Bowel Complications following Lateral Lumbar Interbody Fusion Surgery

Presented at SMISS Annual Forum 2016
By Sean Keem MD

Disclosures: Sean Keem MD B; NuVasive, Aegis Spine.


Lateral lumbar interbody fusion (LLIF) surgery has gained popularity in recent years. The ability to indirectly decompress spinal canal based on ligamentotaxis principal without open laminectomy, and to correct deformity with minimal tissue dissection/blood loss have made the approach a favorite surgical approach for many MIS spine surgeons. Thanks to its less approach-related morbidity, LLIF could be offered to older patients and patients with significant comorbidities, who would not be able to tolerate conventional spine fusion surgeries. Overall favorite surgical outcomes have encouraged MIS surgeons to eagerly explore more applications for this procedure and some pushing the boundary to expand the indications. 


Although there are some limitations for LLIF, contraindications for LLIF however are few and “MIS surgeons” have been enthusiastically advocating the procedure to be overall safe to patients and other surgeons. Complications that occur in association with the procedure are not often discussed because we tend to view them as “operator errors” that occur to less experienced surgeons and surgeons in general are loath to discuss negative outcomes associated with procedure that they advocate and of which they advertise themselves to be the expert. 


I present two cases bowel perforations that occurred following LLIF procedures. Both patients were older (in 70’s), very thin and had undergone XLIF for same indications. They were operated by the spine surgeon who has performed more than 1,000 levels of LLIF over 10 years. Both developed ileus and bowel perforation a few days after an uneventful surgery. 


Both patients required emergent exploration and bowel repair. One of the exploration and bowel repair surgery was personally attended by the spine surgeon. Intraoperative findings included bowel perforation at the same side and approximately at the same level of surgical approach. The surgical hardware however was not exposed to be seen because of intact peritoneum. The author therefore has concluded the bowel perforation/rupture in these cases were not due to direct surgical trauma, but rather combination of several other factors that may have led to functional bowel obstruction and rupture. 


Ogilvie syndrome is a functional obstruction of bowel that can lead to colonic perforation. It has been well-described in surgical literatures, but not in association with LLIF. The author proposes a few cautionary measures to minimize this potentially devastating complication.