A 32-year-old male weighing 59 Kg with a height of 167 cm presented to the outpatient clinic as a case of an unrelated renal kidney donor. He had a history of irritable bowel syndrome (IBS) and was taking medication only when flair-ups occurred. He had no surgical or blood transfusion procedures, no history of allergies, and no record of active infectious disease. The patient’s clinical and laboratory parameters were normal.

At the time of admission, the patient had a soft and lax abdomen with no scars. The Laparoscoendoscopic single site (LESS) donor nephrectomy procedure took place the next morning. The operation went well; however, a minor complication arose, which was a mesenteric defect that occurred while mobilizing the left colic flexure and was left un-closed. It was left un-closed due to its size being considered too large for a hernia to occur.

The patient had an uneventful postoperative (post-op) course. The day after the surgery upon inspection, the abdomen was soft and lax, able to tolerate oral feeding, and was passing flatus. The patient was discharged on that day, with no complaints and in good condition.

One day after discharge (day 2 post-op), the patient presented to the emergency room (ER) complaining of abdominal pain and thus received intravenous (IV) hydration and analgesia. After a slight improvement in symptoms, he decided to go home against medical advice. He returned to the ER a few hours later with the same complaint and was managed conservatively and discharged.

The next day (day 3 post-op), the patient presented to the ER with abdominal pain, nausea, and vomiting for 1 h. Upon examination, his abdomen was distended with mild tenderness all over his abdomen. Laboratory reports presented; Hb 14.3 g/dL, WBC 24.83 × 10⁹/L, and CRE 107 µmol/L. CT was also done, showing dilated jejunal and proximal ileal loops reaching up to 3.5 cm with focal abrupt transition points seen in the distal jejunum with collapsed distal small bowel loops. Based on CT scans, lab results, and examination, the patient was diagnosed with small bowel obstruction (SBO).

The patient was admitted and kept on nothing by mouth (NPO). Anesthesia was consulted and the patient was prepared for a laparoscopic exploration using the same incision and the same technique as the previous LESS.

Intraoperatively, dilated bowel loops with herniated small bowel through a mesenteric defect were found as shown in Fig. 1. It is believed that even though the defect was too large to cause herniation it was split into two smaller openings via a crossing artery. A transitional zone was identified, and the bowel was taken out of the mesenteric defect and found to be healthy with no necrosis. The mesenteric defect was closed using V- Lock monofilament (Glycolide, dioxanone, and trimethylene carbonate. 710 Medtronic Parkway Minneapolis, MN55432-5604USA) stitch, and hemlock, suction of fluids and then closure was done as seen in Fig. 2. The decision to use V- Lock monofilament was due to it not requiring any ties which are difficult to do during LESS, saving time. The hemlock was used as a precautionary step to minimize the chance of the stitch slipping backward due to any stretch or pressure.

Postoperatively, the patient was sent to recovery after extubating and all vitals were stable.

The patient stayed for 2 days and was discharged in good condition after he tolerated oral intake, passed normal bowel movements, and all parameters were found to be within normal ranges. He later came to the outpatient clinic for a follow-up and was doing fine.

Left colon mesenteric defect with small bowel going through the hernia site

The use of hemlock and V- Lock monofilament (Glycolide, dioxanone, and trimethylene carbonate. 710 Medtronic ParkwayMinneapolis, MN55432-5604USA) to close the mesenteric defect. The use of hemlock was avoided in parts where a significant mesenteric vessel was at the edge of the defect