Internal hernia of small bowel after laparoscopic aortobifemoral bypass surgery treated with omentoplasty: A case report with video

Abstract

Laparoscopic aortobifemoral bypass surgery is a frequently performed procedure for occlusive arterial disease. Gastrointestinal complications such as paralytic ileus are common. However, internal hernia is a rare complication and the treatment can be technically difficult.

We present the case of a 62-year-old male patient presenting at the emergency department with clinical signs of intestinal obstruction: abdominal distension and pain, vomiting and absence of flatus and stools. Four years prior he had a laparoscopic aortobifemoral bypass in the treatment of occlusive arterial disease. CT scan showed a closed loop obstruction of small intestine. An urgent laparoscopy was planned. On exploration, an internal herniation of the small intestine was found through an opening below the right iliac branch of the aortobifemoral graft, creating a closed loop obstruction. The bowel was reduced. As there was no option to close the opening with a peritoneal flap, an omentoplasty was performed occluding the opening to prevent recurrence.

Internal hernia underneath the vascular graft of an aortobifemoral bypass is very rare. To our knowledge only one case has been described in the current available literature, this was treated with a peritoneal flap. Closing the defect can be technically difficult, especially when it is not possible to create a peritoneal flap, in our case this was not possible because the bypass surgery was 4 years prior. Omentoplasty can be an efficient and durable surgical solution to this problem.