Laparoscopic Repair of a Posttraumatic Left-Sided Diaphragmatic Hernia Complicated by Strangulation and Colon Obstruction

Background:

Posttraumatic diaphragmatic hernias (PDH) are serious complications of blunt and penetrating abdominal or thoracic trauma. Traditional thoracic or abdominal operations are usually performed in these cases.

Methods:

We present 2 cases of posttraumatic left-sided diaphragmatic hernia complicated by strangulation and colon obstruction. Both cases were successfully treated with laparoscopy.

Results:

We found that laparoscopy is a safe, successful, and gentle procedure not only for diagnosis but also for treatment of complicated PDH. Strangulation and colon obstruction were not contraindications to performing laparoscopic procedures. The postoperative course and long-term follow-up (range, 12 to 30 months) were uneventful and short. We expect the same good long-term results after laparoscopic repair as after open conventional surgery.

Conclusion:

We recommend the use a minimally invasive approach to treat posttraumatic diaphragmatic hernia complicated by strangulation and colon obstruction in hemodynamically stable patients.     

Early intervention in intersigmoid hernia may prevent bowel resection-A case report

INTRODUCTION

Intersigmoid hernia is a rare internal hernia presenting with symptoms of bowel obstruction. Preoperative diagnosis is uncommon but computerised tomography (CT) may show signs to suggest internal hernia.

PRESENTATION OF CASE

A 63-year-old female presented with abdominal pain, vomiting and absolute constipation. Examination revealed a tense distended abdomen. A plain abdominal radiograph showed features of small bowel obstruction. Conservative management was initiated without success and a CT scan was performed which showed a dilated distal oesophagus, stomach and small bowel with a non-dilated length of distal ileum and large bowel. Internal hernia was suggested as a possible cause and the patient underwent a laparotomy where a loop of small bowel was found to be strangulated and gangrenous within the intersigmoid fossa. The gangrenous bowel was resected, an end-to-end anastamosis was performed and the fossa was closed. The patient made an uneventful recovery.

DISCUSSION

Hernias of the sigmoid mesocolon account for 6% of internal hernias with internal hernias themselves causing between 0.2 and 4.1% of intestinal obstruction. This report presents a case of intersigmoid hernia, a rare internal hernia which should be suspected in patients presenting with acute obstruction, no past surgical history and no external hernia. Patients with these symptoms should receive an urgent CT scan to facilitate early surgery and minimise strangulation and prevent bowel resection.

conclusion

Intersigmoid hernia presents with acute obstruction, no past surgical history and no external hernia. Urgent CT scanning and early surgery may minimise strangulation, conserve bowel and reduce patient morbidity and mortality.     

Internal abdominal hernia: Intestinal obstruction due to trans-mesenteric hernia containing transverse colon

INTRODUCTION

Internal abdominal hernias are infrequent but an increasing cause of bowel obstruction still often underdiagnosed. Among adults its usual causes are congenital anomalies of intestinal rotation, postsurgical iatrogenic, trauma or infection diseases.

PRESENTATION OF CASE

We report the case of a 63-year-old woman with history of chronic constipation. The patient was hospitalized for two days with acute abdominal pain, abdominal distension and inability to eliminate flatus. The X-ray and abdominal computerized tomography scan (CT scan) showed signs of intestinal obstruction. Exploratory laparotomy performed revealed a trans-mesenteric hernia containing part of the transverse colon. The intestine was viable and resection was not necessary. Only the hernia was repaired.

DISCUSSION

Internal trans-mesenteric hernia constitutes a rare type of internal abdominal hernia, corresponding from 0.2 to 0.9% of bowel obstructions. This type carries a high risk of strangulation and even small hernias can be fatal. This complication is specially related to trans-mesenteric hernias as it tends to volvulize.Unfortunately, the clinical diagnosis is rather difficult.

CONCLUSION

Trans-mesenteric internal abdominal hernia may be asymptomatic for many years because of its nonspecific symptoms. The role of imaging test is relevant but still does not avoid the necessity of exploratory surgery when clinical features are uncertain.     

Paraduodenal herniation: An internal herniation in a virgin abdomen

INTRODUCTION

A paraduodenal hernia is an uncommon hernia that results from an abnormal rotation of the midgut. Commonly, these hernias are congenital in nature, and are reported to cause 1.5–5.8% of intestinal obstructions. These hernias occur when a part of the jejunum herniates through the posterior portion of the ligament of Treitz. Diagnosing these hernias preoperatively has been shown to be difficult, despite the studies that are available. Early diagnosis is imperative to the patient in order to avoid strangulation of the bowel, which is associated with a high mortality.

PRESENTATION OF CASE

In this case, we present a case of a left-sided paraduodenal hernia in a virgin abdomen in a 38-year-old African American male with a herniation of a loop of jejunum through a defect of the posterior portion of the ligament of Treitz. The patient also had a volvulized segment of the proximal jejunum, and part of this bowel was found to be ischemic.

DISCUSSION

Acute intestinal obstruction caused by a left paraduodenal hernia is a rare cause of intestinal obstruction. A literary search of PubMed between 1980 and 2012 indicated only 44 cases of intestinal obstruction secondary to a left paraduodenal hernia.

CONCLUSION

The patient underwent exploratory laparotomy, and the herniated bowel was found to be ischemic. The hernia was reduced, and the ischemic bowel resected. The defect was closed, and the patient had a non-complicated recovery.     

Aspiration pneumonia as a complication of a rare type of hernia

INTRODUCTION

Inguinal hernias are a common pathology and can contain unusual abdominal contents; the stomach is only infrequently involved due to its position in the abdominal cavity.

PRESENTATION OF CASE

An 85-year old male patient presented with symptoms of bowel obstruction and was subsequently found to have an incarcerated stomach within his chronic left-sided inguinal hernia. The patient had also developed aspiration pneumonia.

DISCUSSION

Aspiration pneumonia is a yet unreported complication of this unusual type of hernia. Our aim is to describe the presentation and management of this complication.

CONCLUSION

Development of aspiration pneumonia in a patient with an incarcerated stomach within an inguinal hernia.     

The Laparoscopic Approach for Repair of Morgagni Hernias

Background and Objectives:

Morgagni hernias are unusual congenital diaphragmatic hernias that are generally asymptomatic and discovered incidentally. Surgical treatment is indicated once the diagnosis is made. These hernias have traditionally been repaired by the open abdominal or thoracic approaches. We report a case of Morgagni hernia repaired successfully via the laparoscopic approach.

Methods and Results:

The patient was noted to have a large anteromedial diaphragmatic hernia by chest radiograph and CT imaging. He underwent laparoscopy, during which the hernia was reduced and the defect repaired with mesh placement. We used intracorporeal suture placement to anchor the mesh. The patient recovered uneventfully after a short hospitalization.

Conclusions:

The laparoscopic approach for repair of Morgagni hernias offers diagnostic advantages as well as the potential for reduced morbidity when compared to laparotomy. We report intracorporeal knot-tying for fixation of the mesh to be a secure and satisfactory means to achieve the laparoscopic repair.     

Laparoscopic repair of posttraumatic diaphragmatic rupture. Report of three cases

INTRODUCTION

Posttraumatic diaphragmatic rupture (PTDR) is a rare complication of thoracoabdominal injuries. In the emergency phase, it is generally treated via wide laparotomy. The laparoscopic approach is controversial and it is reserved for the chronic type of PTDR. Herein we present three cases of laparoscopic treatment of PTDR, one of which was conducted early after the injury.

PRESENTATION OF CASE

The patients’ age was 42, 66 and 53 years and the time from the injury until the operation 1 week, 2 months and 4 years, respectively. Hernia involved the left hemidiaphragm in two patients and the right hemidiaphragm in the second patient. Prolapsing viscera were the omentum/stomach/spleen, the small intestine and the omentum/large bowel, respectively. The PTDR was diagnosed right after the injury of the first patient but its treatment was postponed until the fourth day of hospitalization because of severe respiratory distress due to bilateral pneumothorax, flail chest and extended bilateral lung contusions. All patients underwent laparoscopic operation and correction of the hernia with the use of non-absorbable sutures or endoclips in two patients. There were no serious intra- or postoperative complications and the patients were discharged 30, 5, 6 days after the operation. After a period of 1, 8 and 9 years, respectively the patients remain without clinical evidence of recurrence.

DISCUSSION

Trauma is the major cause of acquired diaphragmatic hernias.

CONCLUSION

Laparoscopy is an attractive approach for the management of chronic PTDR. Moreover, it may offer the benefits of minimally invasive surgery during the acute phase of injury in highly selected patients.Abbreviations: DH, diaphragmatic hernia; PTDR, posttraumatic diaphragmatic rupture; ICU, intensive care unit; CT, computed tomography; FAST, Focused Abdominal Sonography for Trauma     

Symptomatic Right-Sided Diaphragmatic Hernia in the Third Trimester of Pregnancy

Background:

Laparoscopic repair of incarcerated diaphragmatic hernias is widely recognized as both safe and effective. However, symptomatic diaphragmatic hernias encountered in the setting of pregnancy, while rare, present a significant surgical challenge. Furthermore, right-sided diaphragmatic hernias account for only 13% of cases. Here, we present a case in which a symptomatic, posterior right-sided diaphragmatic hernia, presenting in the later stages of pregnancy, was successfully repaired using a laparoscopic approach.

Methods:

Our patient is a 42-y-old gravid woman who, at 27 wk gestation, was admitted to the gynecology service with a 2-d history of right upper quadrant abdominal pain, right shoulder pain, abdominal distension, and obstipation.

Results:

Computed tomography of the chest demonstrated an incarcerated right diaphragmatic hernia. Surgical consultation was obtained, and the patient was taken to the operating room urgently for repair. Intraoperatively, the cecum was reduced and the diaphragm repaired primarily using a laparoscopic approach. The patient recovered well and was discharged home on postoperative day 8 with no complications to the patient or the pregnancy.

Conclusion:

Laparoscopic reduction and repair of symptomatic incarcerated diaphragmatic hernia can be safely performed in the third trimester of pregnancy.     

A combined Richter's and de Garengeot's hernia

INTRODUCTION

de Garengeot''s hernia is very rare. Richter''s hernia is responsible for 10% of acute strangulated hernias.

PRESENTATION OF CASE

A 91-year-old woman with three days of abdominal distention was found on computed tomogram to have an incarcerated femoral hernia. Operation revealed a de Garengeot''s hernia combined with a Richter''s hernia of small bowel. Primary repair was performed along with appendectomy.

DISCUSSION

We discuss these rare hernias, not previously reported in combination, and options for management.

CONCLUSION

Combined de Garengeot''s and Richter''s hernias are rare, represent a significant diagnostic challenge, and should be repaired urgently to prevent ischemic bowel, or limit contamination if ischemia is already present. Use of computed tomography will likely lead to increased pre-operative diagnosis of this rare entity.     

Laparoscopic Repair of a Right Paraduodenal Hernia

Background and Objectives:

Right paraduodenal hernia (PDH) results from a primitive gut malrotation. The resultant jejunal mesenteric defect posterior to the superior mesenteric vessels allows decompressed jejunum to herniate retroperitoneally. PDH make up 53% of all internal hernias, but account for only 0.2% to 5.8% of all cases of intestinal obstruction. In addition, PDH exhibits male and left-sided predominance. Ours is the second report to describe the preoperative diagnosis and totally laparoscopic repair of a right PDH.

Methods:

We report the case of a 26-year-old female with symptoms suggestive of partial small bowel obstruction and a 6-year history of intermittent abdominal pain. Physical examination demonstrated lower quadrant tenderness. Plain abdominal radiographs and ultrasonography were nondiagnostic. Contrasted computed tomography of the abdomen revealed jejunum encased within the right upper quadrant suspicious for right PDH.

Results:

The patient underwent successful laparoscopic right PDH repair and was discharged home on postoperative day 1 without late sequelae.

Conclusions:

In the outpatient setting, clinical suspicion and comprehensive radiological investigation permit preoperative diagnosis of right PDH. In acute situations, clinical presentation, plain radiographs, and then diagnostic laparoscopy may be an expeditious diagnostic algorithm. Subsequent laparoscopic repair of right PDH is feasible and may shorten hospital length of stay.     

Laparoscopic port site Richter's hernia - An important lesson learnt

Introduction

We report a case of small bowel obstruction with strangulation caused by a port site hernia following a laparoscopic appendicectomy and the successful management of the problem by employing a laparoscopy assisted technique. The aim of this report is to emphasize the importance of fascial closures of trocar sites in order to significantly decrease postoperative morbidity.

Case report

A 31 years old female presented with a classic clinical picture of acute appendicitis. She underwent an uneventful laparoscopic appendicectomy. A 12 mm trocar was used at the umbilical port. On Postoperative day three, the patient developed abdominal distension, crampy abdominal pain, nausea and bilious vomiting. Her white cell count increased to 16,500/mm³, and CRP was 145. X-ray abdomen showed dilated small bowel with multiple air fluid levels. CT scan showed a herniated loop of small bowel into the trocar site with small bowel obstruction. Laparoscopy was done to confirm the Richter''s hernia into trocar site with small bowel obstruction. The bowel loop could not be reduced laparoscopically. Limited exploration of the trocar site confirmed findings with necrosis of the antimesenteric portion of the small bowel. A limited bowel resection and anastomosis was performed. The patient had an uneventful recovery.

Conclusion

Most port site hernias present within 10 days of the primary procedures, delayed hernias have been reported. CT scan is a helpful adjunct to differentiate port site hematoma from incarcerated small bowel. The knowledge of such a complication and its early diagnosis are important to avoid complications.     

Symptomatic Bochdalek Hernia in an Adult

Background and Objectives:

Bochdalek hernias are congenital diaphragmatic defects resulting from the failure of posterolateral diaphragmatic foramina to fuse in utero. Symptomatic Bochdalek hernias in adults are infrequent and may lead to gastrointestinal dysfunction or severe pulmonary disease. We describe our experience with this rare entity.

Methods:

A retrospective chart review was performed on a single patient for data collection purposes.

Results:

The patient is a morbidly obese 53-year-old female who presented with epigastric pain and diffuse abdominal tenderness. Computed tomography scans of the chest and abdomen revealed a small posterior diaphragmatic defect containing gastric fundal diverticulum. Laboratory work and imaging revealed no other findings. Laparoscopic repair of the Bochdalek hernia was done via an abdominal approach and utilized primary closure with an AlloDerm patch apposed to the defect. The patient has had significant clinical improvement and continues to do well at 9 months postoperatively.

Conclusion:

Laparoscopic repair of symptomatic adult Bochdalek hernias can be performed successfully and may result in significant clinical improvement.     

Obturator Hernia: Laparoscopic Diagnosis and Repair

Objective:

Review of international literature reveals eight reported cases of laparoscopic obturator hernia repair. Non-specific signs and symptoms make the diagnosis of an obturator hernia difficult. Laparoscopic intervention provides a minimally invasive method to simultaneously diagnose and repair these hernias.

Methods and Procedures:

A 35 year old woman presented with lower abdominal pain, vaginal bleeding, and dyspareunia. During gynecological diagnostic laparoscopy, a pelvic floor hernia was suspected, and a general surgical evaluation was sought. At a subsequent laparoscopy, the diagnosis of a left direct inguinal and a right obturator hernia was made. Both were repaired laparoscopically with polypropylene mesh.

Results:

At follow-up at one and six weeks postoperatively, the patient''s complaints of pain had completely resolved.

Conclusion:

The diagnosis of obturator hernia is problematic. The usual presenting signs and symptoms are non-specific. Without conclusive historical or physical findings, laparoscopy is an excellent method for diagnosing obturator hernia. This entity, once diagnosed laparoscopically, can be repaired simultaneously via laparoscopic mesh technique.     

De Garengeot Hernia

Background and Objectives:

We report a case of appendicitis presenting in an incarcerated femoral hernia, otherwise known as de Garengeot hernia. This rare hernia usually presents with both diagnostic and therapeutic dilemmas. We wish to underline the usefulness of laparoscopy in both the diagnosis and treatment of de Garengeot hernias.

Methods:

A diagnostic laparoscopy was performed initially. The appendix was seen to disappear into the hernia sac. A laparoscopic appendectomy was then performed prior to open exploration of the groin.

Results:

We were able to obtain a correct diagnosis and perform an appendectomy prior to making a groin incision. Operative findings included an incarcerated, inflamed appendix within a femoral hernia.

Conclusions:

Diagnostic laparoscopy could be a valuable tool in the correct diagnosis and management of unusual presentations of incarcerated groin hernias.     

A pseudo-TEP repair of an incarcerated obturator hernia

Introduction

Obturator hernia (OH) is a rare condition and difficult to diagnose. While they account for as few as 0.073% of all hernias, mortality can be as high as 70%. The typical clinical presentation for OH is small bowel obstruction. Computed tomography is the diagnostic tool of choice. Surgical repair is mandatory in virtually all cases of OH and traditionally consists of performing an exploratory laparotomy.

Presentation of case

A 90-year-old female was admitted to our surgical service with signs of small bowel obstruction and a CT scan revealing incarcerated fatty tissue and small bowel within a left OH.

Discussion

The role of laparoscopic surgery in the management of OH has been limited to elective repairs; most reports detail that the OH was found serendipitously during laparoscopic inguinal hernia operations or other pelvic procedures. A few reports describe the use of laparoscopy to treat OH associated with bowel obstruction in an emergency setting using a TAPP approach. A strict TEP hernia repair is not indicated for all patients with OH, and should rarely be performed in emergency situations given its limitation to assess or resect bowel if necessary. In selected cases, a formal exploratory laparoscopy that is negative for compromised bowel can be safely followed by a TEP repair using the same umbilical access as shown in our patient.

Conclusion

A 90-year-old female with a small bowel obstruction related to an incarcerated OH was treated effectively with an extraperitoneal laparoscopic approach.     

Blood bezoar causing obstruction after laparoscopic Roux-en-Y gastric bypass

INTRODUCTION

Bowel obstruction is a known complication after bariatric surgery especially Roux-en-Y gastric bypass. The known etiologies include internal hernia, jejunojejunostomy stricture, ileus, intussusceptions, superior mesenteric artery syndrome, incarcerated port site hernia, and adhesions. Blood bezoar is a rare cause of small intestinal obstruction after Roux-en-Y gastric bypass.

PRESENTATION OF CASE

We are going to present two cases of small bowel obstruction after Roux-en-Y gastric bypass due to blood bezoar.

DISCUSSION

Blood clot as the etiology of small bowel obstruction after Roux-en-Y gastric bypass is an unusual event. In the presence of postoperative small intestinal obstruction an obstructive blood bezoar should be in differential diagnosis. As any other etiology of postoperative obstruction it should be treated immediately to prevent its adverse lethal complications.

CONCLUSION

The best way for prevention of blood bezoar is prevention of bleeding at staple line and doing hemostasis at stapler line.     

Minimally Invasive Spigelian Hernia Repair

Introduction:

Spigelian hernia is an uncommon ventral hernia characterized by a defect in the linea semilunaris. Repair of spigelian hernia has traditionally been accomplished via an open transverse incision and primary repair. The purpose of this article is to present 2 case reports of incarcerated spigelian hernia that were successfully repaired laparoscopically using Gortex mesh and to present a review of the literature regarding laparoscopic repair of spigelian hernias.

Methods:

Retrospective chart review and Medline literature search.

Results:

Two patients underwent laparoscopic mesh repair of incarcerated spigelian hernias. Both were started on a regular diet on postoperative day 1 and discharged on postoperative days 2 and 3. One patient developed a seroma that resolved without intervention. There was complete resolution of preoperative symptoms at the 12-month follow-up.

Conclusion:

Minimally invasive repair of spigelian hernias is an alternative to the traditional open surgical technique. Further studies are needed to directly compare the open and the laparoscopic repair.     

Repair of Bochdalek hernia in an adult complicated by abdominal compartment syndrome,gastropleural fistula and pleural empyema: Report of a case

INTRODUCTION

Bochdalek''s diaphragmatic hernia (BDH) rarely developed symptomatic in adulthood but mostly required an operation. In adult BDH cases, long-term residing of the massive intraabdominal organs in the thoracic cavity passively causes loss of domain for abdominal organs (LOD).

PRESENTATION OF CASE

A 63-year-old man presented at our institution complaining of sudden left upper quadrant abdominal pain. Chest radiography showed a hyperdense lesion containing bowel gas in the left pleural space. Computed tomography revealed a dilated bowel above the diaphragm and intestinal obstruction suggestive of gangrenous changes. These findings were consistent with the diagnosis of incarcerated BDH and an emergency laparotomy was performed. Operative findings revealed the hypoplastic lung, lack of hernia sac, and location of the diaphragmatic defect, which indicated that his hernia was true congenital. Organs were reduced into the abdominal cavity, and large defect of the diaphragm was repaired with combination of direct vascular closure and intraperitoneal onlay mesh reinforcement using with expanded polytetrafluoroethylene (ePTFE) mesh. On the postoperative day 1, the patient fell into the shock and was diagnosed to have abdominal compartment syndrome (ACS). Conservative therapies were administered, but resulted in gastropleural fistula and pleural empyema, which required an emergency surgery. Mesh extraction and fistulectomy were performed.

DISCUSSION

A PubMed search for the case of ACS after repair of the adult BDH revealed only three cases, making this very rare condition.

CONCLUSION

In dealing with adult BDH, possible post-repair ACS should be considered.     

CRITICAL ANALYSIS OF EXPERIMENTAL MODEL FOR STUDY OF ADHESIONS AFTER INCISIONAL HERNIAS INDUCED IN RATS’ AND REPAIR OF ABDOMINAL WALL WITH DIFFERENT BIOMATERIALS

Background:

Adhesions induced by biomaterials experimentally implanted in the abdominal cavity are basically studied by primary repair of different abdominal wall defects or by the correction of incisional hernias previously performed with no precise definition of the most appropriate model.

Aim:

To describe the adhesions which occur after the development of incisional hernias, before the prosthesis implantation, in an experimental model to study the changes induced by different meshes.

Methods:

Incisional hernias were performed in 10 rats with hernia orifices of standardized dimensions, obtained by the median incision of the abdominal wall and eversion of the defect edges. Ten days after the procedure adhesions of abdominal structures were found when hernias were repaired with different meshes.

Results:

The results showed hernia sac well defined in all rats ten days after the initial procedure. Adhesions of the greater omentum occurred in five animals of which two also showed adhesions of small bowel loops besides the omentum, and another two showed liver adhesions as well as the greater omentum, numbers with statistical significance by Student''s t test (p<0.05).

Conclusion:

Although it reproduces the real clinical situation, the choice of experimental model of incisional hernia repair previously induced implies important adhesions, with possible repercussions in the evaluation of the second operation, when different implants of synthetic materials are used.     

Emergency Intraperitoneal Onlay Mesh Repair of Incarcerated Spigelian Hernia

Background and Objectives:

Spigelian hernia is a rare cause of incarcerated ventral abdominal hernia that may pose a diagnostic dilemma. However, with the increasing utilization of double contrast computed tomography (CT) for undiagnosed small bowel obstruction in a virgin abdomen, more such cases are being diagnosed with increasing confidence. Furthermore, with the rapid expansion of the indications for minimal access surgery in emergency situations, these rare emergencies are increasingly tackled using a laparoscopic approach leading to swift patient recovery and discharge.

Methods:

We present the case of an emergency intraperitoneal onlay mesh (IPOM) repair of Spigelian hernia, causing acute small bowel obstruction in a 55-year-old man with liver disease and ascites that was diagnosed using a CT scan. We conducted a search of Medline, Embase, Science Citation Index, Current Contents, PubMed, and the Cochrane Database to review the history of laparoscopic repair of Spigelian hernia and its various advancements, which are briefly presented here.

Results:

The hernia was successfully reduced using laparoscopy, revealing a moderate-size defect in the linea semilunaris. The hernial defect was repaired with a composite mesh that was tacked into position. The patient was discharged from the hospital on the second postoperative day.

Conclusions:

Spigelian hernia in an emergency setting can be easily and swiftly repaired using the IPOM method utilizing a composite mesh.