Treatment of delayed jejunal perforation after irreducible femoral hernia repair with open abdomen management and delayed abdominal closure with skin flap approximation

1. Introduction

Delayed bowel perforation has rarely been reported after blunt abdominal trauma (BAT), conductive burn injuries of bowel with cautery or necrosis of strangulated bowel in a hernia sac ^{[1], [2]}. The exact mechanism of delayed presentation of small bowel perforation remains controversial. In a patient with BAT where the mesenteric injury is not severe and consists of only minor tears and contusions, the clinical presentation would follow a period of normal bowel function and may be delayed by a time period ranging from 2 weeks to 3 months. In the absence of a direct bowel injury, a patient may initially tolerate a diet and display normal bowel function ^[1]. Bowel perforations due to thermal injuries are fundamentally different from direct mechanical injuries. Contact burn injuries from cautery may be recognized at the time of surgery and treated appropriately. In contrast, conductive burns are not recognized at all or are recognized when perforation occurs 1–3 weeks after the initial procedure ^[2]. Furthermore, the consequences of bowel injury can be catastrophic. A delay in diagnosis of bowel perforation can lead to sepsis, and even death, if not diagnosed and treated promptly ^[3].

Open abdomen (OA) management is a life-saving and challenging strategy in situations such as abdominal compartment syndrome (ACS), damage-control surgery, and severe generalized peritonitis ^{[4], [5]}. The OA is defined in the World Society of Abdominal Compartment Syndrome guidelines as one that requires a temporary abdominal closure due to the skin and fascia not being closed after laparotomy ^[6]. Mortality rates up to 50% were reported and were even higher in the infected OA ^{[7], [8]}. Enteric fistulas are one of the most devastating abdominal complications in abdominal surgery ^[9].

According to our knowledge, there is no report about delayed bowel perforation after the surgery of irreducible femoral hernia in the literature. Here, we report the management of a septic OA patient with the help of negative pressure therapy (NPT) and delayed abdominal closure with skin flap approximation in a 76-year-old woman with delayed jejunal perforation, 8 days after irreducible femoral hernia operation.

2. Presentation of Case

A 76-year-old woman was admitted to the emergency department with complaints of abdominal pain, constipation, vomiting, anuria and shortness of breath. The patient reported abdominal pain especially on the right inferior part of abdomen that had been present for a long time. The severity of the pain had increased in the last 2 days. Comorbidities included hypertension, diabetes, hyperlipidemia, coronary arterial disease and chronic obstructive lung disease. A previous abdominal operation for a perforated appendix occurred 15 years prior. Upon physical examination, the patient's blood pressure (BP) measured105/55 mmHg, heart rate (HR) was 96, and temperature was 36.9 °C. The abdominal examination revealed hyperactive bowel sounds and minimal distention. Sensitivity and rigidity were observed in the right inferior quadrant of abdomen. An irreducible femoral hernia was present on the right side of the abdomen. Prerenal acute renal failure and mild metabolic acidosis were present (Table 1). X-rays showed the abdominal air/fluid level.

Table 1

Laboratory value of patients before femoral hernia operation.

Consultation with cardiology, internal medicine, endocrinology and anesthesia was performed, and the patient hydrated during this period. During a 3-h period following hydration, urine output was measured at 200 cc; 1400 cc of small intestinal contents were drained via nasogastric tube. The patient underwent an emergency operation for irreducible femoral hernia. The hernia sac and small intestine were isolated, and the small intestine was thought to be viable (Fig. 1). The abdomen was explored from femoral defect after dilating this opening. There was only serous fluid was present without any other pathology. Femoral hernia repair was performed by preperitoneal mesh insertion (Fig. 2), as Yetisir previously described ^[10]. The patient started to defecate on postoperative day 1, and oral intake was initiated. On postoperative day 3, the general condition of patient was well; she was conscious and oriented. Prerenal acute renal failure had improved (Table 2), and the patient was discharged from hospital.

Fig. 1

Presentation of hernia sac and small intestine.

Fig. 2

Mesh was placed under the fascia and over the peritoneum after preperitoneal preparation from dilated femoral opining.

Table 2

Laboratory value of the patients 3 days after the femoral hernia operation.

The patient was readmitted to the emergency department with the complaint of abdominal pain, vomiting, anuria and shortness of breath on postoperative day 8. Her general condition, consciousness and orientation were not well. In physical examination, her BP measured 80/55 mmHg, HR was 114, respiratory rate was 36, and temperature was 38 °C. The patient's intra-abdominal pressure (IAP) was 18 mmHg. On her abdominal examination, there were no bowel sounds or distention. The patient was in septic shock and metabolic acidosis. d-Dimer was high (Table 3), and the white blood cell count (WBC), c-reactive protein (CRP), procalcitonin, and lactate levels were increased (Fig. 3, Fig. 4). Air/fluid levels in the small bowel and intra-abdominal fluid collection were present in the abdominal computerized tomography (CT) scan (Fig. 5). The sequential organ failure assessment score (SOFA) of the patient was 15, and her estimated mortality was 80%. The patient was selectively intubated, Clexane 2 × 0.6 was administered, and antibiotic therapy was started. Fluid and electrolyte resuscitation and low vasopressor support were started. The patient underwent an emergency operation where 2–3 liters of enteric influents were present and all intestinal tissue was very edematous and fragile during exploration. The patient's open abdomen classification was 2C according to the new Björck score (Fig. 6). All intra-abdominal content was washed and irrigated with saline. After gentle dissection, a perforation point of jejunum 150 cm from the ligament of Treitz was seen (Fig. 7). The perforated part of jejunum was resected and double barrel jejunostomy was created. Abdominal NPT (ABThera™ Open Abdomen Negative Pressure Therapy System, KCI, an Acelity company, San Antonio, TX) was applied (Fig. 8). On postoperative day 2, vital and laboratory parameters were improved and vasopressor support was stopped. On postoperative day 6, all the vital and laboratory parameters continued to improve, and intra-abdominal sepsis was resolved (Fig. 9). The skin was dissected from the fascia, and delayed abdominal closure was performed by approximation of skin flap (Fig. 10). The patient was discharged from the hospital 33 days after the operation with instructions for oral diphenoxylate/atropine 4 × 2 mg (author to confirm dosage units) and 1000 cc iv fluid intake a day. Jejunostomy was closed 4 months later (Fig. 11) without complications. A planned ventral hernia at the end of the 12-month follow-up period (Fig. 12).

Fig. 4

Change in the white blood cell count and c-reactive protein level from hospitalization to closure of OA are shown.

Fig. 5

Abdominal CT shows excessive amount of intra-abdominal free fluid collection.

Fig. 6

Excessive amount of enteric influents and edematous bowel are shown.

Fig. 7

Proximal and distal parts of perforation point of jejunum are shown.

Fig. 8

Application of abdominal NPT with jejunostomy.

Fig. 9

Intra-abdominal visceral showing no enteric content or sepsis.

Fig. 10

Delayed abdominal closure by approximation of skin flap and NPT application.

Fig. 11

Closed jejunostomy is shown.

Fig. 12

No complications at 12 month follow-up period.

Table 3

Laparatory value of the patients 8 day after femoral hernia operation.

3. Discussion

In this case, we thought that the occurrence of delayed jejunal perforation approximately 8 days after irreducible femoral hernia surgery was due to necrosis of the strangulated bowel, which was believed to be viable during the initial operation. This necrosis may have been enhanced by unintentional conductive burn injuries of cautery during dissection. The patient's comorbidities may have also contributed to the occurrence of the perforation and worsened the situation. Bovie injury to the bowel can be hidden, causing a slow transmural tissue necrosis, and may also impair local healing and eventually lead to perforation ^[2]. In cases of Bovie injury, the average time from injury to diagnosis was 10.4 days ^[2]. Chapron et al. reported that approximately 75% of bowel injuries were diagnosed within the first postoperative week ^[3].

Mortality within 30 days of groin hernia surgery increases significantly when an emergency operation is needed, ranging from 2.8 to 3.1% ^[11] and is even higher when bowel resection is needed. Significant factors associated with increased mortality in emergency settings are female gender and increasing age ^[12]. Our case had all these factors. Duration of strangulation is the most important determinant of the outcome regarding gut viability, resection-anastomosis rate, morbidity and mortality ^[13]. Andrews noted mortality rates of 1.4%, 10% and 21%, for strangulated hernia when presented within 24 h, 24–48 h and after 48 h, respectively ^[14]. In our case, duration of strangulation was more than 48 h.

In severe hemodynamic instability and physiologic derangements, definitive repair and definitive closure could not be obtained, and restoration of intestinal continuity is postponed to other operations ^[15]. In our case, a double barrel jejunostomy was preferred over anastomosis; OA management with NPT was also performed instead of direct abdominal closure after fistula control due to the patient's comorbidities, septic abdomen, high IAP and hemodynamic instability. Kubiak et al. examined ischemia reperfusion of the intestine and intra-abdominal sepsis in a porcine model of multiple organ injury and reported that the application of peritoneal NPT significantly reduced lung, kidney, liver and intestinal pathology and improved pulmonary parameters, which may have been due to peritoneal cytokine removal ^[16].

There are lots of different delayed OA closure methods. Some methods deal with fascial closure and use strategies allowing the re-approximation of the fascial edges in conjunction with NPT. This method can lead to high closure rates ^{[4], [8], [17]}. In elderly patients with more comorbid diseases, delayed OA closure is utilized to decrease the number of operations and duration of treatment. Some delayed OA closures employ skin closure with flap approximation and skin grafting, as performed in our case.

4. Conclusion

Delayed bowel perforation may develop after irreducible femoral hernia surgery, even if the bowel was seen as viable during operation, especially in elderly patients with comorbidities. Patients need to be notified of this situation. OA management with NPT is an optimal treatment modality for hemodynamically instable patients with a septic abdomen and high IAP. Delayed OA closure with skin flap approximation may be the most suitable way for closure in these kinds of patients.