br Case Report A year

Case Report A 72-year-old man with a chief complaint of painless macroscopic hematuria and considerable weight loss for 3 months was presented to us. The left loin mass was painless, and he did not have any other constitutional symptoms. A 4-phase computed tomography (CT) scan of the kidneys revealed an 8-cm large mass arising from the lower pole of the left kidney, probably indicating renal cell carcinoma (Figures 1A and 1B), an evident left renal artery and vein, and a minimal surrounding perinephric fat streakiness. The patient\'s blood investigation and chest X-ray results were normal. He underwent laparoscopic transperitoneal left radical nephrectomy, where the colon and splenic flexure were mobilized, ureter and gonadal vein were identified, and renal artery and vein were ligated. The left adrenal gland was preserved during nephrectomy. The immediate postoperative period was uneventful. However, on Day 2 of surgery, the patient complained of an acute-onset, abrupt, and early abdominal distension, and he was unable to pass stool. Physical examination revealed a soft, mildly distended abdomen with no masses, rebound tenderness, and no guarding. The patient was hemodynamically stable, and routine blood tests, including complete blood count, liver and kidney functions, and serum amylase, were all normal. No causes for ileus, such as electrolyte imbalance, sepsis, or drug use, were identified; therefore, mechanical bowel obstruction was suspected. A TAE226 cost CT scan of the abdomen showed a transitional zone, suggesting mechanical obstruction with no collections (Figure 2). Therefore, laparotomy was performed on Day 3 following surgery. A 2-cm defect in the mesentery of the sigmoid colon was found, and the small bowel (ileum) was herniated through this defect, causing a constriction band near the ileum at ∼65 cm from the ileocecal junction. The small bowel proximal to the constricting ileal band was grossly dilated. The incarcerated bowel nonviable loops were reduced, resected, and primarily anastomosed. Subsequently, the defect was repaired with absorbable sutures. Following this, the patient\'s recovery was uneventful, and ovule was discharged 6 days later.
Discussion The incidence of LN complications ranges from 5% to 8.2%. Vascular injury is the most common complication, whereas bowel-related complications are rare (< 1%) and manifest as postoperative ileus. In general, IO resulting from internal bowel herniation via a mesenteric defect is rare. It is possibly created due to extensive colonic mobilization or mesenteric dissection to maximize the length of renal vessels for subsequent anastomosis. Cases of internal bowel herniation via mesenteric defects have been reported following laparoscopy-assisted colectomy. In such operations, mesenteric incisions are necessary, but they are not routinely closed. The incidence of IO is 0.7–2.7% and that of internal herniation is 0.37%. The mesenteric defect is created during descending colon mobilization, which can be avoided by dissecting medial to the Gerota fascia and staying lateral to the gonadal vein. Risk factors causing mesenteric defects during descending colon mobilization include tumor size, left-sided tumor, larger potential space in the left renal fossa than in the right renal fossa, and extensive manipulation due to adhesions or fecally loaded colon. In our case, the 2-cm mesenteric defect and the potential space in the left renal fossa facilitated small bowel herniation. This is distinct from other bowel complications such as bowel injury or ileus in which patients remain unwell from the time of initial surgery. Our case reinforced the utility of CT scans for the diagnosis of complications after laparoscopic urological surgery. Regardless of its size, a mesenteric defect leads to a risk of bowel herniation. In a large defect, a wider neck is thought to prevent incarceration or strangulation of the herniated bowel. However, adhesion around the defect can reduce neck size, leading to this complication. Smaller defects can also cause such complications. Therefore, careful inspection of the mesentery after laparoscopic surgery is mandatory for preventing this rare morbid complication.