A laparoscopic approach to the surgical management of enterocutaneous fistula in a wound healing by secondary intention.

Traditional surgical management of a chronic enterocutaneous fistula requires laparotomy, but the optimal site of incision is unclear. Laparoscopy and adhesiolysis may offer an alternative approach. Two cases of non-healing enterocutaneous fistula within chronic, granulating wounds are described. The laparoscope was placed subcostally using the Hasson technique with additional ports placed under direct vision. After clearing the anterior abdominal wall of all but the fistula-containing bowel, an incision was made circumferentially around the granulation bed. Resection and primary anastomosis was performed in standard fashion. Lateral component separation allowed primary wound closure. Both patients were discharged without sequelae and doing well at last follow-up (mean 12 months). A laparoscopic approach to non-healing enterocutaneous fistulas seems safe and technically feasible. When combined with lateral component separation, it may result in reduction of inadvertent enterotomies and optimal management of the wound without the use of prosthetic mesh.

Laparoscopic repair of a right paraduodenal hernia.

BACKGROUND: Laparoscopic repair of a right paraduodenal hernia has never been described in the literature. A 24-year-old woman was admitted after 2 weeks of intermittent abdominal pain associated with nausea and vomiting. Physical examination was normal. Laboratory studies and upper endoscopy were normal. Computed tomography revealed that the small bowel was on the right side of the abdomen and the colon on the left, suspicious for malrotation. Subsequent upper gastrointestinal series with small bowel follow-through revealed the ligament of Treitz on the right with the small bowel encased within a probable hernia sac. A presumptive diagnosis of a right paraduodenal hernia was made. METHODS AND RESULTS: Initial access was obtained with a 10-mm infraumbilical port followed by placement of 5-mm ports in the right and left upper and lower quadrants. The duodenum was identified and the small bowel was found encased within a hernia sac, which was opened widely from the duodenum to the pelvis. The hernia sac was opened laterally to avoid injury to the superior mesenteric vessels. The small bowel was then released from the sac into the peritoneal cavity. The entire bowel was inspected and no other abnormalities were noted. The patient had resolution of her abdominal pain and her postoperative course was uncomplicated. She was discharged home on postoperative day 3 and has since done exceptionally well. CONCLUSIONS: Paraduodenal hernia, a rare cause of small bowel obstruction, can present a diagnostic challenge. However, when the diagnosis is made preoperatively, a laparoscopic repair is a feasible and practical option.