is removed, a significant free space is frequently created between the arching retroperitoneal vessels. There are no established guidelines regarding prevention of internal hernias following retroperitoneal lymphadenectomy. Reperitonealization although logical, has not been shown to change outcomes.3 Filling the free space beneath the vessels with surgical cellulose or closing the posterior peritoneum by raising peritoneal flaps adds minimal operative time and may decrease the risk of this rare complication.
References Figure 3. Right common iliac artery with herniated ileum underneath.
Internal hernias involving the retroperitoneal vascular axis have been reported 4 times in medical literature, and always following retroperitoneal lymphadenectomy.1,2
e24
1. Dumont K, Wexels JC. Laparoscopic management of a strangulated internal hernia underneath the left external iliac artery. Int J Surg Case Rep. 2013;4:1041. 2. Ardelt M, Dittmar Y, Scheuerlein H, et al. Post-operative internal hernia through an orifice underneath the right common iliac artery after Dargent’s operation. Hernia. 2014;18:907. 3. Bamigbote AA, Hofmeyr GJ. Closure versus non-closure of the peritoneum at caesarean section: short- and long-term outcomes. Cochrane Database Syst Rev. 2014;8:CD000163.
UROLOGY 86 (5), 2015