ORIGINAL CONTRIBUTION

Long-Term Consequences of Not Closing the

Mesenteric Defect After Laparoscopic Right
Colectomy
Jennifer C. Cabot, B.A.1 • Sang A. Lee, M.D.2 • James Yoo, M.D.3
Abu Nasar, M.S.1 • Richard L. Whelan, M.D.1 • Daniel L. Feingold, M.D.1
1 Section of Colon and Rectal Surgery, Department of Surgery, New York-Presbyterian Hospital-Columbia Campus, New
York, New York
2 Weill Cornell Department of Surgery, New York, New York
3 Colorectal Surgery Program, University of California, Los Angeles, Los Angeles, California

PURPOSE: The controversy regarding closing the
mesenteric defect after laparoscopic right colectomy
remains a subject of debate. This study describes the
consequences of not closing the mesenteric defect.
METHODS: A 7-year prospective database revealed 530
consecutive patients who underwent laparoscopic right
colectomy for neoplasia. No mesenteric defects were
closed. Small bowel obstruction was determined by
clinical assessment and diagnostic imaging. Statistical
analysis included the Student t test and Mann-Whitney U
test.
RESULTS: On average, the 530 patients (44% male) were
69.6 years old ⫾ 12.5 years with American Society of
Anesthesiologists’ category 2, body mass index 26.6 ⫾
5.7, operative time 175 ⫾ 65 minutes, incision length
5.7 ⫾ 3.0 cm. Thirty-six patients (6.8%) were converted.
Median length of stay was 5 days (interquartile range
4 –7). Median follow-up was 20 months (interquartile
range 8 – 45). Four patients (0.8%) had complications
attributed to the mesenteric defect: 2 had small bowel
obstruction due to internal herniation and 2 had torsion
of the anastomosis through the defect. Twenty-six
patients (4.9%) had a small bowel obstruction during the
Financial Disclosures: None reported.
Poster presentation at the meeting of The American Society of Colon and
Rectal Surgeons and Tripartite, Boston, MA, June 6 to 11, 2008.
Correspondence: Daniel L. Feingold, M.D., Section of Colon and Rectal
Surgery, Department of Surgery, New York Presbyterian Hospital-Co-
lumbia Campus, 177 Fort Washington Ave, New York, NY 10032. Email:
df347@columbia.edu
Dis Colon Rectum 2010; 53: 289 –292
DOI: 10.1007/DCR.0b013e3181c75f48
©The ASCRS 2010
DISEASES OF THE COLON & RECTUM VOLUME 53: 3 (2010)
follow-up period. Nonoperative treatment was successful
in 12 patients. In the 14 patients who were operated on,
small bowel obstruction was due to adhesions (4),
incarcerated abdominal wall hernias (4), mesenteric
defect (4), and cancer recurrence (2). The small bowel
obstruction group (n ⫽ 26) had a significantly higher
percentage of males than the non-small bowel
obstruction group (n ⫽ 504; 69% vs 43%; P ⫽ .008).
CONCLUSIONS: These data do not support routinely
closing the mesenteric defect after laparoscopic right
colectomy for neoplasia. Additional studies with
extended long-term follow-up are needed.
KEY WORDS: Internal hernia; Small bowel obstruction;
Laparoscopy; Right colectomy.
aparoscopic right colectomy (LRC) has become the
L preferred surgical approach to right colectomy for
many surgeons. Although laparoscopic techniques
for right colectomy have been described in detail, a contro-
versy exists regarding whether to close the mesenteric de-
fect. Leaving the defect open may increase the incidence
of internal hernia and subsequent small bowel obstruc-
tion (SBO). Laparoscopic closure of the defect is techni-
cally challenging, however, and may jeopardize the blood
supply to the anastomosis. The potential morbidity asso-
ciated with closing the defect, including possible injury to
the bowel and vasculature, may outweigh the risks of leav-
ing the defect open.
No large-scale studies have examined the conse-
quences of repairing the mesenteric defect or leaving it
open during laparoscopic or open colectomy. A review of
internal hernias suggested that the small size of mesenteric
defects (2–5 cm) and the lack of encapsulation associated
with a variety of laparoscopic abdominal operations may
289
290 CABOT ET AL: CONSEQUENCES OF OPEN MESENTERIC DEFECT

cause volvulus and strangulation of herniated loops of

TABLE 1. Summary of patient data
bowel.1 Although symptomatic internal hernia has been
reported to occur in up to 9% of laparoscopic Roux-en-Y Demographics Outcomes
gastric bypass cases, the incidence of this complication is Age, y 69.6 ⫾ 12.5
thought generally to be low following laparoscopic colec- Sex, male (%) 233 (44)
Incision length, cm 5.7 ⫾ 3.0
tomy.2 Investigations specifically examining laparoscopic
Operative time, min 175 ⫾ 65
Roux-en-Y gastric bypass surgery emphasize the number Length of stay, days* (range) 5 (4–7)
of defects and the presence of nonphysiologic anatomy as Body mass index 26.6 ⫾ 5.7
risk factors for SBO due to internal hernia. These studies Follow-up time, mo* (range) 20 (8–45)
may not be generalizable to laparoscopic colorectal resec- Previous abdominal surgery (%) 115 (22)
Major complications (%) 26 (4.9)
tion.2– 8 Only 6 case reports of internal hernia following
Total no. SBO cases (%) 26 (4.9)
laparoscopic colectomy have been published.9 –14 These re- SBO due to mesenteric defect (%) 4 (0.8)
views are limited in scope and do not resolve the contro- 30-day mortality (%) 1 (0.2)
versy regarding the mesenteric defect. Because the anat- Indication for surgery
omy of the mesentery varies according to the segment of Cancer (%) 357 (67)
Polyp (%) 173 (33)
colon in terms of length, thickness, and vasculature, the
Resection performed
risks and benefits of leaving the mesenteric defect open Right colectomy (%) 456 (86)
would be best evaluated separately for each type of colo- Extended right colectomy (%) 74 (14)
rectal resection. The present study, the largest of its kind, Data are presented as mean ⫾ SD unless otherwise indicated. SBO indicates small
retrospectively evaluates the consequences of leaving the bowel obstruction.
mesenteric defect open during LRC for neoplasia. *Median (interquartile range).

METHODS
The study population consisted of 530 patients who under-
went LRC for neoplasia at the New York-Presbyterian
Hospital. Patient data were obtained from a 7-year, insti-
tutional research board–approved, prospective database
including any patients undergoing elective colorectal re-
section for any indication. The patients of 9 colorectal sur-
geons are included in this computerized database, and data
were compiled via data intake questionnaires and system-
atic review of charts, office records, and radiographic im-
aging, as well as patient interviews. Surgeon preference de-
termined whether an open or laparoscopic approach was
used in each case independent of any research study. The
present study was approved by the hospital’s institutional
research board.
Query of the database revealed 550 patients who un-
derwent an LRC or extended right colectomy for neoplas-
tic conditions. Operative reports were used to determine
the technical aspects with regard to the mesenteric defect;
all of the reports documented whether the defect was
closed. Twenty patients were excluded for the following
reasons: loss to follow-up immediately postoperative (17),
placement of Seprafilm following conversion (2), and clo-
sure of the defect following conversion (1). The study
group comprised the remaining 530 patients.
The following information was recorded for each pa-
tient: age, sex, American Society of Anesthesiologists’ cat-
egory, body mass index, operative time, incision length,
length of stay, intraoperative and postoperative courses,
incidence and treatment of SBO, and length of follow-up.
Information regarding the incidence of SBO was gathered
from office charts, hospital records, and telephone inter-
views for the majority of patients and was gathered from
charts and records alone for those unavailable by tele-
phone. SBO was determined by clinical assessment and
imaging studies including abdominal x-ray and CT. In
cases of SBO in which patients were successfully treated
nonoperatively and without CT imaging, no inference was
made as to the etiology of the SBO. For 2 of 3 patients
treated nonoperatively and with CT imaging available, the
location and probable cause of the SBO were able to be
determined.
Statistical analysis was performed on the data with the
Student t test and the Mann-Whitney U test. All of the
statistical analyses were performed using GraphPad Prism
version 4.1 software for Windows (GraphPad Software,
San Diego, CA). P values of less than .05 were considered
statistically significant. No adjustment of the P value was
made for multiple tests.
RESULTS
All 530 patients underwent LRC for neoplasia. No mesen-
teric defects were closed, and no adhesion barriers were
used. The study included 233 males (44%) and 297 females
(56%) with a mean age of 69.6 ⫾ 12.5 years, mean Amer-
ican Society of Anesthesiologists category of 2, mean body
mass index of 26.6 ⫾ 5.7, mean operative time of 175 ⫾ 65
minutes, and mean incision length of 5.7 ⫾ 3.0 cm (Table
1). The median length of stay was 5 days (interquartile
range 4 –7). Indications for LRC included cancer (n ⫽ 357,
67%) and polyp (n ⫽ 173, 33%). A total of 115 patients
(22%) underwent previous abdominal surgery for other
indications.
DISEASES OF THE COLON & RECTUM VOLUME 53: 3 (2010) 291

All of the cases began with the laparoscopic approach,

TABLE 3. Comparison of patient groups
and 36 cases (6.8%) were converted. The reasons for con-
version were adhesions (n ⫽ 13), large tumors or T4 can- Non-SBO
SBO group group
cers (n ⫽ 11), miscellaneous reasons (n ⫽ 8), and bleeding
(n ⫽ 26) (n ⫽ 504) P
(n ⫽ 4). The resections were right colectomy (n ⫽ 456,
70.3 ⫾ 12.7 69.5 ⫾ 12.5
86%) and extended right colectomy (n ⫽ 74, 14%). A total Age, y .748
Sex, malea (%) 18 (69) 215 (43) .008
of 26 major complications occurred, including anasto- Incision length, cm 5.8 ⫾ 3.3 5.7 ⫾ 3.0 .885
motic leak (n ⫽ 8, 1.5%), myocardial infarction (n ⫽ 6, Operative time, min 201 ⫾ 97 173 ⫾ 63 .178
1.1%), reoperation within the first postoperative month Length of stay, daysb (range) 6.5 (5–11) 5 (4–7) .056
(n ⫽ 11, 2.1%), and death (n ⫽ 1, 0.2%). Eighty-four per- Body mass index 27.9 ⫾ 7.9 26.5 ⫾ 5.6 .219
Follow-up time, mob (range) 28 (16–55) 19 (8–45) .123
cent of patients had follow-up of 6 months or greater; me-
Previous abdominal surgery (%) 5 (19) 110 (22) .754
dian follow-up was 20 months (interquartile range 8 – 45).
Data presented as mean ⫾ SD, unless otherwise indicated.
The office charts and hospital records of all of the patients a
Median (interquartile range).
were reviewed. For more up-to-date follow-up, 75% of b
Statistically significant.
patients were successfully reached by telephone. As previ-
ously mentioned, 17 of the original 550 patients were lost
to follow-up immediately following surgery and were not operation. The anastomosis was resected in all 4 cases and
included in the analysis. then reconstructed. The mesenteric defect was not closed
Overall, 26 patients (4.9%) were diagnosed with SBO in any of the reoperations. Three patients recovered un-
during the follow-up period. Of the 26 cases, 12 cases oc- eventfully without any further episodes of SBO. One pa-
curred within the first postoperative month and 21 within tient died on postoperative day 5 following the initial op-
the first year. The longest interval between surgery and eration (postoperative day 3 following reoperation due to
SBO was 53 months. Twelve patients successfully re- internal hernia) caused by multisystem organ failure.
sponded to conventional nonoperative treatment. Al- The SBO group (n ⫽ 26) and non-SBO group (n ⫽
though 9 patients were evaluated with abdominal radio- 504) were compared on all relevant parameters using the
graphs alone, CT imaging was used to assess 3 patients. In Student t test and the Mann-Whitney U test (Table 3).
these cases, CT imaging revealed SBO caused by a left in- Compared with the non-SBO group, the SBO group had a
guinal hernia in an obese patient and mechanical obstruc- significantly higher percentage of males (69% vs 43%, P ⫽
tion due to edema at the ileocolic anastomosis in another .008). No other statistically significant differences were
patient. The third patient demonstrated no evidence of found between the 2 groups with regard to any other pa-
SBO on CT imaging. rameter examined, including prior abdominal surgery.
Fourteen patients either failed nonoperative therapies
or required urgent operative intervention. The following DISCUSSION
causes of SBO were documented in these patients: adhe-
sions (n ⫽ 4), incarcerated abdominal wall hernias (n ⫽ 4), The incidence of SBO due to any cause in this series was
mesenteric defect (n ⫽ 4), and cancer recurrence (2). Of 4.9%. Only 4 patients (0.8%) had SBO related to the mes-
the 4 SBO cases related to the mesenteric defect, 2 cases enteric defect. Two cases involved torsion of the anasto-
involved torsion of the anastomosis through the mesen- mosis through the mesenteric defect, and 2 cases were due
teric defect and 2 were due to internal herniation of the to herniation of the small bowel through the defect. Given
small bowel through the defect (Table 2). Three of these 4 the possibility of twisting the anastomosis through the de-
patients presented with SBO within 10 days of colectomy; fect during LRC, consideration should be given to reinsuf-
the fourth patient presented 8 months after surgery. None flating after extracorporeal anastomosis to confirm correct
of the 4 cases had been converted at the time of the initial orientation of the bowel limbs.
Beyond the inherent shortcomings of a retrospective
review, analysis of this series was further limited by the
TABLE 2. Small bowel obstruction characteristics inability to accurately determine the cause of SBO in pa-
Total no. cases 26 (4.9%) tients who were successfully treated nonoperatively. Nine
No. surgically treated 14 (54%) of these patients were evaluated by abdominal radiographs
Laparoscopic exploration 3 alone, which confirmed SBO but did not clarify the etiol-
Laparotomy or hernia repair 11 ogy of SBO. Three patients underwent CT scans; 2 were
Etiology*
Adhesions 4
found to have SBO due to internal hernia and postopera-
Abdominal wall hernia 4 tive anastomotic edema and 1 was found to have no evi-
Mesenteric defect 4 dence of SBO on CT imaging. Therefore, the incidence of
Cancer recurrence 2 internal herniation may have been underestimated in the
*No cause was determined for small bowel obstruction treated nonsurgically. group that was treated nonoperatively.
292
In addition, evaluation of the long-term consequences
of not closing the mesenteric defect may have been limited
in some patients by the length of follow-up after surgery.
Although the majority of patients had follow-up of 6
months or greater, 16% had a shorter follow-up period;
furthermore, a small number of patients and families were
not available by telephone.
Although closing the mesenteric defect laparoscopi-
cally is feasible, it is time consuming and technically chal-
lenging. Alternatively, the mesenteric defect may be closed
in an open fashion through the wound protector. Al-
though not specifically evaluated in the present study, this
practice is unlikely to allow for safe and complete closure
of the defect in the majority of patients given the average
incision length of LRC. A narrow residual defect (2–5 cm)
due to incomplete closure may increase the risk of symp-
tomatic internal herniation.11
Previous studies have reported an overall incidence of
SBO following laparoscopic colectomy ranging from 0.8%
to 2.5%.13,15–17 The most common cause of SBO in the
literature is incarcerated Richter’s hernia at a previous tro-
car site; obstruction due to an internal hernia is a rare oc-
currence.12 Internal hernia has been reported following a
number of laparoscopic abdominal procedures, including
laparoscopic Roux-en-Y gastric bypass,2– 8 laparoscopic
donor nephrectomy,18 laparoscopic Nissen fundoplica-
tion,19 and various laparoscopic genitourinary proce-
dures.20 Certain laparoscopic approaches to Roux-en-Y
gastric bypass surgery may be associated with a higher in-
cidence of symptomatic internal hernia than open meth-
ods, but the explanation remains unclear. Koppman et al
have suggested that the reduction in postoperative adhe-
sion formation after laparoscopic surgery, along with the
creation of potential spaces, leads to a loss of small bowel
fixation and a higher incidence of internal hernia.21
The present study is the first large-scale investigation
of the consequences of leaving the mesenteric defect open
during laparoscopic right colectomy. In this study, mesen-
teric defects were not associated with a significant rate of
clinically relevant internal hernia. These data support the
practice of leaving the mesenteric defect open after LRC for
neoplasia. Studies with extended long-term follow-up are
needed to further evaluate this practice in LRC.
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