Double Obstruction Following Third Renal Transplant: A Case Report

Internal Herniation Causing Double Obstruction of the Small Bowel and Urinary Tract: A Rare Case Presentation

Small bowel obstruction is one of the most common urgent surgical conditions, caused by a variety of factors, with adhesions, malignancies, and hernias, internal and external, being the most common. Many types of internal hernias have been described in the literature; however, internal hernia caused by the ureter as a secondary complication of ureteroplasty is rare and only a few cases have been reported worldwide. This presentation discusses an interesting case of small bowel obstruction accompanied by obstruction of the urinary tract due to an internal hernia caused by the ureter. A 58-year-old female presented to the emergency department (ED) with acute pain in the abdominal and right lumbar region. Her surgical history includes hysterectomy, right ureter injury, and ureteroplasty performed 10 years ago. Clinical examination showed tenderness in the lower abdomen, positive Giordano's sign on the right, and metallic bowel sounds. A computer tomography scan revealed right-sided hydronephrosis, absence of excretion in the right urinary tract, and dilated loops of the small intestine. An exploratory laparoscopy revealed a small bowel loop strangulated by the ureter, followed by laparotomy, resection of a segment of the ileum, oblique anastomosis, and reimplantation of the right ureter. The patient was discharged eight days postoperatively without any complications. This case underscores the significance of surgical history in order to recognize even rarer causes of small bowel obstruction.

Unique cases of large and small bowel obstruction in intraperitoneal renal transplantations: a case series and review of literature

Bowel obstruction is a common cause for the acute abdomen with different aetiologies that shapes subsequent management plans. Small bowel obstruction often develop due to intra-abdominal adhesions in patients with prior abdominal surgery and for large bowel obstructions, more commonly due to tumours and lesions. Disruptions to normal intra-abdominal anatomy as seen in pancreatic-kidney transplantation or kidney transplant alone can result in increased risk of bowel obstruction-especially if the donor graft is implanted within the intraperitoneal plane. We present two patients from separate institutions with history of simultaneous pancreas-kidney (SPK) transplantation (Patient 1) and intraperitoneal renal (Patient 2) transplant whom both presented with bowel obstruction requiring surgical intervention. Given the specificity and operative intricacies of our cases, we aim to present our findings and surgical management of these rare presentations in hopes of increasing awareness to this uncommon but significant cause of bowel obstruction in a transplant patient.

The transplant ureter causing small bowel obstruction following intraperitoneal kidney transplantation: a case report

Internal bowel herniation under the ureter of an intraperitoneally transplanted kidney is a rare complication yet carries a high burden of morbidity and potential mortality if not recognized and managed appropriately. We describe a case where early intervention salvaged the bowel without ureteral injury. We also describe a technique to close the space beneath the ureter to prevent further episodes of internal herniation.

Paraureteric space post-ureteric re-implantation: a rare cause of small bowel obstruction

A female patient in her 80s presented with a 2-day history of abdominal pain and absolute constipation, having previously undergone a robotic left distal ureterectomy with ureteric re-implantation. CT revealed a closed-loop small bowel obstruction with transition point adjacent to the left ureter and resultant upstream hydronephrosis. An emergency laparotomy revealed small bowel herniation into a paraureteric space created by her previous surgery and defined by the distal ureter medially, the common iliac vessels laterally and the mobilised bladder dome anteriorly. The viable small bowel was reduced, and the space was eliminated by omental flap transposition after omentoplasty. The patient made a full recovery. Preoperative diagnosis of such an unusual cause of internal herniation can be challenging. This very rarely reported case raises awareness of the condition and proposes a treatment strategy.

Between a Rock and a Hard Place-Colonic Obstruction Between Two Kidneys: A Case Report

We report a case of a 70-year-old woman with a history of end-stage renal disease secondary to polycystic kidney disease with a previous failed transplant who presented for a cadaveric extraperitoneal renal transplant. The patient developed a progressively worsening bowel obstruction postoperatively and evidence of an obstruction was observed on computed tomography imaging with a transition point at the level of the sigmoid colon. Consequent to this, she underwent an exploratory laparotomy, which revealed kinking of the colon secondary to the compression between the transplanted and the left native polycystic kidneys. There were adhesive bands between the native kidney and the descending colon in the retroperitoneal space maintaining it in a fixed position mechanically. The addition of a retroperitoneal transplant exacerbated this kink and was responsible for the bowel obstruction. Her left colon was completely mobilized to relieve her obstruction, and owing to her bowel distension, her abdomen was left open for 2 days before returning to the operating room to remove her left native polycystic kidney to allow space for safe closure. This report highlights an extremely unusual cause of large bowel obstruction post-kidney transplantation.

Beware the band adhesion: an unexpected cause of double obstruction following intraperitoneal kidney transplantation

Small bowel obstruction (SBO) following intraperitoneal renal transplantation, either solitary or due to simultaneous pancreas-kidney transplantation, is a known complication. While SBO is most commonly due to adhesions, there have been documented cases of internal herniation following simultaneous pancreas-kidney transplantation with enteric drainage due to the formation of a mesenteric defect. We present a unique complication in which the transplant ureter has caused strangulation and necrosis of a length of small intestine. The transplant ureter was mistaken for a band adhesion and divided. Post-operative anuria signalled this difficult diagnosis. Subsequent re-look laparotomy and ureteric reimplantation with Boari flap were required. Therefore, it is important to consider the ureter as a cause of internal herniation in kidney transplant patients and recognize that a band adhesion within the pelvis may in fact be the transplant ureter, obstructing a loop of small intestine beneath its course.