Skip to main content
SpringerLink
Log in

Internal hernia after laparoscopic colorectal surgery: an under-reported potentially severe complication. A systematic review and meta-analysis

  • Review Article
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Internal hernia following laparoscopic colorectal surgery is often under-reported. The aim of this review was to evaluate the occurrence rate of internal hernia following laparoscopic colorectal surgery, and to describe clinical presentation and management strategies.

Methods

A comprehensive literature review was conducted including MEDLINE/Pubmed, EMBASE, SCOPUS, clinicaltrials.gov, and the Cochrane Database of Systematic Reviews through April 2018. The review was conducted according to MOOSE guidelines. Quality was appraised with the Methodological Index for Non-Randomized Studies (MINORS) tool. Meta-analysis was performed using a random effects model. Studies reporting data on internal hernia after laparoscopic colorectal surgery were included.

Results

Ten observational studies with a total of 8453 patients were included. All included articles were non-comparative prospective or retrospective cohort studies with an average MINORS score of 8.3 (range 6–11). Summary estimate of proportion of patients developing internal hernia after laparoscopic colorectal resection was 0.5% (95% CI 0.3–0.8%). Heterogeneity was moderate (I2 46%, p = 0.03) and study size (> 1000 vs. <1000 patients) was found to have a significant contribution to heterogeneity (p = 0.002). Thirty patients (90.9%) required surgery, with 5 non-fatal and 3 fatal postoperative complications. Quality of some studies was limited; some patients were followed up for less than 1 year; primary surgical procedures included different laparoscopic approaches.

Conclusions

Occurrence rate of internal hernia after laparoscopic colorectal resection is around 5 per 1000 patients. Small-sized studies are likely to overestimate the occurrence of internal hernia. Need for reoperation is high with a substantial risk of mortality.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Martin LC, Merkle EM, Thompson WM (2006) Review of internal hernias: radiographic and clinical findings. AJR Am J Roentgenol 186:703–717

    Article  PubMed  Google Scholar 

  2. Sereno Trabaldo S, Anvari M, Leroy J, Marescaux J (2009) Prevalence of internal hernias after laparoscopic colonic surgery. J Gastrointest Surg 13:1107–1110

    Article  PubMed  Google Scholar 

  3. Steele KE, Prokopowicz GP, Magnuson T, Lidor A, Schweitzer M (2008) Laparoscopic antecolic Roux-en-Y gastric bypass with closure of internal defects leads to fewer internal hernias than the retrocolic approach. Surg Endosc 22:2056–2061

    Article  CAS  PubMed  Google Scholar 

  4. Comeau E, Gagner M, Inabnet WB, Herron DM, Quinn TM, Pomp A (2005) Symptomatic internal hernias after laparoscopic bariatric surgery. Surg Endosc 19:34–39

    Article  CAS  PubMed  Google Scholar 

  5. Toh JW, Lim R, Keshava A, Rickard MJ (2016) The risk of internal hernia or volvulus after laparoscopic colorectal surgery: a systematic review. Colorectal Dis 18:1133–1141

    Article  CAS  PubMed  Google Scholar 

  6. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, Heath RM, Brown JM, MRC CLASICC trial group (2005) Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365:1718–1726

    Article  PubMed  Google Scholar 

  7. Fleshman J, Sargent DJ, Green E, Anvari M, Stryker SJ, Beart RW, Hellinger M, Flanagan R, Peters W, Nelson H, Clinical Outcome of Surgery Therapy Study Group (2007) Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg 246:655–662

    Article  Google Scholar 

  8. Hazebroek EJ, COLOR Study Group (2002) COLOR: a randomized clinical trial comparing laparoscopic and open resection for colon cancer. Surg Endosc 16:949–953

    Article  CAS  PubMed  Google Scholar 

  9. Green BL, Marshall HC, Collinson F, Quirke P, Guillou P, Jayne DG, Brown JM (2013) Long-term follow-up of the Medical Research Council CLASICC Trial of conventional versus laparoscopically assisted resection in colorectal cancer. Br J Surg 100:75–82

    Article  CAS  Google Scholar 

  10. Reza MM, Blasco JA, Andradas E, Cantero R, Mayol J (2006) Systematic review of laparoscopic versus open surgery for colorectal cancer. Brit J Surg 93:921–928

    Article  CAS  PubMed  Google Scholar 

  11. Van de Velde CJ, Boelens PG, Borras JM, Coebergh JW, Cervantes A, Blomqvist L, Beets-Tan RG, van de Broek CB, Brown G, Van Cutsem E, Espin E, Haustermans K, Glimelius B, Iversen LH, van Krieken JH, Marijnen CA, Henning G, Gore-Booth J, Meldolesi E, Mroczkowski P, Nagtegaal I, Naredi P, Ortiz H, Pahlman L, Quirke P, Rodel C, Roth C, Rutten H, Schmoll HJ, Smith JJ, Tanis PJ, Taylor C, Wibe A, Wiggers T, Gambacorta MA, Aristei C, Valentini V (2014) EURECCA colorectal: multidisciplinary management. In: European consensus conference on colon and rectum. Eur J Cancer 50:1.e1–1.e34

  12. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 283:2008–2012

    Article  CAS  Google Scholar 

  13. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J (2003) Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg 73:712–716

    Article  PubMed  Google Scholar 

  14. Viechtbauer W (2010) Conducting meta-analyses in R with the metafor package. J Stat Softw 36:1–48

    Article  Google Scholar 

  15. R Core Team (2016) R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna

    Google Scholar 

  16. Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558

    Article  Google Scholar 

  17. Duval SJ, Tweedie RL (2000) Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 56:455–463

    Article  CAS  PubMed  Google Scholar 

  18. Higgins JPT, Green S (eds) (2011) Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. The Cochrane Collaboration. http://www.handbook.cochrane.org. Accessed 31 Aug 2018

  19. Svraka M, Wilhelmsen M, Bulut O (2017) Internal hernia following laparoscopic colorectal surgery: single center experience. Pol Przegl Chir 89:19–22

    Article  PubMed  Google Scholar 

  20. Angelini P, Sciuto A, Cuccurullo D, Pirozzi F, Reggio S, Corcione F (2017) Prevention of internal hernias and pelvic adhesions following laparoscopic left-sided colorectal resection: the role of fibrin sealant. Surg Endosc 31:3048–3055

    Article  PubMed  Google Scholar 

  21. Lee SY, Kim CH, Kim YJ, Kim HR (2017) Internal hernia following laparoscopic colorectal surgery: a rare but fatal complication. Hernia 21:299–304

    Article  CAS  PubMed  Google Scholar 

  22. Ansari N, Keshava A, Rickard MJ, Richardson GL (2013) Laparoscopic repair of internal hernia following laparoscopic anterior resection. Int J Colorectal Dis 28:1739–1741

    Article  PubMed  Google Scholar 

  23. O’Riordan JM, Larkin JO, Mehigan BJ, McCormick PH (2013) Re-laparoscopy in the diagnosis and treatment of post-operative complications following laparoscopic colorectal surgery. Surgeon 11:183–186

    Article  PubMed  Google Scholar 

  24. Saklani A, Naguib N, Tanner N, Moorhouse S, Davies CE, Masoud AG (2012) Internal herniation following laparoscopic left hemicolectomy: an underreported event. J Laparoendosc Adv Surg Tech A 22:496–500

    Article  PubMed  Google Scholar 

  25. Cabot JC, Lee SA, Yoo J, Nasar A, Whelan RL, Feingold DL (2010) Long-term consequences of not closing the mesenteric defect after laparoscopic right colectomy. Dis Colon Rectum 53:289–292

    Article  PubMed  Google Scholar 

  26. Rotholtz NA, Laporte M, Lencinas SM, Bun ME, Aued ML, Mezzadri NA (2009) Is a laparoscopic approach useful for treating complications after primary laparoscopic colorectal surgery? Dis Colon Rectum 52:275–279

    Article  PubMed  Google Scholar 

  27. Lacy AM, García-Valdecasas JC, Delgado S, Grande L, Fuster J, Tabet J, Ramos C, Piqué JM, Cifuentes A, Visa J (1997) Postoperative complications of laparoscopic-assisted colectomy. Surg Endosc 11:119–122

    Article  CAS  PubMed  Google Scholar 

  28. Fielding GA, Lumley J, Nathanson L, Hewitt P, Rhodes M, Stitz R (1997) Laparoscopic colectomy. Surg Endosc 11:745–749

    Article  CAS  PubMed  Google Scholar 

  29. Kok KY, Ngoi SS, Kum CK, Tekant Y, Tashi I, Goh P (1996) Laparoscopic-assisted large bowel resection. Ann Acad Med Singapore 25:650–652

    CAS  PubMed  Google Scholar 

  30. Malas MB, Katkhouda N (2002) Internal hernia as a complication of laparoscopic Nissen fundoplication. Surg Laparosc Endosc Percutan Tech 12:115–116

    Article  PubMed  Google Scholar 

  31. Hunter JP, Saratzis A, Sutton AJ, Boucher RH, Sayers RD, Bown MJ (2014) In meta-analyses of proportion studies, funnel plots were found to be an inaccurate method of assessing publication bias. J Clin Epidemiol 67:897–903

    Article  PubMed  Google Scholar 

  32. Yoshida T, Kinugasa T, Oka Y, Mizobe T, Ishikawa H, Mori N, Isobe T, Katayama E, Akagi Y (2014) Bowel obstruction caused by an internal hernia that developed after laparoscopic subtotal colectomy: a case report. J Med Case Rep 8:470

    Article  PubMed  PubMed Central  Google Scholar 

  33. Blanc P, Delacoste F, Atger J (2003) A rare cause of intestinal obstruction after laparoscopic colectomy. Ann Chir 128:619–621

    Article  CAS  PubMed  Google Scholar 

  34. Masubuchi S, Okuda J, Tanaka K, Kondo K, Asai K, Kayano H, Yamamoto M, Uchiyama K (2013) Internal hernia projecting through a mesenteric defect to the lesser omental cleft following laparoscopic-assisted partial resection of the transverse colon: report of a case. Surg Today 43:814–817

    Article  PubMed  Google Scholar 

  35. O’Connor DB, Winter DC (2012) The role of laparoscopy in the management of acute small-bowel obstruction: a review of over 2000 cases. Surg Endosc 26:12–17

    Article  PubMed  Google Scholar 

  36. Teixeira PG, Karamanos E, Talving P, Inaba K, Lam L, Demetriades D (2013) Early operation is associated with a survival benefit for patients with adhesive bowel obstruction. Ann Surg 258:459–465

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors wish to thank the corresponding authors of two studies included in this systematic review who kindly provided additional information upon request.

Author information

Authors and Affiliations

  1. Department of General Surgery, Azienda ULSS 6, Cittadella, Via Casa di Ricovero 40, 35013, Cittadella, Padua, Italy

    Giuseppe Portale

  2. Department of General and Visceral Surgery, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany

    George Octavian Popescu

  3. Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada

    Matteo Parotto

  4. Independent Statistician, Solagna, Italy

    Francesco Cavallin

Authors
  1. Giuseppe Portale
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. George Octavian Popescu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Matteo Parotto
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Francesco Cavallin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Giuseppe Portale.

Ethics declarations

Disclosures

Drs. Giuseppe Portale, George Octavian Popescu, Matteo Parotto, and Francesco Cavallin have no conflict of interests or financial ties to disclose.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Portale, G., Popescu, G.O., Parotto, M. et al. Internal hernia after laparoscopic colorectal surgery: an under-reported potentially severe complication. A systematic review and meta-analysis. Surg Endosc 33, 1066–1074 (2019). https://doi.org/10.1007/s00464-019-06671-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-019-06671-8

Keywords

Search

Navigation