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SMV Interposition Graft for Iatrogenic Injury During Right Hemicolectomy
Farah Karipineni, MD, MPH, Nyali Taylor, MD, Rashad Choudry, MD, FACS, Amit Joshi, MD, FACS.
Albert Einstein Medical Center, Philadelphia, PA, USA.
Objective
Superior mesenteric vein (SMV) injury after abdominal surgery or major trauma is an uncommon complication associated with high mortality. Management is highly varied and most studies are confined to the trauma population rather than elective colorectal cases. This case report seeks to address the operative management of SMV injury during an elective right hemicolectomy.
Methods
A comprehensive chart review of the case was performed. Additionally, a literature search was performed on PubMed to identify all case reports, case series and studies addressing management of SMV injury, including both iatrogenic and traumatic events.
Results
We report the case of a 73 year old female with biopsy-proven colonic adenocarcinoma who underwent laparoscopic hand-assisted right hemicolectomy complicated by SMV injury. The injury was managed with heparinization, temporary abdominal closure, SMV interposition graft with polytetrafluoroethylene graft (PTFE), and several trips to the operating room to re-assess bowel perfusion. No ischemic bowel was encountered, the patient was never hemodynamically unstable, and she was discharged on warfarin on hospital day 8 in good condition.
Conclusion
Options for management of SMV injury at the time of surgery are primary venorrhaphy, end-to-end anastomosis, interposition graft or bypass with PTFE or vein, and ligation. In the trauma literature, repair and ligation are associated with similar mortality rates, making ligation an acceptable approach in the setting of hemodynamic instability and potential polytrauma. However, in patients undergoing elective surgery, revascularization should be attempted in the otherwise stable patient, and a high suspicion for delayed ischemic bowel should be maintained.
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