Closed loop small bowel obstruction post laparoscopic rectopexy

Case contributed by Dr Ashesh Ishwarlal Ranchod

Presentation

Severe abdominal distension, pain and vomiting following laparoscopic rectopexy two weeks prior.

Patient Data

Age: 40 years
Gender: Female

Distended, fluid-filled, small bowel loops with minimal distal large bowel feacal loading. Features are suggestive of significant but partial distal small bowel obstruction. Titanium and radio-opaque surgical tacks are identified overlying the sacral promontory. There is no free air or pneumatosis intestinalis.

Multiphasic CT imaging confirms a central closed loop small bowel obstruction. This is demonstrated by markedly distended, fluid-filled, small bowel loops, with a whirl sign secondary to the tight mesentery and associated c-shaped small bowel loops. This is identified just above the lumbosacral junction. There is significant free fluid and no free intraperitoneal air. There are non-enhancing small bowel loops suspicious for ischemic bowel.

There are titanium surgical tacks at the lumbosacral junction specifically overlying the anterior inferior L5 vertebral body and sacral promontory. The patient had a prior hysterectomy.

There is incidental bilateral breast augmentation surgery with intact implants in situ.

Annotated 3D and MPR MIP images demonstrate the lumbosacral titanium surgical tacks applied to the sacral promontory (anterior longitudinal ligament).

Case Discussion

This patient underwent laparoscopic rectopexy. Rectopexy is also called proctopexy. This entails suturing the rectum to the sacrum with the use of a polypropylene mesh that attaches to the sides of the lifted rectum and is attached to the anterior longitudinal ligament at the sacral promontory with the use of surgical titanium tacks or alternatively nonabsorbable glue. The procedure is usually done as an open surgical procedure. Nowadays, due to improved laparoscopic expertise and experience, the procedure is done laparoscopically and also robotically with the use of the Da Vinci robotic system. This patient underwent a laparoscopic rectopexy and developed a severe subacute small bowel obstruction due to an internal hernia and consequent closed loop small bowel obstruction. Ischemic and gangrenous small bowel was found at the time of surgical intervention and bowel resection was performed. The patient had an otherwise unremarkable recovery post emergency surgery.

Disclosure: I, Ashesh I Ranchod, have no actual or potential ethical or financial conflict of interest in relation to this device. This case is not intended to be a personal endorsement or recommendation of this product.

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