1717Vol. 11 | No. 03 | May - June 2014 |U R O LO G Y J O U R N A L Acute Jejunal Obstruction Following Lapa- roscopic Nephrectomy Albert Abhinay Kota,1 Sukria Nayak,1 Rajiv Paul Mukha,2 Nitin S Kekre2 Corresponding Author: Albert Abhinay Kota, MD Department of Surgery IV, Christian Medical College and Hospital, Vellore, Tamil Nadu. 632004, India. Tel: +91 416 228 2441 E-mail: albertkota@cmcvellore.ac.in Received June 2013 Accepted April 2014 1 Department of Surgery IV, Christian medical college and hospital, Vellore, India. 2 Department of Urology, Christian medical college and hospital, Vellore, India. CASE REPORT Keywords: intestinal obstruction; etiology; jejunum; kidney neoplasms; surgery; laparos- copy; nephrectomy; adverse effects. INTRODUCTION In acute small bowel obstruction, internal hernias have an incidence of 1.9-3%. (1) Most often, the clinical features are nonspecific and hence the diagnosis can be delayed caus- ing increased morbidity and the risk of gangrene requiring resection. CASE REPORT Sixty five year old male incidentally detected to have left renal mass. He did not have any past surgeries. After discussion, he underwent laparoscopic transperitoneal radical left ne- phrectomy as he opted for the procedure. He was positioned in a modified right lateral de- cubitus position. We used the standard three port technique. Pneumoperitoneum was created via open technique through a 10 mm port in the midclavicular line 2 cm lateral to the level of umbilicus, 10 mm port in the left subcostal region in the anterior axillary line and another 10 mm port in the anterior axillary line at the level of anterior iliac crest. The left colon was mobilized medially after incising the Toldt’s line. The ureter and gonadal vein were identified and traced superiorly till the lower pole of the kidney. The lower pole was identified and el- evated. The renal artery was dissected, isolated, clipped and divided. Similarly the renal vein was divided. The Gerota’s fascia at the upper pole was then incised and the adrenal glands 1718 | separated. The kidney was dissected posteriorly with the Gerota intact. The ureter and gonadal vein were divided; the specimen was placed in an endobag and removed through a Pfannenstiel incision. The procedure was done in 1 hour fif- teen minutes and the intraoperative course was uneventful. Histopathology of the nephrectomy specimen was reported as papillary carcinoma (pT1aN0M0 Fuhrman nuclear grade II). On the fifth postoperative day, he developed abdominal distension, upper abdominal discomfort, nausea and bilious vomiting. Examination was normal. On imaging, comput- ed tomography (CT) scan revealed proximal small bowel obstruction with internal herniation of the jejunal loops in the left renal fossa bed (Figures 1, arrow head) through the transverse mesocolon (arrow heads in Figures 2). He un- derwent emergency operation involving laparoscopy con- verted into exploratory laparotomy due to dense adhesions. Release of the internal herniated dilated jejunal loops and closure of the mesocolonic defect was done. The dilated je- junal loops were congested but recovered to normal color with arterial pulsations and peristalsis following the release of adhesions. After the procedure he recovered well. DISCUSSION Small bowel obstruction (SBO) is a common surgical emer- gency. Adhesive related small bowel obstruction is the most commonest cause of mechanical SBO.(2) Internal hernias are rare. Post-operative transmesenteric hernias are a com- mon type of internal hernias.(3) They have been often re- ported following bariatric procedures like gastric bypass. (4) Urological operations like nephrectomy have been rarely reported to cause intestinal obstruction. Laparoscopic ne- phrectomies have reported complications like vascular in- juries, bowel injuries, solid organ injuries, access related, renal artery pseudoaneurysm, bladder perforation.(5-7) Our patient developed acute intestinal obstruction follow- ing left nephrectomy. In literature, there are only 8 case re- ports of the intestinal obstruction following nephrectomies, all of which were left sided.(4,8,9) The main mechanism of occurrence is thought be due to rent in the transmesocolic defect during medial mobilization of the left colon along the Toldt’s line while preserving the gonadal vein and po- tential space in the renal fossa bed causing migration of the small intestinal loops, eventually leading to kinking and extrinsic obstruction. Seldom do these loops of small bowel get strangulated. However if there was undetected prolonged obstruction, it can lead to gangrene and perfo- ration requiring resection of small bowel. The presenting symptoms are often vague and vary from upper abdominal discomfort, bloating, nausea, vomiting with no abdominal signs. When the bowel becomes strangulated or gangre- nous, then there can be signs like tenderness and localized guarding.(8) Diagnosis is mainly based on imaging. Abdom- inal plain X-rays may reveal dilated proximal small bowel Figure 1. Computed tomography scan (axial section) revealed revealed proximal small bowel obstruction with internal herniation of the jejunal loops in the left renal fossa bed. Figure 2 . Computed tomography scan (coronal section) revealed scan revealed proximal small bowel obstruction with internal herniation of the (arrow heads). Case Report 1719Vol. 11 | No. 03 | May - June 2014 |U R O LO G Y J O U R N A L Jejunal Obstruction Following Laparoscopic Nephrectomy | Kota et al loops. Contrast enhanced computerized tomography is di- agnostic. Some have used small bowel series for diagno- sis.(8) Treatment involves emergency exploration, releasing the small bowel loops and closing the transmesocolic rent. This can be done laparoscopically or as an open procedure. This potential problem can be prevented by identifying the defect in the mesocolon intraoperatively and suturing appropriately. Other techniques mentioned in literature to prevent the creation of the defect include, staying close to the gerotas fascia and staying lateral to the gonadal veins during dissection.(10) It is also prudent to remember that the splenic flexure is an important watershed area and injury to the marginal vessels can cause ischemic injury to the colon. CONCLUSION Acute small bowel obstruction following laparoscopic ne- phrectomy warrants an urgent imaging and exploration to prevent strangulation. Care should be taken while dissect- ing the mesocolon to prevent causing any defect which can lead to this complication. CONFLICT OF INTEREST None declared. REFERENCES 1. Ghosheh B, Salameh JR. Laparoscopic approach to acute small bow- el obstruction: review of 1061 cases. Surg Endosc. 2007;21:1945-9. 2. Miller G, Boman J, Shrier I, Gordon PH. Etiology of small bowel ob- struction. Am J Surg. 2000;180:33-6. 3. Ghiassi S, Nguyen SQ, Divino CM, Byrn JC, Schlager A. Internal herni- as: clinical findings, management, and outcomes in 49 nonbariatric cases. J Gastrointest Surg. 2007;11:291-5. 4. Wadhawan R, Raul S, Gupta M, Verma S. Management of intestinal obstruction following laparoscopic donor nephrectomy. J Minim Access Surg. 2012;8:149-51. 5. Maghsoudi R, Azaripour A. Bladder perforation during laparoscopic donor nephrectomy. Urol J. 2007;4:123-4. 6. Shakhssalim N, Nouralizadeh A, Soltani MH. Renal artery pseudoa- neurysm following a laparoscopic partial nephrectomy: hemor- rhage after a successful embolization. Urol J. 2010;7:12-4. 7. Pareek G, Hedican SP, Gee JR, Bruskewitz RC, Nakada SY. Meta-anal- ysis of the complications of laparoscopic renal surgery: comparison of procedures and techniques. J Urol. 2006;175:1208-13. 8. Cox R, Dalatzui N, Hrouda D, Buchanan GN. Systematic review of internal hernia formation following laparoscopic left nephrectomy. Ann R Coll Surg Engl. 2009;91:667-9. 9. Wong JF, Ho HS, Tan YH, Cheng CW. 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