mesenteric venous thrombosis is a rare but potentially fatal complication associated with laparoscopy which has now become common practice and gold standard for many procedures in general surgery .
there are only few scattered case reports in the literature describing this postoperative thrombotic event .
in the present study , we describe a patient presenting with severe abdominal pain at 25 days following an uneventful laparoscopic paraesophageal hernia ( peh ) repair and nissen fundoplication .
exploratory laparotomy revealed an extensive small bowel ischemia requiring bowel resection followed by a second look laparotomy .
retrospectively performed hematologic workup revealed a genetic mutation associated with hyperhomocysteinemia in addition to her hyperfibrinogenemia .
mesenteric venous thrombosis is a rare but potentially serious complication after laparoscopic surgery especially in patients with underlying hypercoagulability .
peritoneal insufflation during laparoscopic surgery may carry significant morbidity of thrombosis in the mesenteric venous system .
its clinical presentations vary from a nonspecific abdominal discomfort to an acute abdomen mandating an exploratory laparotomy .
warren and eberhard in 1935 reported 34% mortality rate . in more modern day however , prompt diagnosis followed by an aggressive use of anticoagulation , thrombolytic agents and relatively new endovascular techniques seem to improve outcomes .
previously published reports have described mvt in association with roux - en - y gastric bypass , splenectomy , colectomy , cholecystectomy and appendectomy . in this article , we report a patient who developed an extensive small bowel infarction due to mesenteric venous thrombosis ( mvt ) following a laparoscopic paraesophageal hernia repair and nissen fundoplication . a 61 year old female with history of hypertension and gastroesophageal reflux
was referred to our facility for a repair of type iii paraesophageal hernia with 75% intrathoracic stomach .
her postoperative course was unremarkable and she was discharged home on postoperative day ( pod ) 2 . on pod 9
after appropriate investigation , she was released on an oral antibiotic for urinary tract infection . during
follow up in our clinic 2 weeks postoperatively she complained of nonspecific abdominal pain and moderate gas bloatedness consistent with common complaints following nissen fundoplication .
computed tomography ( ct ) scan demonstrated thickened small bowel loops consistent with mural ischemia ( fig .
1 ) and nearly complete filling defects in the superior mesenteric / portal veins ( fig .
laboratory findings showed leukocytosis of 25,000/mm and elevated lactic acid of 9.4 mg / dl .
sagittal section of small bowel mural thickening consistent with mesenteric ischemia.demonstration of intraluminal narrowing is facilitated by administration of oral contrast agent .
coronal section of portal venous system showed near complete filling defects in the superior mesenteric and portal veins .
intravascular thrombosis presents as hypodense areas in the vascular lumen during the portal phase of intravenous contrast administration .
patient was immediately heparinized and taken to the operating room for an exploratory laparotomy when 110 cm of ischemic jejunum with complete thrombosis of the superior mesenteric vein ( smv ) were found .
jejunal resection with primary anastomosis was performed and the abdomen was left open . during a second look laparotomy on the following day , dusky terminal ileum was again seen with adequately perfused surrounding small bowel and cecum mandating an additional 10 cm terminal ileum resection .
comprehensive hematologic workup revealed a c-677-t point mutation associated with methylenetetrahydrofolate reductase ( mthfr ) deficiency leading to an elevated level of homocysteine .
it is postulated that mvt is caused by physiologic derangements associated with laparoscopy since it occurs at a much lower incidence following open surgery .
an early prospective study conducted by masataka ikeda et al on patients undergoing splenectomy revealed that portal venous system thrombosis occured at a significantly higher rate in laparoscopic group versus open group , 55% and 19% respectively .
twenty four previously reported cases of mvt that we have collected along with our current case are displayed in table 1 .
previously published reports on splanchnic venous thrombosis following laparoscopic operations a variety of factors associated with laparoscopy such as pneumoperitoneum induced hemodynamic changes , hypercapnia induced mesenteric vasoconstriction , and coagulation impairment may contribute to the development of mvt .
takagi et al showed that portal venous trunk diameter and blood flow were significantly decreased with intraperitoneal pressure elevation above 10 mmhg .
quantitatively measured , elevation of intraperitoneal pressure during laparoscopy to 7 and 14 mmhg is associated with 37% and 53% reduction in mean portal blood flow respectively .
majority of splanchnic vein thrombosis developed within the widely accepted insufflation pressure of 12 to 15 mmhg .
serum level of vasopressin related to hypercapnia is a well documented phenomenon that also occurs in response to peritoneal insufflation using carbondioxide ( co2 ) .
epstein et al discovered that hypercapnia induced by breathing co2 at a concentration less than 5 percent increases portal venous pressure and results in mesenteric vasonconstriction .
soft tissue trauma associated with surgery releases tissue factors that can lead toward mvt in patients with previously undiagnosed hypercoagulable state .
our literature review showed that 44% of patients have had underlying prothrombotic state which was diagnosed retrospectively only after occurrence of this complication ( table 1 ) .
the more likely occurrence of mvt during laparoscopic operations for inflammatory pathologies such as diverticulitis seems to support this theory .
in addition , literature has also described a controversy on alteration of coagulation associated with laparoscopy .
edematous bowel or mesenteric fat stranding , although not conclusive , should also prompt consideration of mvt in the absence of other obvious clinical etiologies . even though angiography is the gold standard in diagnosing arterial thrombosis
other tests such as transabdominal doppler ultrasound , and magnetic resonance imaging are less accurate and more expensive without additional benefit respectively .
diagnostic laparoscopy is controversial for a suspected mvt because it may compound the primary problem .
however , many surgeons prefer to perform diagnostic laparoscopy to exclude bowel ischemia therefore cimcumventing the need for nontherapeutic laparotomy[1618 ] .
not to undermine the superiority of ct scan in diagnosing mvt , it is however notoriously to be inaccurate in determining the extent of bowel ischemia .
all patients with known underlying prothrombotic states should be placed on a preoperative thrombotic prophylaxis regiment . in our opinion
, a consultation with a hemato - oncologist is an appropriate step in this situation .
aggressive intravenous hydration , bowel rest and total parenteral nutrition are important adjunctive measures to operative intervention .
abu et al demonstrated a 12% reduction in mortality in patients undergoing resection and anticoagulation versus those who underwent resection alone .
less invasive measures such as surgical thrombectomy , percutaneous transhepatic thrombectomy , intra - arterial papaverin infusion through superior mesenteric artery , and thrombolytics ( urokinase and streptokinase ) have also been successfully used[162124 ] . for those with primary coagulation disorder ,
splanchnic venous thrombosis is a rare but potentially serious complication associated with laparoscopic surgery especially in patients with underlying hypercoagulability disorders .
high index of suspicion is needed for early diagnosis and treatment when this condition occurs .
primary care physicians including general surgeons should be well aware of this potential untoward event post laparoscopic operations .
 context : mesenteric venous thrombosis is a rare but potentially fatal complication associated with laparoscopy which has now become common practice and gold standard for many procedures in general surgery . 
 there are only few scattered case reports in the literature describing this postoperative thrombotic event.case report : in the present study , we describe a patient presenting with severe abdominal pain at 25 days following an uneventful laparoscopic paraesophageal hernia ( peh ) repair and nissen fundoplication . 
 exploratory laparotomy revealed an extensive small bowel ischemia requiring bowel resection followed by a second look laparotomy . retrospectively performed hematologic workup revealed a genetic mutation associated with hyperhomocysteinemia in addition to her hyperfibrinogenemia . 
 previously published data were collected and discussed.conclusions:mesenteric venous thrombosis is a rare but potentially serious complication after laparoscopic surgery especially in patients with underlying hypercoagulability . 
 high index of suspicion is important in early diagnosis and subsequent treatment . 
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Case Report:
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Introduction
Conclusions