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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 2  |  Issue : 1  |  Page : 18-20

Drain site small bowel hernia following laparoscopic dermoid cyst excision: Known but rare complication of abdominal drains


1 Department of Gynaecology and Obstetrics, Nivedita Seva Sadan, Raiganj, Uttar Dinajpur, West Bengal, India
2 Department of Anaesthesiology, Malda Medical College, Malda, West Bengal, India
3 Department of General Surgery, Raiganj Super Speciality Hospital, Raiganj, Uttar Dinajpur, West Bengal, India

Date of Web Publication10-Jul-2017

Correspondence Address:
Udayan Kundu
Satish Bhaban, Arabindo Road, Ukilpara, Raiganj, Uttar Dinajpur - 733 134, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SJL.SJL_4_17

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  Abstract 

Laparoscopic surgery, though considered to be an ambulatory procedure, is associated with many unanticipated complications. We encountered a case of drain site hernia in a 40-year-old woman who presented with abdominal distension with pain with features suggestive of intestinal obstruction on the third postoperative day in a case of primary infertility patient admitted for Hysteroscopy and Laparoscopy (Diagnostic and Therapeutic) for left-sided dermoid cyst excision.

Keywords: Drain site hernia, laparoscopic complication, dermoid cyst


How to cite this article:
Kundu U, Lahiri S, Seth S. Drain site small bowel hernia following laparoscopic dermoid cyst excision: Known but rare complication of abdominal drains. Saudi J Laparosc 2017;2:18-20

How to cite this URL:
Kundu U, Lahiri S, Seth S. Drain site small bowel hernia following laparoscopic dermoid cyst excision: Known but rare complication of abdominal drains. Saudi J Laparosc [serial online] 2017 [cited 2019 Jul 18];2:18-20. Available from: http://www.saudijl.org/text.asp?2017/2/1/18/209998


  Introduction Top


With the advancement of technology, we are using laparoscopic surgical technique every day in many gynecological procedures. It helps us not only to reduce morbidity, hospital stay, pain but also fasten recovery time leading to an earlier resumption of normal activity. Sometimes, we use drain in laparoscopy therapeutically aiming to reduce morbidity and enhance recovery of patients. However, drains may complicate the scenario and recovery process of disease may be delayed due to drain related complications. The complications range from drain site infection to drain site hernia (DSH) of omentum or small bowel leading to strangulation and necrosis. The incidence of DSH is reported to be ranged from 0.14% to 3.4%.[1]

We had a 40-year-old female patient of primary infertility who underwent laparoscopic excision of the left-sided ovarian dermoid cyst. On the third postoperative day, she developed abdominal distension and pain with features suggestive of intestinal obstruction, which was later diagnosed as DSH.


  Case Report Top


A 40-year-old female patient presented with primary infertility with 16 years of married life. Her ultrasonography showed echogenic area within the left ovary (about 2.59 cm) which can be dermoid cyst or hemorrhagic ovarian cyst. Her all investigation (hematological, electrocardiogram, chest X-ray) reports were normal. She was posted for operation on day 10 of a regular 28-day menstrual cycle. Diagnostic hysteroscopy shows multiple anterior wall small polyps within uterine cavity. Pneumoperitoneum was established with a veress needle. A 10-mm umbilical camera port and one 5-mm on the right lower quadrant and one 10-mm on left quadrant working ports were made. A 3.5-cm dermoid cyst in the left ovary was found. Dye test was negative both side as no free spillage of dye. Right ovary appeared normal. Uterus appeared normal. The cyst was excised using Storz monopolar hook. A 28 Fr Romo ADK drain was placed in the left lower quadrant port and removed after 48 h with minimal drainage. She was discharged in favorable condition after removal of drain. Approximately, 12 h after drain removal, she complained of pain at the drain site. She was admitted with nil orally, intravenous fluid, analgesic, antibiotic, a nasogastric tube was inserted which drained 1.5 L of bilious fluid over 24 h. On 2nd day of readmission, she began to vomit with upper abdominal fullness. On examination, she was afebrile, and her upper abdomen was slightly distended. A repeat ultrasound demonstrated minimal free fluid collection in the pouch of Douglas. Abdominal radiograph revealed a few prominent loops of small bowel with no gas in the rectum [Figure 1]. She was treated for postoperative ileus by correction of hypokalemia (K = 3.4 mmol/L). As she did not become febrile, conservative treatment was continued. On day 3, her nasogastric aspirates were only 0.2 L/day, and nasogastric tube was removed 4th day. However, again she developed abdominal distension after taking clear fluid orally. A computed tomography scan was done and it diagnosed the case as “there is dilatation of small bowel loops with herniation of small bowel loop through a defect in the anterior abdominal wall in the left lower quadrant. It shows complete obstruction as evidenced by collapsed distal small bowel loops” [Figure 2] and [Figure 3] she was taken to OT for laparotomy. On closer inspection, a viable loop of ileum was found to have herniated through the left lower quadrant 10-mm drain site causing small bowel obstruction. This was reduced and proximal gut loop distension was decompressed. The stitch line was closed in layers. Drain site was repaired separately. Six days after laparotomy, she was discharged.
Figure 1: Abdominal radiograph revealed a few prominent loops of small bowel with no gas in the rectum

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Figure 2: Computed tomography scan abdomen transverse view

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Figure 3: Computed tomography scan abdomen longitudinal view

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  Discussion Top


DSH in laparoscopic procedure is rare but established complication in medical literature. It is found to occur more commonly in laparoscopic surgery than with open abdominal surgery. The incidence of DSH is reported to be ranged from 0.14% to 3.4%.[1] These hernias may occur between day 2 and day 229 postoperatively and contains either small bowel or omentum. However, in other rare cases, the appendix and nodules of endometriosis have been reported in DSH.[2] Hence, it is necessary to remove port under vision to note any hernia or any fascial defect more than the skin incision. If the fascial defect found more it can be closed under vision by maintaining pneumoperitoneum with newer suturing devices like the Carter–Thomason Close Sure ® system (Inlet Medical, USA).[3] If omentum is the content of DSH, it can be managed under local anesthesia by enlarging port site, reduce the content by gentle finger dissection and push it in abdomen and close the port under vision as the closure of umbilical port. If small bowel is the content, it should be reduced under general anesthesia by laparoscopy or laparotomy if gut resection and anastomosis are suspected. In conclusion, obese patient, large size of drain, increased intra-abdominal pressure, port site infection can predispose to DSH. In obese patient, late diagnosis is possible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Makama JG, Ameh EA, Garba ES. Drain site hernia: A review of the incidence and prevalence. West Afr J Med 2015;34:62-8.  Back to cited text no. 1
[PUBMED]    
2.
Gass M, Zynamon A, von Flüe M, Peterli R. Drain-site hernia containing the vermiform appendix: Report of a case. Case Rep Surg 2013;2013:198783.  Back to cited text no. 2
    
3.
Elashry OM, Nakada SY, Wolf JS Jr., Figenshau RS, McDougall EM, Clayman RV. Comparative clinical study of port-closure techniques following laparoscopic surgery. J Am Coll Surg 1996;183:335-44.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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