Sunteți pe pagina 1din 4

ORIGINAL CONTRIBUTION

Long-Term Consequences of Not Closing the


Mesenteric Defect After Laparoscopic Right
Colectomy
Jennifer C. Cabot, B.A.1 • Sang A. Lee, M.D.2 • James Yoo, M.D.3
Abu Nasar, M.S.1 • Richard L. Whelan, M.D.1 • Daniel L. Feingold, M.D.1
1 Section of Colon and Rectal Surgery, Department of Surgery, New York-Presbyterian Hospital-Columbia Campus, New
York, New York
2 Weill Cornell Department of Surgery, New York, New York
3 Colorectal Surgery Program, University of California, Los Angeles, Los Angeles, California

PURPOSE: The controversy regarding closing the follow-up period. Nonoperative treatment was successful
mesenteric defect after laparoscopic right colectomy in 12 patients. In the 14 patients who were operated on,
remains a subject of debate. This study describes the small bowel obstruction was due to adhesions (4),
consequences of not closing the mesenteric defect. incarcerated abdominal wall hernias (4), mesenteric
defect (4), and cancer recurrence (2). The small bowel
METHODS: A 7-year prospective database revealed 530
obstruction group (n ⫽ 26) had a significantly higher
consecutive patients who underwent laparoscopic right
percentage of males than the non-small bowel
colectomy for neoplasia. No mesenteric defects were
obstruction group (n ⫽ 504; 69% vs 43%; P ⫽ .008).
closed. Small bowel obstruction was determined by
clinical assessment and diagnostic imaging. Statistical CONCLUSIONS: These data do not support routinely
analysis included the Student t test and Mann-Whitney U closing the mesenteric defect after laparoscopic right
test. colectomy for neoplasia. Additional studies with
extended long-term follow-up are needed.
RESULTS: On average, the 530 patients (44% male) were
69.6 years old ⫾ 12.5 years with American Society of
Anesthesiologists’ category 2, body mass index 26.6 ⫾ KEY WORDS: Internal hernia; Small bowel obstruction;
5.7, operative time 175 ⫾ 65 minutes, incision length Laparoscopy; Right colectomy.
5.7 ⫾ 3.0 cm. Thirty-six patients (6.8%) were converted.
Median length of stay was 5 days (interquartile range aparoscopic right colectomy (LRC) has become the
4 –7). Median follow-up was 20 months (interquartile
range 8 – 45). Four patients (0.8%) had complications
attributed to the mesenteric defect: 2 had small bowel
obstruction due to internal herniation and 2 had torsion
L preferred surgical approach to right colectomy for
many surgeons. Although laparoscopic techniques
for right colectomy have been described in detail, a contro-
versy exists regarding whether to close the mesenteric de-
of the anastomosis through the defect. Twenty-six fect. Leaving the defect open may increase the incidence
patients (4.9%) had a small bowel obstruction during the of internal hernia and subsequent small bowel obstruc-
tion (SBO). Laparoscopic closure of the defect is techni-
Financial Disclosures: None reported. cally challenging, however, and may jeopardize the blood
supply to the anastomosis. The potential morbidity asso-
Poster presentation at the meeting of The American Society of Colon and ciated with closing the defect, including possible injury to
Rectal Surgeons and Tripartite, Boston, MA, June 6 to 11, 2008. the bowel and vasculature, may outweigh the risks of leav-
Correspondence: Daniel L. Feingold, M.D., Section of Colon and Rectal
ing the defect open.
Surgery, Department of Surgery, New York Presbyterian Hospital-Co- No large-scale studies have examined the conse-
lumbia Campus, 177 Fort Washington Ave, New York, NY 10032. Email: quences of repairing the mesenteric defect or leaving it
df347@columbia.edu open during laparoscopic or open colectomy. A review of
Dis Colon Rectum 2010; 53: 289 –292
internal hernias suggested that the small size of mesenteric
DOI: 10.1007/DCR.0b013e3181c75f48 defects (2–5 cm) and the lack of encapsulation associated
©The ASCRS 2010 with a variety of laparoscopic abdominal operations may
DISEASES OF THE COLON & RECTUM VOLUME 53: 3 (2010) 289
290 CABOT ET AL: CONSEQUENCES OF OPEN MESENTERIC DEFECT

cause volvulus and strangulation of herniated loops of


TABLE 1. Summary of patient data
bowel.1 Although symptomatic internal hernia has been
reported to occur in up to 9% of laparoscopic Roux-en-Y Demographics Outcomes
gastric bypass cases, the incidence of this complication is Age, y 69.6 ⫾ 12.5
thought generally to be low following laparoscopic colec- Sex, male (%) 233 (44)
Incision length, cm 5.7 ⫾ 3.0
tomy.2 Investigations specifically examining laparoscopic
Operative time, min 175 ⫾ 65
Roux-en-Y gastric bypass surgery emphasize the number Length of stay, days* (range) 5 (4–7)
of defects and the presence of nonphysiologic anatomy as Body mass index 26.6 ⫾ 5.7
risk factors for SBO due to internal hernia. These studies Follow-up time, mo* (range) 20 (8–45)
may not be generalizable to laparoscopic colorectal resec- Previous abdominal surgery (%) 115 (22)
Major complications (%) 26 (4.9)
tion.2– 8 Only 6 case reports of internal hernia following
Total no. SBO cases (%) 26 (4.9)
laparoscopic colectomy have been published.9 –14 These re- SBO due to mesenteric defect (%) 4 (0.8)
views are limited in scope and do not resolve the contro- 30-day mortality (%) 1 (0.2)
versy regarding the mesenteric defect. Because the anat- Indication for surgery
omy of the mesentery varies according to the segment of Cancer (%) 357 (67)
Polyp (%) 173 (33)
colon in terms of length, thickness, and vasculature, the
Resection performed
risks and benefits of leaving the mesenteric defect open Right colectomy (%) 456 (86)
would be best evaluated separately for each type of colo- Extended right colectomy (%) 74 (14)
rectal resection. The present study, the largest of its kind, Data are presented as mean ⫾ SD unless otherwise indicated. SBO indicates small
retrospectively evaluates the consequences of leaving the bowel obstruction.
mesenteric defect open during LRC for neoplasia. *Median (interquartile range).

METHODS views for the majority of patients and was gathered from
The study population consisted of 530 patients who under- charts and records alone for those unavailable by tele-
went LRC for neoplasia at the New York-Presbyterian phone. SBO was determined by clinical assessment and
Hospital. Patient data were obtained from a 7-year, insti- imaging studies including abdominal x-ray and CT. In
tutional research board–approved, prospective database cases of SBO in which patients were successfully treated
including any patients undergoing elective colorectal re- nonoperatively and without CT imaging, no inference was
section for any indication. The patients of 9 colorectal sur- made as to the etiology of the SBO. For 2 of 3 patients
geons are included in this computerized database, and data treated nonoperatively and with CT imaging available, the
were compiled via data intake questionnaires and system- location and probable cause of the SBO were able to be
atic review of charts, office records, and radiographic im- determined.
aging, as well as patient interviews. Surgeon preference de- Statistical analysis was performed on the data with the
termined whether an open or laparoscopic approach was Student t test and the Mann-Whitney U test. All of the
used in each case independent of any research study. The statistical analyses were performed using GraphPad Prism
present study was approved by the hospital’s institutional version 4.1 software for Windows (GraphPad Software,
research board. San Diego, CA). P values of less than .05 were considered
Query of the database revealed 550 patients who un- statistically significant. No adjustment of the P value was
derwent an LRC or extended right colectomy for neoplas- made for multiple tests.
tic conditions. Operative reports were used to determine
the technical aspects with regard to the mesenteric defect; RESULTS
all of the reports documented whether the defect was
closed. Twenty patients were excluded for the following All 530 patients underwent LRC for neoplasia. No mesen-
reasons: loss to follow-up immediately postoperative (17), teric defects were closed, and no adhesion barriers were
placement of Seprafilm following conversion (2), and clo- used. The study included 233 males (44%) and 297 females
sure of the defect following conversion (1). The study (56%) with a mean age of 69.6 ⫾ 12.5 years, mean Amer-
group comprised the remaining 530 patients. ican Society of Anesthesiologists category of 2, mean body
The following information was recorded for each pa- mass index of 26.6 ⫾ 5.7, mean operative time of 175 ⫾ 65
tient: age, sex, American Society of Anesthesiologists’ cat- minutes, and mean incision length of 5.7 ⫾ 3.0 cm (Table
egory, body mass index, operative time, incision length, 1). The median length of stay was 5 days (interquartile
length of stay, intraoperative and postoperative courses, range 4 –7). Indications for LRC included cancer (n ⫽ 357,
incidence and treatment of SBO, and length of follow-up. 67%) and polyp (n ⫽ 173, 33%). A total of 115 patients
Information regarding the incidence of SBO was gathered (22%) underwent previous abdominal surgery for other
from office charts, hospital records, and telephone inter- indications.
DISEASES OF THE COLON & RECTUM VOLUME 53: 3 (2010) 291

All of the cases began with the laparoscopic approach,


TABLE 3. Comparison of patient groups
and 36 cases (6.8%) were converted. The reasons for con-
version were adhesions (n ⫽ 13), large tumors or T4 can- Non-SBO
SBO group group
cers (n ⫽ 11), miscellaneous reasons (n ⫽ 8), and bleeding
(n ⫽ 26) (n ⫽ 504) P
(n ⫽ 4). The resections were right colectomy (n ⫽ 456,
70.3 ⫾ 12.7 69.5 ⫾ 12.5
86%) and extended right colectomy (n ⫽ 74, 14%). A total Age, y .748
Sex, malea (%) 18 (69) 215 (43) .008
of 26 major complications occurred, including anasto- Incision length, cm 5.8 ⫾ 3.3 5.7 ⫾ 3.0 .885
motic leak (n ⫽ 8, 1.5%), myocardial infarction (n ⫽ 6, Operative time, min 201 ⫾ 97 173 ⫾ 63 .178
1.1%), reoperation within the first postoperative month Length of stay, daysb (range) 6.5 (5–11) 5 (4–7) .056
(n ⫽ 11, 2.1%), and death (n ⫽ 1, 0.2%). Eighty-four per- Body mass index 27.9 ⫾ 7.9 26.5 ⫾ 5.6 .219
Follow-up time, mob (range) 28 (16–55) 19 (8–45) .123
cent of patients had follow-up of 6 months or greater; me-
Previous abdominal surgery (%) 5 (19) 110 (22) .754
dian follow-up was 20 months (interquartile range 8 – 45).
Data presented as mean ⫾ SD, unless otherwise indicated.
The office charts and hospital records of all of the patients a
Median (interquartile range).
were reviewed. For more up-to-date follow-up, 75% of b
Statistically significant.
patients were successfully reached by telephone. As previ-
ously mentioned, 17 of the original 550 patients were lost
to follow-up immediately following surgery and were not operation. The anastomosis was resected in all 4 cases and
included in the analysis. then reconstructed. The mesenteric defect was not closed
Overall, 26 patients (4.9%) were diagnosed with SBO in any of the reoperations. Three patients recovered un-
during the follow-up period. Of the 26 cases, 12 cases oc- eventfully without any further episodes of SBO. One pa-
curred within the first postoperative month and 21 within tient died on postoperative day 5 following the initial op-
the first year. The longest interval between surgery and eration (postoperative day 3 following reoperation due to
SBO was 53 months. Twelve patients successfully re- internal hernia) caused by multisystem organ failure.
sponded to conventional nonoperative treatment. Al- The SBO group (n ⫽ 26) and non-SBO group (n ⫽
though 9 patients were evaluated with abdominal radio- 504) were compared on all relevant parameters using the
graphs alone, CT imaging was used to assess 3 patients. In Student t test and the Mann-Whitney U test (Table 3).
these cases, CT imaging revealed SBO caused by a left in- Compared with the non-SBO group, the SBO group had a
guinal hernia in an obese patient and mechanical obstruc- significantly higher percentage of males (69% vs 43%, P ⫽
tion due to edema at the ileocolic anastomosis in another .008). No other statistically significant differences were
patient. The third patient demonstrated no evidence of found between the 2 groups with regard to any other pa-
SBO on CT imaging. rameter examined, including prior abdominal surgery.
Fourteen patients either failed nonoperative therapies
or required urgent operative intervention. The following DISCUSSION
causes of SBO were documented in these patients: adhe-
sions (n ⫽ 4), incarcerated abdominal wall hernias (n ⫽ 4), The incidence of SBO due to any cause in this series was
mesenteric defect (n ⫽ 4), and cancer recurrence (2). Of 4.9%. Only 4 patients (0.8%) had SBO related to the mes-
the 4 SBO cases related to the mesenteric defect, 2 cases enteric defect. Two cases involved torsion of the anasto-
involved torsion of the anastomosis through the mesen- mosis through the mesenteric defect, and 2 cases were due
teric defect and 2 were due to internal herniation of the to herniation of the small bowel through the defect. Given
small bowel through the defect (Table 2). Three of these 4 the possibility of twisting the anastomosis through the de-
patients presented with SBO within 10 days of colectomy; fect during LRC, consideration should be given to reinsuf-
the fourth patient presented 8 months after surgery. None flating after extracorporeal anastomosis to confirm correct
of the 4 cases had been converted at the time of the initial orientation of the bowel limbs.
Beyond the inherent shortcomings of a retrospective
review, analysis of this series was further limited by the
TABLE 2. Small bowel obstruction characteristics inability to accurately determine the cause of SBO in pa-
Total no. cases 26 (4.9%) tients who were successfully treated nonoperatively. Nine
No. surgically treated 14 (54%) of these patients were evaluated by abdominal radiographs
Laparoscopic exploration 3 alone, which confirmed SBO but did not clarify the etiol-
Laparotomy or hernia repair 11 ogy of SBO. Three patients underwent CT scans; 2 were
Etiology*
Adhesions 4
found to have SBO due to internal hernia and postopera-
Abdominal wall hernia 4 tive anastomotic edema and 1 was found to have no evi-
Mesenteric defect 4 dence of SBO on CT imaging. Therefore, the incidence of
Cancer recurrence 2 internal herniation may have been underestimated in the
*No cause was determined for small bowel obstruction treated nonsurgically. group that was treated nonoperatively.
292 CABOT ET AL: CONSEQUENCES OF OPEN MESENTERIC DEFECT

In addition, evaluation of the long-term consequences nal hernias after laparoscopic Roux-en-Y gastric bypass. Obes
of not closing the mesenteric defect may have been limited Surg. 2003;13:596 – 600.
in some patients by the length of follow-up after surgery. 4. Cho M, Pinto D, Carrodeguas L, et al. Frequency and manage-
Although the majority of patients had follow-up of 6 ment of internal hernias after laparoscopic antecolic antegastric
Roux-en-Y gastric bypass without division of the small bowel
months or greater, 16% had a shorter follow-up period;
mesentery or closure of mesenteric defects: review of 1400 con-
furthermore, a small number of patients and families were secutive cases. Surg Obes Relat Dis. 2006;2:87–91.
not available by telephone. 5. Comeau E, Gagner M, Inabnet WB, Herron DM, Quinn TM,
Although closing the mesenteric defect laparoscopi- Pomp A. Symptomatic internal hernias after laparoscopic bari-
cally is feasible, it is time consuming and technically chal- atric surgery. Surg Endosc. 2005;19:34 –39.
lenging. Alternatively, the mesenteric defect may be closed 6. Coleman MH, Awad ZT, Pomp A, Gagner M. Laparoscopic
in an open fashion through the wound protector. Al- closure of the Petersen mesenteric defect. Obes Surg. 2006;16:
though not specifically evaluated in the present study, this 770 –772.
practice is unlikely to allow for safe and complete closure 7. Eckhauser A, Torquati A, Youssef Y, Kaiser JL, Richards WO.
of the defect in the majority of patients given the average Internal hernia: postoperative complication of Roux-en-Y gas-
incision length of LRC. A narrow residual defect (2–5 cm) tric bypass surgery. Am Surg. 2006;72:581–585.
8. Higa KD, Ho T, Boone KB. Internal hernias after laparoscopic
due to incomplete closure may increase the risk of symp-
Roux-en-Y gastric bypass: incidence, treatment and prevention.
tomatic internal herniation.11 Obes Surg. 2003;13:350 –354.
Previous studies have reported an overall incidence of 9. Blanc P, Delacoste F, Atger J. A rare cause of intestinal obstruc-
SBO following laparoscopic colectomy ranging from 0.8% tion after laparoscopic colectomy. Ann Chir. 2003;128:619 – 621.
to 2.5%.13,15–17 The most common cause of SBO in the 10. Elio A, Veronese E, Frigo F, Residori C, Salvato S, Orcalli F. Ileal
literature is incarcerated Richter’s hernia at a previous tro- volvulus on internal hernia following left laparoscopic-assisted
car site; obstruction due to an internal hernia is a rare oc- hemicolectomy. Surg Laparosc Endosc. 1998;8:477– 478.
currence.12 Internal hernia has been reported following a 11. Hosono S, Ohtani H, Arimoto Y, Kanamiya Y. Internal hernia
number of laparoscopic abdominal procedures, including with strangulation through a mesenteric defect after laparos-
laparoscopic Roux-en-Y gastric bypass,2– 8 laparoscopic copy-assisted transverse colectomy: report of a case. Surg Today.
donor nephrectomy,18 laparoscopic Nissen fundoplica- 2007;37:330 –334.
12. Jimi S, Hotokezaka M, Eto TA, et al. Internal herniation through
tion,19 and various laparoscopic genitourinary proce-
the mesenteric opening after laparoscopy-assisted right colec-
dures.20 Certain laparoscopic approaches to Roux-en-Y tomy: report of a case. Surg Laparosc Endosc Percutan Tech. 2007;
gastric bypass surgery may be associated with a higher in- 17:339 –341.
cidence of symptomatic internal hernia than open meth- 13. Kawamura YJ, Sunami E, Masaki T, Muto T. Transmesenteric
ods, but the explanation remains unclear. Koppman et al hernia after laparoscopic-assisted sigmoid colectomy. JSLS.
have suggested that the reduction in postoperative adhe- 1999;3:79 – 81.
sion formation after laparoscopic surgery, along with the 14. Nagata K, Tanaka J, Endo S, Tatsukawa K, Hidaka E, Kudo SE.
creation of potential spaces, leads to a loss of small bowel Internal hernia through the mesenteric opening after laparos-
fixation and a higher incidence of internal hernia.21 copy-assisted transverse colectomy. Surg Laparosc Endosc Percu-
The present study is the first large-scale investigation tan Tech. 2005;15:177–179.
of the consequences of leaving the mesenteric defect open 15. Fielding FA, Lumley J, Nathanson L, Hewitt P, Rhodes M, Stitz
R. Laparoscopic colectomy. Surg Endosc. 1997;11:745–749.
during laparoscopic right colectomy. In this study, mesen-
16. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Postoperative
teric defects were not associated with a significant rate of complications of laparoscopic-assisted colectomy. Surg Endosc.
clinically relevant internal hernia. These data support the 1997;11:119 –122.
practice of leaving the mesenteric defect open after LRC for 17. Kok KY, Ngoi SS, Kum CK, Tekant Y, Tasci I, Goh P. Laparo-
neoplasia. Studies with extended long-term follow-up are scopic-assisted large bowel resection. Ann Acad Med Singapore.
needed to further evaluate this practice in LRC. 1996;25:650 – 652.
18. Regan JP, Cho ES, Flowers JL. Small bowel obstruction after
laparoscopic donor nephrectomy. Surg Endosc. 2003;17:108 –110.
REFERENCES
19. Malas MB, Katkhouda N. Internal hernia as a complication of
1. Martin LC, Merkle EM, Thompson WM. Review of internal laparoscopic Nissen fundoplication. Surg Laparosc Endosc. 2002;
hernias: radiographic and clinical findings. AJR Am J Roentge- 12:115–116.
nol. 2006;186:703–717. 20. Wasserman SA. Incarcerated hernia after laparoscopically as-
2. Steele KE, Prokopowicz GP, Magnuson T, Lidor A, Schweitzer sisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc. 1994;
M. Laparoscopic antecolic Roux-en-Y gastric bypass with clo- 1(4 Pt 1):415– 416.
sure of internal defects leads to fewer internal hernias than the 21. Koppman JS, Li C, Gandsas A. Small bowel obstruction after
retrocolic approach. Surg Endosc. 2008;22:2056 –2061. laparoscopic roux-en-y gastric bypass: a review of 9,527 patients.
3. Champion JK, Williams M. Small bowel obstruction and inter- J Am Coll Surg. 2008;200:571–584.