, we describe the first case of fatal large bowel ischemia in the aftermath of laparoscopic incisional hernia repair .
a literature search using pubmed was performed to identify all published cases of intestinal ischemia following laparoscopic procedures .
our search revealed 13 cases of intestinal ischemia following various laparoscopic procedures . including this one , 10 of 14 cases reported on so far had impaired cardiovascular , hepatic or renal function or atherosclerosis .
patient - related risk factors seem to play the most important role in the development of this rare but devastating complication . preventive measures and methods to identify patients at risk for developing intestinal ischemia during and after laparoscopy
patient selection , an optimal hydration status , an optimized technique with lowest insufflation pressure possible , and intermittent decompressions of the abdomen when the procedure is lengthy are the measures that have a potential to prevent this complication .
whatever laparoscopic procedure has been performed , intestinal ischemia should be considered in any patient with nonspecific abdominal symptoms .
it has been described after laparoscopic cholecystectomy , inguinal hernia repair , gynecologic myolysis , and fundoplication .
laparoscopic repair of ventral and incisional hernia ( lrvih ) is gaining popularity due to its low recurrence rate , short hospital stay , and low complication rate . in this report
a 47-year - old obese woman ( bmi of 42 ) with a large incisional hernia at midline laparotomy was referred for laparoscopic correction .
her medical history was significant for hypertension , transabdominal gynecologic surgery , peripheral vascular disease , and included multiple angioplasties of the iliac arteries .
a 15-minute break that included decompression of the abdomen was made halfway through the operation .
this is locally a common practice during long operations and was not triggered by any specific adverse event .
the hernia defect measured 20 cm  16 cm and correction required application of two 30cm20 cm expanded polytetrafluoroethylene meshes ( dualmesh , wl gore , flagstaff , az , usa ) .
the meshes were fixed both with tackers ( protack , tycouss , norwalk , ct , usa ) and transabdominal sutures .
c - reactive protein was significantly raised . to evaluate the possibility of a missed bowel lesion , we decided on a relaparoscopy .
intraabdominal pressure was maintained at 12 mm hg throughout this short procedure that took not more than 12 minutes . upon exploration , only bowel distension
was found with no signs of contamination , perforation , or ischemia . given these findings
postoperatively , the patient developed systemic inflammatory response syndrome , respiratory insufficiency , and required transfer to the intensive care unit . within the next few days , the patient slowly stabilized , required less and less support , and experienced no apparent infection .
on postoperative day 9 , she produced bloody diarrhea that prompted us to perform a colonoscopy . examination revealed severe ischemic colitis in the transverse colon .
mesenteric angiography was performed showing an occluded superior mesenteric artery and a compensatory distended inferior mesenteric artery with a pinpoint stenosis at its origin .
balloon angioplasty ( figure 1 ) successfully dilated this stenosis , the patient was placed on anticoagulants and , afterward , the patient steadily improved .
another colonoscopy was performed that showed multiple perforations of the ischemic transverse colon . at subsequent laparotomy , a fecal peritonitis due to multiple perforations of the ischemic
postoperatively , the patient deteriorated further and died the next day , 16 days after the first operation .
acute mesenteric ischemia is the result of a sudden reduction in intestinal blood flow that is insufficient to meet the metabolic demands of the bowel .
specific risk factors include advanced age , atherosclerosis , low cardiac output states , cardiac arrhythmias , severe cardiac valvular disease , administration of medications known to reduce intestinal perfusion ( such as diuretics , digoxin , alpha - adren - ergic agonists ) , various forms of shock , septicemia , dehydration , hypotension , and others .
although a few cases of fatal bowel ischemia are described after open cholecystectomy , various cardiac and peripheral vascular procedures , cystectomy , esophagectomy , and others , the incidence of postoperative bowel ischemia is extremely low .
this indicates that the effects of surgery on bowel perfusion are usually well tolerated and have no clinical consequences . a number of physiologic changes during laparoscopy create an additional risk of compromised mesenteric circulation .
the intraabdominal hypertension created by the pneumoperitoneum reduces mesenteric perfusion , cardiac output , and mesenteric outflow .
direct absorption of insufflated carbon dioxide into the circulation may also lead to mesenteric vasoconstriction .
however , all these adverse physiological effects of pneumoperitoneum are obviously well tolerated in the vast majority of patients , because a clinically manifested bowel ischemia after laparoscopic procedures is an extremely rare complication . a literature search using pubmed revealed only 13 case reports before the present one 
 ( table 1 ) .
once it occurs though , intestinal ischemia following a laparoscopic procedure is a devastating complication .
eleven of 14 patients including this one died as a consequence , creating an overall mortality of 79% .
reported cases of intestinal ischemia after laparoscopic procedures ns = not specified ; iap = intraabdominal pressure .
rapid diagnosis is essential to prevent the catastrophic events associated with mesenteric ischemia . because early signs and symptoms are nonspecific
however , given the negligible incidence of intestinal ischemia amid the large number of laparoscopic procedures performed , the diagnosis is as a rule missed or delayed . in only one reported case was the diagnosis established clinically and relatively early .
this patient was treated with high - dose anticoagulants and recovered . in all other reported cases ,
the risk seems to be particularly high in patients with impaired hepatic or renal function or atherosclerosis . including this one , 10 of 14 patients ( 71% ) reported on so far had at least one of the previously mentioned risk factors present .
it has been previously stated that the risk is higher when the laparoscopic procedure is lengthy .
although in this case intestinal ischemia developed after an indeed very lengthy procedure , data from the literature do not provide strong support of that view . of 13 previously published reports , duration of surgery
was specified in 10 of them on average equaling 67.5 minutes ( median , 62.5 , range 22 to 120 ) , which is quite usual for procedures that were performed .
we used decompression once halfway through this long procedure , but it did not prevent development of fatal intestinal ischemia .
it is probably a futile endeavor to precisely determine the specific role of laparoscopy in the cascade of events that led to mortality in the patient we describe .
long laparoscopy in the patient at risk with unknown preexisting compromised mesenteric circulation definitely carried a potential to further compromise bowel perfusion .
it is also possible that development of postoperative ileus in combination with systemic inflammatory response syndrome played a triggering role in the development of this complication .
no signs of intestinal ischemia at relaparoscopy and a relatively long clinical course in our patient might offer certain support to this second possibility . to the best of our knowledge ,
this is the first reported case of intestinal ischemia following lvihr and the only one we have experienced in a series of 401 lrvih performed so far ( incidence of 0.25% ) .
carbajo et al , reporting earlier on their experience with lvihr , mentioned in brief among postoperative complications  a case of a small bowel leakage due to ischemia  but did not provide any further details on this issue .
patient selection , an optimal hydration status , an optimized technique using the lowest insufflation pressure possible , and intermittent decompressions of the abdomen when the procedure is lengthy are the measures that have a potential to prevent this rare complication .
whatever a laparoscopic procedure has been performed , intestinal ischemia should be considered in any patient with nonspecific abdominal symptoms .
 background and objectives : intestinal ischemia is a very rare complication of laparoscopic procedures . in this report 
 , we describe the first case of fatal large bowel ischemia in the aftermath of laparoscopic incisional hernia repair.methods:a literature search using pubmed was performed to identify all published cases of intestinal ischemia following laparoscopic procedures.results:our search revealed 13 cases of intestinal ischemia following various laparoscopic procedures . including this one , 
 10 of 14 cases reported on so far had impaired cardiovascular , hepatic or renal function or atherosclerosis . 
 none of these patients - at - risk survived . in this series , 
 no indications of faulty operative technique could be identified.conclusion:patient-related risk factors seem to play the most important role in the development of this rare but devastating complication . preventive measures and methods to identify patients at risk for developing intestinal ischemia during and after laparoscopy are not completely clear . 
 patient selection , an optimal hydration status , an optimized technique with lowest insufflation pressure possible , and intermittent decompressions of the abdomen when the procedure is lengthy are the measures that have a potential to prevent this complication . 
 whatever laparoscopic procedure has been performed , intestinal ischemia should be considered in any patient with nonspecific abdominal symptoms . 
Background and Objectives:
Methods:
Results:
Conclusion:
INTRODUCTION
CASE REPORT
DISCUSSION