Internal Hernia Associated with Colostomy After Laparoscopic Surgery for Rectal Malignancy: A Report of 3 Thought-Provoking Cases

Case series Patients: Male, 70 • Male, 75 • Male, 85 Final Diagnosis: Internal hernia Symptoms: Abdominal and/or epigastric pain Medication: — Clinical Procedure: — Specialty: Surgery OBJECTIVE: Diagnostic/therapeutic accidents BACKGROUND: Colostomy creation via intraperitoneal route is often performed during laparoscopic Hartmann’s operation or abdominoperineal resection (APR). Herein, we report 3 rare cases of internal hernia associated with colostomy (IHAC). CASE REPORTS: The first case involved a 70-year-old man with IHAC after laparoscopic APR. Laparoscopy revealed the small intestine passed through a defect between the lifted sigmoid colon and left lateral abdominal wall in a cranialto-caudal direction. The dislocated bowel with ischemic change was restored to its normal position and the lateral defect was covered with lateral peritoneum and greater omentum. The second case involved a 75-year-old man with IHAC after laparoscopic APR. Intraperitoneal findings were similar to those in the first case, except for the size of the lateral defect. This defect was too large for primary closure or patching; therefore, no surgical repair was performed. Unfortunately, this led to IHAC recurrence and creation of a new colostomy via extraperitoneal route. The third case involved an 85-year-old man with acute peritonitis resulting from IHAC after laparoscopic Hartmann’s operation. Surgery revealed incarcerated bowels forming a closed loop and a perforation in the lifted sigmoid colon. The perforated colon was compressed by the dilated herniated bowel. The resected sigmoid colon showed perforation at the ulcer, which was shown on pathology to be caused by ischemia. CONCLUSIONS: IHAC can lead not only to ischemia of strangulated bowel, but also to secondary damage to the lifted colon. During laparoscopic Hartmann’s operation or APR, the colostomy should be created via extraperitoneal route to avoid IHAC.