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Images
in Women's Health
December 2002
Case
Samuel C. Johnson, MD
A 36-year-old gravida 4 para 1 female underwent a laparoscopic-assisted
vaginal hysterectomy with lysis of adhesions following an 8-month
history of menometrorrhagia. Two weeks after the surgical procedure,
the patient returned with complaints of severe abdominal pain, nausea,
vomiting, and constipation. A supine radiograph of the abdomen and
ultrasound of the right lower quadrant were performed.
Utrasound Findings
The abdominal radiograph demonstrates a prominently dilated loop
of small intestine in the midabdomen (arrows, Figure 1), with a
paucity of bowel gas in the remainder of the abdomen, indicative
of a small bowel obstruction. On the ultrasound exam, multiple fluid-filled
bowel loops are demonstrated in the right hemi-abdomen (black arrows,
Figure 2a). An immobile multi-layered intestinal loop with an inverted
u-shape is present in the subcutaneous layer of the right lower
quadrant, located directly beneath a surgical port. This loop extends
inferiorly through a defect in the abdominal wall musculature (open
arrows, Figure 2b). The patient successfully underwent laparotomy
that day for reduction of the ventral hernia.
Trocar-site hernias following laparoscopic surgery have been reported
in approximately 1% of cases. The small intestine is usually affected,
and two thirds of these hernias are of the Richter’s type.1
Factors related to the development of these hernias are the diameter
and design of the trocar, and body habitus of the patient. Multiple
reinsertions or dislodgements of a trocar during a procedure may
produce an abdominal wall defect larger than the trocar size.2
Peritoneal and fascial closure when blunt trocars larger than 10
mm are employed, or the use of nonbladed laparoscopic trocars, are
two techniques advocated in the prevention of this complication.1,3
The occurrence of a bowel obstruction following laparoscopy should
raise the suspicion of this entity, which can be confirmed with
ultrasound or computed tomography. Prompt diagnosis is imperative
to prevent the complication of ischemic bowel.
Diagnosis
Trocar-site intestinal hernia
References
- 1. Holzinger F, Klaiber C: Trocar site hernias. A rare but
potentially dangerous complication of laparoscopic surgery. Chirurg.
2002;73(9):899-904.
- Nakajima K, Wasa M, Kawahara H, et al: Revision laparoscopy
for incarcerated hernia at a 5-mm trocar site following pediatric
laparoscopic surgery. Surg Laparosc Endosc Percutan Tech.
1999;9(4):294-295.
- Liu CD, McFadden DW: Laparoscopic port sites do not require
fascial closure when nonbladed trocars are used. Am Surg.
2000;66(9): 853-854.
What is the diagnosis on these images? (click images to enlarge)
Figure 1 |
Figure 2a |
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Figure 2b |
Samuel C. Johnson, MD, is
assistant professor, diagnostic radiology, Department of Radiology,
Hutzel Hospital, Wayne State University School of Medicine, Detroit,
Mich. Elizabeth Puscheck, MD, MS, CCD is a reproductive endocrinologist
and infertility specialist who has developed expertise in gynecologic
ultrasound, bone densitometry, and medical education. She is currently
on faculty at Wayne State University Medical School, Detroit, Mich.
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