PMC10087278_01
Images of computed tomography scan before initial operation and before reoperation. Before initial operation: the patient had a mobile cecum, and the third portion of the duodenum ran dorsal to the superior mesenteric artery (SMA) and superior mesenteric vein (SMV). Before reoperation: the duodeno-jejunal transition was located on the right side of the abdomen, and the SMV was located to the left of the SMA
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Preoperative computed tomography (CT) scan revealed that the cecum and ascending colon were unattached to the lateral peritoneum; however, the third portion of the duodenum normally ran dorsal to the SMA and superior mesenteric vein (SMV) (Figure 1). During the diagnostic workup, the CT scan showed that the duodeno-jejunal transition was in the right abdomen, the SMV was to the left of the SMA, known as the SMV rotation sign (Figure 1). The CT scan also showed that the duodenal third portion was not running dorsal to the SMA and SMV (Figure S1), and the obstruction point was the distal ileum near the pouch.
Laparoscopic upper-abdominal view at the initial operation. The superior mesenteric vein (SMV) was located to the right of the superior mesenteric artery (SMA), and the third portion of the duodenum was located dorsal to them. L, left side of the patient; MCA/V, middle colic artery/vein; R, right side of the patient. Arrows show surgical clips for MCA/V
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After confirmation that there was no abnormality in the anatomical placement of the small intestines (Figure 2), the pouch was guided to the anus without torsion of the small bowel mesentery during the laparoscopic procedure.
Laparoscopic pelvic view at the reoperation. Most of the small intestine passed through the dorsal side of the SMA from the left side to the right side of the patient, and that the distal ileum was compressed by the SMA near the pouch. L, left side of the patient; R, right side of the patient; SMA, superior mesenteric artery. White line with arrow shows the running of the SMA. Dotted line with arrow shows the running the ileum. Dotted circle shows the point of intestinal obstruction
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By converting to laparotomy, we performed ileo-ileo bypass across the ventral side of the SMA (Figures 3 and 4), and the patient's symptoms improved.
Schema of the cause of intestinal obstruction and reoperation. Left: state after total proctocolectomy and ileal-pouch anal anastomosis in patients without intestinal malrotation. Center: because the duodenum was not fixed to the retroperitoneum, most of the small intestine passed through the dorsal superior mesenteric artery (SMA) from the left side to the right side, and the distal ileum was compressed by the SMA near the pouch. Right: an ileo-ileo bypass was performed across the ventral side of the SMA
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By converting to laparotomy, we performed ileo-ileo bypass across the ventral side of the SMA (Figures 3 and 4), and the patient's symptoms improved.