Presentation
Severe abdominal pain. History of VHL and right nephrectomy for clear cell carcinoma.
Patient Data
Right nephrectomy. Cluster of abnormal loops of small bowel within the nephrectomy bed which are fluid-filled, have thickened walls with slightly diminished enhancement, and are associated with mesenteric edema. The afferent and efferent loops of this cluster converge centrally at a single point, consistent with passing through an internal hernia defect or tight adhesive band. Proximally, the small bowel is mildly dilated with gradual transition of enteric contrast into fluid-filled loops of bowel. Distally, the small bowel is decompressed.
POSTOPERATIVE DIAGNOSIS: Closed loop small bowel obstruction, secondary to an internal hernia in the right dorsal peritoneum.
Operation
Exploratory laparotomy with lysis of adhesions and release of bowel obstruction, with reduction of internal hernia.
Procedure/Description
...The peritoneal cavity was sharply entered. He had markedly dilated proximal small bowel loops. The diameter of the bowel approached 6 cm. The bowel was run and he was found to have a round internal hernia measuring approximately 5 cm in diameter in the right retroperitoneum. An approximately 25 cm segment of incarcerated, strangulated small bowel was reduced from that. The surface of the small bowel was erythematous and hemorrhagic, but the bowel was clearly viable and did peristalse normally. Its color became less and less congested and more and more normal with time...The neck of the retroperitoneal defect was then oversewn so that no further herniation would be possible..."
Case Discussion
The cluster of abnormal small bowel loops in the right nephrectomy bed is impressive. On a single coronal image, you might even think it looks like XGP on first glance!
Both afferent (going in) and efferent (going out) limbs of the closed loop are narrowed and obstructed at the same location, and can be difficult to distinguish from each other (best followed on the axial and sagittal images). Given the history of nephrectomy and the tight, focal narrowing resulting in closed loop obstruction, internal hernia cannot be favored over adhesion as the cause, although it would be appropriate to provide both in the differential diagnosis. Either way, this case is a surgical emergency as the vascular supply of the bowel has been compromised and concerning for ischemia (see operative note).
Companion cases of closed-loop obstructions:
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