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424 R. A. Jacobson et al.
3
1
2
Retrocolic Antecolic
Fig. 43.3 Sites of potential internal hernias following bypass surgery. (1) Herniation of small
bowel between the roux limb mesentery and the transverse mesocolon (Petersen’s space), (2) The
mesenteric opening at the biliopancreatic limb, (3) The opening through the transverse mesentery
when the bypass is retrocolic
1
2
Clinical Presentation
Mesenteric hernias are considered internal hernias because they do not extrude
outside of the abdominal cavity. As with any internal hernia, patients with
mesenteric hernia present with a spectrum of clinical severity from asymptomatic
abnormalities incidentally detected to acute mesenteric ischemia. Symptoms are
typical of a bowel obstruction, including nausea, vomiting, abdominal pain and
bloating, and may resolve if the hernia spontaneously reduces. Internal hernias are
difficult to detect on physical exam as they lack an external bulge through the
musculature of the abdominal wall. Laboratory testing may disclose contraction
alkalosis after a prolonged obstruction and leukocytosis if the herniated bowel is
ischemic. Computerized tomography (CT) with and without intravenous contrast is
the imaging test of choice, as it can determine the location and type of hernia based
on its relationship to mesenteric vessels and provide evidence of bowel ischemia.
43 Mesenteric Hernia 425
Diagnosis
Patients with a surgical history who present with obstructive symptoms and
abdominal dist ention on physical examination should be evaluated for adhesive
small bowel obstruction (the most likely diagnosis) as well as internal hernia.
Patients without a surgical history should be evaluated for endoluminal causes of
obstruction such as gallstone ileus, bezoar, intussusception, inflammatory stricture
or neoplasm, however internal hernia should be considered in the differential
diagnosis as well [Beardsley Am J Surg]. In all the above cases, abdominal CT is
warranted and necessary to make the diagnosis. CT findings associated with internal hernias include: dilated small bowel consistent with obstruction, swirling of
mesenteric fat around the superior mesenteric artery known as the swirl sign,
strangulation of the superior mesenteric vein, and engorged mesenteric vessels and
edema. A CT scan of an internal hernia can be seen in Fig. 43.4a. A demonstrating
the worrisome swirl sign associated with an internal hernia follow ing bariatric
surgery. Barium swallow can also be used to determine the presence and level of
obstruction. If fluoroscopic imaging is performed in the presence of an internal
hernia, clustering of loops of small bowel along with distended bowel proximal to
the site of obstruction are present (Fig. 43.4b).
ab
Fig. 43.4 Imaging of internal hernias. a Shows a CT scan demonstrating the presence of a
mesenteric swirl sign concerning for the presence of an internal hernia. Jens Brøndum Frøkjær
et al. The diagnostic performance and interrater agreement of seven CT findings in the diagnosis of
internal hernia after gastric bypass operation. Abdominal Radiology 2018. 43 (12): 3220–3226.
Reused with permission. © Springer Nature. b is a barium swallow showing an unusual clustering
of jejunum in the left upper quadrant. Courtesy of Dr. Abraham Dachman and Dr. Justin Ramirez.
Reused with permission
426 R. A. Jacobson et al.
Management
Confirmed symptomatic mesenteric hernias should be surgically repaired. Patients
with obstructive symptoms should be admitted to the hospital, given nasogastric
decompression, resuscitated and medically optimized for surgery. Those with
clinical, laboratory or radiographic evidence of bowel ischemia should proceed to
the operating room expediently. Repair can be performed open or laparoscopically,
depending on the history and specific condition of the patient.
Summary
Any patient with a previous Roux-en-Y reconstruction of the foregut who presents
with a bowel obstruction should be suspected to have an internal hernia-CT scan is
indicated. Inspection for swirling or spiraling or the mesenteric arteries about the
axial rotation of the gut can be subtle signs of an internal hernia. Rapid surgical
exploration is indicated when the diagnosis is suspected; this may result in a
negative laparoscopy or laparotomy, which is an acceptable outcome.
Suggested Reading
1. Nobuyki, et al. CT of internal hernias. RSNA education exhibits. RadioGraphics. 2015;25(4).
https://doi.org/10.1148/rg.254045035.
2. Shadhu K, Ramlagun D, Ping X. Para-duodenal hernia: a report of five cases and review of
literature. BMC Surg. 2018;18:32. https://doi.org/10.1186/s12893-018-0365-8.
3. Jones TW. Paraduodenal hernia and hernias of the foramen of Winslow. In: Nyhus LM,
Harkins HN, editors. Hernia. Philadelphia: JB Lippincott Co.; 1964. p. 577–601.
4. Eckhauser A, Torquati A, Youssef Y, Kaiser JL, Richards WO. Internal hernia: postoperative
complication of Roux-en-Y gastric bypass surgery. Am Surg. 2006;72(7):581–5.
5. Doishita S, Takeshita T, Uchima Y, Kawasaki M, Shimono T, Yamashita A, Miki Y. Internal
hernias in the era of multidetector CT: correlation of imaging and surgical findings.
Radiographics. 2015;36(1):88–106.
6. Beardsley C, Furtado R, Mosse C, Gananadha S, Fergusson J, Jeans P, Beenen E. Small bowel
obstruction in the virgin abdomen: the need for a mandatory laparotomy explored. Am J Surg.
2014;208(2):243–8.
7. Champion JK, Williams M. Small bowel obstruction and internal hernias after laparoscopic
Roux-en-Y gastric bypass. Obes Surg. 2003;13(4):596–600.
Surgical Management of Bands and Adhesions
Ashley J. Williamson, Robert C. Keskey, and John C. Alverdy
Definition and Clinical Features
The intestine is fixed at two peritoneal reflections: the ligament of Treitz proximally
and the ileocecal fold, or ligament of Treves distally. Normal embryologic rotation
is required for the fixation of these points and orientation of the intestine.
Embryologic rotation may be arrested resulting in malrotation most commonly
diagnosed within the first year of life which is discussed in detail in another chapter.
Rarely, malrotation is diagnosed in adult patients and adhesions between the cecum
and duodenum (Ladd bands), or a narrow mesentery base are identified. By far the
most common cause of intestinal obstruction in Western world is adhesions caused
by previous surgery and scarring. Approximately 95% of patients who undergo
abdominal surgery will develop adhesive disease which is a result of normal
healing.
Unlike children, malrotation in adults may be asymptomatic or found incidentally on imaging studies. If symptomatic, both mesenteric bands and adhesions will
present with symptoms of obstruction. Patients are likely to present with nausea,
bilious emesis, dehydration, decreased flatus or bowel movement, and abdominal
distension.
44
Description of Procedures
If malrotation in adults is suspected or diagnosed and the patient presents with an
indolent course, an elective Ladd procedure (Fig. 44.1) may be performed with
goal to broaden the base of the mesentery and reduce risk of volvulus. Obstruction
from surgical adhesive disease is attempted to be managed conservatively with
A. J. Williamson R. C. Keskey J. C. Alverdy (&)
Department of Surgery, University of Chicago, 5841 S. Maryland, Chicago, IL 60637, USA
e-mail: jalverdy@surgery.bsd.uchicago.edu
© Springer Nature Switzerland AG 2021
E. D. Ehrenpreis et al. (eds.), The Mesenteric Organ in Health and Disease,
https://doi.org/10.1007/978-3-030-71963-0_44
427
428 A. J. Williamson et al.
BA
DC
Fig. 44.1 Ladd’s Procedure: The bowel is detorsed in a counterclockwise fashion (a and b). The
Ladd bands are divided (c). The base of the mesentery is widened and the appendix is removed
nothing per mouth, nasogastric tube decompression, seri al abdominal exams, and
hydration prior to operating as any operation will further disease.
However, in patients with signs of bowel ischemia or hemodynamic instability:
i.e. leukocytosis, acute kidney injury, peritonitis, or patients who do not improve
with nasogastric tube decompression, urgent operative evaluation with exploratory
laparoscopy or laparotomy is indicated based on surgeon comfort.
44 Surgical Management of Bands and Adhesions 429
Indications for Surgery
The diagnosis of adult band or adhesive disease should be considered in patients
who present with indolent symptoms of intermittent bilious emesis, food intolerance, failure to thrive and possibly chronic diarrhea (Table 44.1).
Patients with known abdominal surgical history presenting with small bowel
obstruction without symptoms of ischemia are likely candidates for initial conservative management with nasogas tric tube and rehydration. However, signs of
compromised bowel or hemodynamic instability require urgent operat ive intervention. Further, patients whose abdominal tenderness does not improve or who are
unable to progress their diets with nasogastric tube decompression warrant exploration in the operating room.
Specific indications for an elective adhesiolysis also include treatment of
infertility and recurrent pregnancy loss in patients with prior pelvic surgery. New
data is emerging for the use of adhesiolysis as treatment for chronic abdominal pain,
however this body of literature is still evolving.
Contraindications
Patients who have never gone an operation and have no known surgical history
require appropriate work up to indicate that scarring from adhesions is the cause of
their bowel obstruction. Although certainly possible in the “virgin” abdomen,
adhesive bowel obstruction is highly unlikely. Malignancy, hernias, and intestinal
malrotation should all be looked for in these patients by using multi-modality
diagnostic techniques and an operative evaluation to definitely rule out this diagnosis may also be warranted.
Laparoscopy has become more commonly practiced for abdominal exploration.
Relative contraindications for use of laparoscopy in these situations include ascites
and compromised cardiovascular status. Absolute contraindications include surgeon’s inability to completely assess the abdomen using this approach. Laparotomy
is utilized in these cases as an alternative.
Table 44.1 Indications for
surgery in the setting of
adhesive bowel obstruction
1. Signs of peritonitis: rebound, guarding, rigid abdomen,
diffuse tenderness
2. Concern for bowel ischemia: hypo-enhancement of
intestinal wall or free fluid on CT, pain out of proportion to
physical exam, leukocytosis, hemodynamic instability
3. Failure of conservative management: persistently elevated
NG tube output, persistent or worsening abdominal distension,
persistent lack of bowel function (obstipation/constipation)
430 A. J. Williamson et al.
Preparation of the Patient
Nasogastric decompression, intravenous access and hydration, electrolyte repletion
and a detailed medical and surgical history are imperative in patients presenting
with obstruction secondary to suspected bands or adhesions. If the patients is stable,
obtaining outside operative reports are helpful, if not essential, to understand and
anticipate potential finding in the operating room.
How the Procedure is Performed
The Ladd procedure (Fig. 44.1) is performed for patients with suspected malrotation and may be performed using a laparoscopic or open method. The initial
assessment for a volvulus is accomplished by eviscerating the bowel outside of the
abdomen and assessing for any twist in the mesentery or signs of ischemia-induced
bowel compromise. If a volvulus is present, the bowel is untwisted in a counter-
clockwise fashion. Any necrotic bowel should undergo resection. The surgeon will
perform a close examination of the bowel to look for any Ladd bands. Ladd bands
are fibrinous bands that are present between the duodenum and the cecum. If
present, are surgically divided. The duodenum is straightened for complete evaluation using a Kocher maneuver. The surgeon will also assess for any intermesenteric bands or fibrous bands between other bowel loops. These have the capacity
to compress the blood supply in the mesentery. The bowel is investigated or “run”
in its entirety and these bands are divided. An appendectomy is also performed at
the time of this operation since the appendix is often in a different position than the
right lower quadrant and leads to a delay in diagno sis of acute appendicitis and
increased morbidity in patients with malrotation. The bowel is then placed in its
appropriate anatomic location, as the anatomy allows, and the abdomen is closed.
Exploration in an acute setting or for adhesive disease involves the performance
of either laparoscopic or laparotomy depending on the skill and preference of the
operating surgeon. The abdomen should be explored in entirety looking for evidence of perforation. Other suggestions that a perforation is present include the
occurrence of murky fluid or rush of air upon entry to the abdomen. The bowel
should be examined in its entirety, with a thorough evaluation for any potential
bands or adhesions. Often lysis of these bands will result in resolution of the
symptoms. The viability of the bowel based on perfusion should be evaluated, with
resection of any necrotic bowel after lysis of adhesions. Compromised bowel
should be evaluated after lysis for resolution of perfusion. If it is unclear if the
bowel is viabl e after adhesiolysis, a temporary abdominal closure device may be
placed and a second look operation planned for 24–48 h from initial surgery. This
technique is used to assess need for bowel resection prior to closure of the
abdomen.
44 Surgical Management of Bands and Adhesions 431
Typical Abnormal Findings M
Adult malrotation with volvulus may be visualized on a barium enema when there
is evidence of complete obstruction at the level of the transverse colon and the oral
contrast tapers to a “birds beak” appearance (Fig. 44.2a and b).
Further, malrotation may be identified on abdominal CT scan which may show
the duodenum not crossing midline or the cecum no in the right lower quadrant.
Outcomes and Complications
Given the rarity of adult malrotation, there is often a delay in diagnosis and
increased morbidity. For instance, the erroneous diagnosis of more common surgical diseases such as appendicitis and diverticulitis (that may not occur in the
expected location) can lead to delayed treatment. These patients are more likely to
experience advanced stages of adhesive small bowel disease prior to intervention.
It is estimated that 1% of all general surgery admissions and 3% of laparotomies
are secondary to adhesive disease. Each operation including a lysis of adhesions
operation predisposes the patient to more healing and adhesions. This must be
considered when deciding before the performance of semi-elective or elective
operations.
ab
Fig. 44.2 Axial (a) and coronal (b) CT images demonstrate sharply angulated small bowel loops
radiating to a single point (arrows) suggestive of tethering due to adhesive disease in this patient
who has h ad a prior laparotomy. Note the adjacent, fluid-filled proximal small bowel loops
indicative of small bowel obstruction. With permission from Dr. Abraham Dachman and Dr. Justin
Ramirez)
432 A. J. Williamson et al.
In true cases of intestinal malrotation, morbidity rates remain high
post-operatively in adults and approach 60%. This high morbidity rate is generally
attributed to a delay in diagnosis. Most common complications of operations for
small intestinal adhesions and obstructive small bowel diseases include ileus (or
delayed return of bowel function), small bowel obstruction secondary to adhesive
disease in the future (15%), recurrent volvulus, and rarely short gut syndrome when
midgut resections lead to chronic malabsorption of nutrients, fluids and electrolytes.
Summary
Adhesiolysis in patients without prior surgery is rarely indicated unless the patient
fails non-surgical management or imaging indicates a specific cause. It is essential
that the past medical and surgical history of patients presenting with bowel
obstruction is clearly outlined. A review of all prior operative reports should be
obtained whenever possible. Prior to closing the abdomen, it is critical that the
mesentery is flattened out and that all the bowel is in its proper orientation (Sug-
gested Reading).
Suggested Reading
1. Durkin ET, Lund DP, Shaaban AF, et al. Age-related differences in diagnosis and morbidity of
intestinal malrotation. J AM Col Surg. 2008;658.
2. Dietz DW, Walsh RM, Grundgest-Browniatowski S, et al. Intestinal malrotation: a rare but
important cause of bowel obstruction in adults. Dis Colon Rectum. 2002;45:1381.
3. Davey AK, Maher PJ. Surgical adhesions: a timely update, a great challenge for the future.
J Minim Invasive Gynecol. 2007;14:15.
4. Wilson MS. Practicalities and costs of adhesions. Colorectal Dis. 2007;9(Suppl):60.
Mesenteric Trauma
Evan G. Wong and Joseph V. Sakran
Epidemiology
Bowel and mesenteric injuries are relatively rare but can have devastating consequences. Following blunt abdominal trauma, these injuries can occur in isolation,
seen in about 1–2% of patients and associated with other injuries in around 10–15%
of cases. Mesenteric injuries are found in approximately 10% of laparotomies done
for trauma. Small bowel mesenteric injuries are 5 to 7.5 times more common than
colonic mesenteric injuries. Given the relatively low incidence, clinicians must
ensure to suspect mesenteric injuries in the right clinical context.
A landmark multi-institutional trial through the Eastern Association for the
Surgery of Trauma (EAST) demonstrated that a delay in diagnosis and intervention
was associated with a significant increase in morbidity and mortality. Delays as
short as 8 h were directly attributable to mortality. Further delays in surgical
intervention beyond 24 h were associated with a three-fold increase in death.
Early diagnosis and intervention for bowel and mesenteric injuries is therefore
crucial. The morbidity and mortality from these injuries are mainly attributable to
hemorrhage and sepsis, the latter from the associated bowel perforations. However,
early presentations can be subtle and diagnostic modalities notoriously lack sensitivity. Injuries that lead to laceration of the mesentery may result in a contained
hematoma that could result in an atypical clinical presentation such as peritonitis.
Therefore, the clinical care team must maintain a high index of suspicion for these
potential injuries.
45
E. G. Wong J. V. Sakran (&)
Division of Acute Care Surgery and Adult Trauma Services, Department of Surgery,
Johns Hopkins University, 1800 Orleans St, Sheikh Zayed Tower/Suite 6107A, Baltimore,
MD 21287, USA
e-mail: Jsakran1@jhmi.edu
© Springer Nature Switzerland AG 2021
E. D. Ehrenpreis et al. (eds.), The Mesenteric Organ in Health and Disease,
https://doi.org/10.1007/978-3-030-71963-0_45
433