Laparoscopic management of a strangulated internal hernia underneath the left external iliac artery.

INTRODUCTION: Internal herniation of a small bowel behind pelvic vessels is a rare complication seen after pelvic lymphadenectomy.

PRESENTATION OF CASE: A 56-year-old woman was operated due to a gynecological cancer. 4 years thereafter she presented with a 2 days history of abdominal pain and vomiting. Clinical and radiological findings indicated a small bowel obstruction. A loop of small bowel had herniated behind the left external iliac artery. Using laparoscopic technique the herniated bowel was reduced. Due to limited peritoneum around the area and skeletonized vessel, we decided not to do any repair of the hernia orifice. The postoperative recovery was uneventful, bowel activity returned to normal and she was discharged the next day. Follow-up was done at 1 month and the latest at 10 months. She didn't experience pain or discomfort after the operation.

DISCUSSION: Due to limited peritoneum around the skeletonized vessel, we decided to leave the hernia orifice unrepaired. We found it hazardous to do any direct suture of the orifice or use a free peritoneal graft to repair the defect as the fibrosis and inflammatory process might have compromised the artery or the vein. A longer follow-up of the patient is needed to clearly conclude if this simple procedure has been sufficient. We agreed that if the patient would experience any sign of recurrence and need another operation we would close the defect at that time.

CONCLUSION: 4 years after pelvic lymphadenectomy a small bowel herniation behind an external iliac artery occurred. The patient was successfully treated with reduction of the small bowel using laparoscopic technique. A quick recovery with minimal discomfort and no sign of recurrence after 10 months made our approach an acceptable surgical option.