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.     

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.     

Morgagni hernia treated by reduced port surgery

INTRODUCTION

The laparoscopic repair of a rare diaphragmatic Morgagni hernia using the reduced port approach is described.

PRESENTATION OF CASE

An 85-year-old female presented with a 2 days history of upper abdominal discomfort and loss of appetite. We diagnosed her condition as a Morgagni hernia by morphological studies and performed laparoscopic mesh placement with a multi-channel port and 12-mm port. This elderly patient had a rapid postoperative recovery. A 2-year follow-up CT showed no recurrence of the hernia.

DISCUSSION

Recent trends in laparoscopic procedures have been toward minimizing the number of incisions to reduce invasiveness. This case indicated that the reduced port approach can be considered a suitable and safe procedure for treatment of Morgagni hernia.

CONCLUSION

The reduced port approach is a good indication for Morgagni hernia.     

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.     

Over a thousand ambulatory hernia repairs in a primary care setting

INTRODUCTION

This paper outlines the development and feasibility of a dedicated ambulatory primary care hernia service and examines the outcomes achieved during the period 1 March 2005 to 31 December 2008.

PATIENTS AND METHODS

A prospective analysis of 1164 patients who underwent abdominal wall hernia repair at Probus Surgical Centre during the study period. The operations were carried out by two GPs with a special interest (GPwSI) and one retired surgeon. The techniques used were a Lichtenstein mesh repair or modified Shouldice repair for inguinal hernias and a primary sutured repair for ventral hernias. All procedures were performed as day-cases under local anaesthesia without sedation. All patients were reviewed routinely at 6 weeks. The primary outcomes of the study were recurrence and patient satisfaction levels, and complications such as infection, haematoma and chronic pain.

RESULTS

No patient required conversion to general anaesthesia. There were three (0.3%) recurrences. Complication rates were low and similar to those obtained in other specialist hernia units. More than 90% of patients were satisfied with the service and would recommend it to a friend.

CONCLUSIONS

Routine elective abdominal wall hernia repairs can be performed in a primary care setting, safely and with excellent outcomes.     

Right sided transmesentric hernia: A rare cause of acute abdomen in adults

INTRODUCTION

Transmesenteric mesocolic hernias are a rare cause of acute abdomen in adults with few reported cases in published literature.

PRESENTATION OF CASE

We report a rare case of a 30-year-old male with right-sided transmesenteric hernia of ileum due to a congenital mesocolic defect resulting in acute abdomen, presenting as acute abdomen. The hernia was reduced, small bowel inspected for gangrene and mesenteric hernia repaired, following which the patient made a good recovery and was discharged 5 days later.

DISCUSSION

The insidious onset of transmesenteric herniae and lack of specific radiological or laboratory investigations reaffirms the importance of surgeons maintaining a high index of suspicion for this surgical emergency.

CONCLUSION

Transmesentric hernia though rare can present as a case of acute abdomen in an emergency. The diagnosis is purely by a CT scan and close monitoring of the patient''s general condition in cases of non-specific abdominal pain is essential to identify the rare deteriorating patient for early surgical intervention and optimal outcome.     

A large incarcerated Meckel's diverticulum in an inguinal hernia

INTRODUCTION

Littre''s hernia is a rare finding consisting of a Meckel''s diverticulum inside of a hernia sac. Clinically, it is indistinguishable from a hernia involving small bowel and therefore may be difficult to diagnose pre-operatively.

PRESENTATION OF CASE

We report a case of an inguinal hernia involving an unusually large Meckel''s diverticulum measuring 15 cm in length. The diverticulum was resected using a linear GI stapler and the hernia was repaired without complication.

DISCUSSION

Meckel''s diverticulum is an embryologic remnant of the vitelline duct occurring in 1–3% of the adult population with an estimated 4% becoming complicated and presenting with intestinal obstruction, infection, bleeding or herniation. Surgical resection is the recommended treatment for any Meckel''s diverticulum causing symptoms. In the case of a Littre''s hernia, resection of the diverticulum should be followed by repair of the fascial defect in a standard fashion.

CONCLUSION

Littre''s hernia, although rare, should be a consideration at the time of repair for any abdominal hernia involving small bowel as resection of the Meckel''s diverticulum is critical in avoiding recurrent complications.     

Laparoscopic repair of incidentally found Spigelian hernia

Background and Objectives:

A Spigelian hernia is a rare type of hernia that occurs through a defect in the anterior abdominal wall adjacent to the linea semilunaris. Estimation of its incidence has been reported as 0.12% of all abdominal wall hernias. Traditionally, the method of repair has been an open approach. Herein, we discuss a series of laparoscopic repairs.

Methods:

Case series and review of the literature.

Cases:

Three patients are presented. All were evaluated and taken to surgery initially for a different disease process, and all were incidentally found to have a spigelian hernia. These patients underwent laparoscopic repair of their hernias; 2 were repaired intraperitoneally and one was repaired totally extraperitoneally. Two patients initially underwent a mesh repair, while the third had an attempted primary repair.

Conclusions:

There is evidence that supports the use of laparoscopy for both diagnosis and repair of spigelian hernias. There are also reports of successful repairs both primarily and with mesh. In our experience with the preceding 3 patients, we found that laparoscopic repair of incidentally discovered spigelian hernias is a viable option, and we also found that implantation of mesh, when possible, resulted in satisfactory results and no recurrence.     

Direct inguinal hernia containing bladder carcinoma: A case report and review of the literature

INTRODUCTION

Inguinal hernia containing bladder carcinoma is a very rare occurrence.

PRESENTATION OF CASE

We report a case of a male patient who presented with a left groin hernia containing an irregular mass. The hernia was repaired without the use of mesh and a partial cystectomy was done.

DISCUSSION

Only 1–3% of all inguinal hernias involve the bladder, with very few reports containing a carcinoma.

CONCLUSION

Treatment consists of removing the tumor and repairing the hernia.     

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.     

A De Garengeot Hernia masquerading as a strangulated femoral hernia

INTRODUCTION

De Garengeot hernia is a rare occurrence whereby an appendix is found in a femoral hernia sac. It is rarer still to find an acutely inflamed appendix manifesting itself as a strangulated femoral hernia. This case is important to report as it highlights the diagnostic difficulty this particular condition presents to an emergency surgeon.

PRESENTATION OF CASE

We report the case of an 86 year old female who was found to have a De Garengeot hernia containing a necrotic appendix. A retrograde appendicectomy was performed to prevent peritoneal contamination. The hernia defect was repaired using a standard repair with non-absorbable suture.

DISCUSSION

De Garengeot''s hernia is a rare occurrence, is often unexpected and tends to be diagnosed intra-operatively. Pre-operative diagnosis remains difficult and it will often masquerade as a strangulated femoral hernia. In stable patients, where there is a diagnostic uncertainty CT scanning is a useful adjunct and may allow a laparoscopic approach to be undertaken in the absence of appendicitis.

CONCLUSION

A De Garengeot''s hernia should be considered as a differential diagnosis in patients presenting with clinical signs of a strangulated femoral hernia. It is often an incidental finding during an emergency operation. Although mesh repairs in the presence of appendicitis have been reported, the safest approach remains a primary suture repair.     

Sutureless laparoscopic ventral hernia repair in obese patients

Background and Objective:

Transfascial sutures (TFS) are a standard component of laparoscopic ventral herniorrhaphy (LVHR) that contribute to the durability of repair, but also pain and, resultantly, hospital stay. We sought to examine LVHR without TFS in obese patients with small abdominal wall hernias.

Methods:

Between September 2002 and December 2007, 174 patients underwent LVHR at Yale-New Haven Hospital. Patients with BMI >30kg/m² and small primary abdominal wall hernias were eligible for repair without TFS. Correlation between BMI, defect surface area, operative time, and postoperative stay was assessed.

Results:

Fourteen patients underwent LVHR with no TFS, 2 with normal BMI and recurrent hernia after open repair and 12 with BMI>30 kg/m² and primary small hernia. Mean age was 38.8 years. The average defect size was 5.3cm²; mean operative time (OT) was 42 minutes. Eleven patients (92%) were discharged home the day of surgery. No infectious or bleeding complications occurred. One patient required chronic pain management, and 8 patients (67%) developed seromas that resorbed spontaneously. There was no hernia recurrence at 7-month follow-up.

Conclusion:

LVHR is feasible without TFS provided the hernia defect is small. Surgery can be performed on an outpatient basis in obese individuals with minimal postoperative morbidity.     

Laparoscopic repair of chronic traumatic diaphragmatic hernia using biologic mesh with cholecystectomy for intrathoracic gallbladder

Background and Objectives:

Diaphragmatic rupture is a serious complication of both blunt and penetrating abdominal trauma. In the acute setting, delay in diagnosis can lead to severe cardiovascular and respiratory compromise. Chronic cases can present years later with a plethora of clinical symptoms. Laparoscopic techniques are being increasingly utilized in the diagnosis and treatment of traumatic diaphragmatic hernias.

Method:

We describe a case of a 70-year-old female who presented with signs and symptoms of a small bowel obstruction. She was ultimately found to have an obstruction secondary to a chronic traumatic diaphragmatic hernia with an intrathoracic gallbladder and incarcerated small intestine. A cholecystectomy and diaphragmatic hernia repair were both performed laparoscopically. This case report presents an atypical cause of bowel obstruction and reviews the current literature on laparoscopic management of traumatic diaphragmatic hernias.

Results and Conclusion:

Laparoscopy is increasingly used in the diagnosis and treatment of traumatic diaphragmatic hernias with good results.     

Robotic single-port hernia surgery

Background and Objectives:

Since the introduction of single-incision laparoscopic surgery in 2009, an increasing number of surgical procedures including hernia repair are being performed using this technique. However, its large-scale adoption awaits results of prospective randomized controlled studies confirming its potential benefits. Parallel with single-port surgery development, the issue of the chronic lack of good camera assistants is being addressed by the robotic Freehand® camera controller, which has the potential to replace camera assistants in a large percentage of routine laparoscopic surgery. Although the robotic Freehand has been used in certain operations in urology and gynecology, there have been no published reports in robotic (single-port) hernia surgery.

Methods:

This study reports the first case and a series of 16 patients who underwent robotic single-port total extraperitoneal inguinal hernia repair compared to 16 consecutive cases of conventional single-port inguinal hernia repair. Patients were matched for age, sex, body mass index, American Society of Anesthesiologists classification, and types of hernia.

Results:

Although operation time was comparable in both, the time wasted for scope cleaning was 8.5 minutes for conventional compared to 1.5 minutes for robotic surgery.

Conclusion:

Robotic single-port inguinal hernia repair is feasible and efficient. This represents a further milestone in laparoscopic surgery.     

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.     

Bochdalek hernia and repetitive pancreatitis in a 33 year old woman

INTRODUCTION

Bochdalek hernia presentation in adulthood is rare. The presentation in newborns is the most common, manifesting with data from respiratory failure secondary to pulmonary hypoplasia, requiring urgent surgical intervention with high morbidity and mortality.

PRESENTATION OF CASE

We present the case of a 33 year old woman admitted in the emergency room with severe abdominal pain in the left upper quadrant and disnea. After physical examination and laboratory test we diagnose mild acute pancreatitis. The patient haven’t colelitiasis by ulstrasound or any risk factor for pancreatitis. Initially she received medical treatment and was discharged after one week. After four weeks she presented the same symptoms in two different occasions, with severe and mild pancreatitis respectively. A computed tomography report a left posterolateral diafragmatic hernia. In spite of the rare association of pancreatitis and Bochdalek hernia, we realized it as the etiology until the second event and planned his surgery. We made a posterolateral torachotomy and diafragmatic plasty with a politetrafluoroetileno mesh and after a 6 months follow up she has coursed asymptomatic.

DISCUSSION

The high rate of complications in this type of hernia requires us to perform surgical treatment as the hernia is detected. In this case it is prudent medical treatment prior to surgical correction despite this being the origin of the pancreatitis, because the systemic inflammatory response added by the surgical act could result in a higher rate of complications if not performed at the appropriate time. There is no precise rule to determine the type of approach of choice in this type of hernia which thoracotomy or laparotomy may be used.

CONCLUSION

Bochdalek hernia is a rare find in adults who require treatment immediately after diagnosis because of the high risk of complications. When presented with data from pancreatitis is recommended to complete the medical treatment of pancreatitis before surgery to obtain the best results, unless it exist another abdominal complication.     

Petersen's space hernia: A rare but expanding diagnosis

Background

Petersen''s space hernia is caused by the herniation of intestinal loops through the defect between the small bowel limbs, the transverse mesocolon and the retroperitoneum, after any type of gastrojejunostomy. The laparoscopic approach facilitates the occurrence of this type of hernia, due to the lack of post-operative adhesions which prevent bowel motility and hence, herniation.

Case report

We report the case of a 46 year-old male submitted to an open antrectomy and vagotomy with a Roux-en-Y reconstruction six-years before, for the treatment of bleeding gastric ulcer.He presented with epigastric abdominal pain radiating to the back and alimentary vomiting with a 3 days evolution, with an episode of hematemesis 2 h before admission. His abdomen was bloated and tender at the epigastric region. The laboratory exams revealed mild leucocytosis and CRP elevation with normal pancreatic tests. The abdominal CT scan revealed an intestinal occlusion. An exploratory laparotomy was performed, disclosing an incarcerated Petersen space hernia of the common limb, with obstruction and dilatation of the biliary limb.

Conclusion

The knowledge of this anatomic post-operative defect and a low threshold for diagnosis are crucial to its management, since its nonspecific clinical and laboratory findings. Early operative intervention is warranted in order to avoid the severe complications of bowel necrosis.     

The learning curve in laparoscopic inguinal hernia repair for the community general surgeon

Objective

To determine the learning curve (number of operations required) to stabilize operating times and complication rates for a general surgeon doing laparoscopic inguinal hernia repair in a community practice.

Design

A prospective analysis.

Setting

A 256-bed secondary-care community hospital.

Patients

Ninety-eight consecutive patients booked for elective laparoscopic hernia repair on an outpatient basis.

Interventions

Using the transabdominal preperitoneal approach, 100 operations were carried out to repair 138 groins and a total of 164 separate hernial defects.

Outcome measures

The number of operations required to decrease operative times and complication rates to a steady level.

Results

There were no deaths. There were 5 conversions and 10 admissions, all occurring between the 1st and 46th operations. Two reoperations for reasons other than recurrence were required between the 45th and 55th operations. There were 24 other complications. Complications and surgical times began to level off after 50 operations. The 1 readmission was after the 42nd operation. There were 4 recurrences (2.9% recurrence rate), 2 in each group of 50 operations. Both groups of 2 recurrences occurred within the first 10 operations involving the use of a new stapler. Twenty-two other patients had open hernia repairs because laparoscopy was unsuitable for them.

Conclusion

The learning curve for laparoscopic inguinal hernia repair in the hands of a general surgeon in community practice who is experienced in open herniorraphy and laparoscopic cholecystectomy is at least 50 operations.     

Incarcerated spontaneous transdiaphragmatic intercostal hernia

Introduction

Prolapse of abdominal viscera into the thoracic subcutis through the chest wall is known as transdiaphragmatic intercostal hernia (TIH). Herein, we present the first case of spontaneous TIH presenting as a thoracoabdominal emergency.

Presentation of case

A 78-year-old male presented with acute left thoracoabdominal pain following a sudden bulge at the left posterolateral chest wall corresponding to a partially reducible soft tissue mass with ecchymosis at the overlying skin. Paroxysmal cough during the last four days was also reported along with a prolonged daily application of a special tight abdominal belt that used while milking sheep. CT-scan of the abdomen showed intrathoracic proptosis of the splenic flexure through a defect of the left hemidiaphragm and subcutaneous prolapse of the herniated colon through the 7th intercostal space. On laparotomy, the herniated colon showed signs of ischemic necrosis leading to segmental colectomy followed by repair of the diaphragmatic defect.

Discussion

The clinical diagnosis of spontaneous TIH demands very high index of suspicion and thorough patient''s history. In this case the daily elevation of the intraabdominal pressure due to an abdominal milking belt might have caused gradual slimming and loosening of the diaphragm and the intercostals muscles rendering them vulnerable to sudden increases of the thoracoabdominal pressure due to violent coughing. Such a hypothesis is reasonable in the absence of traumatic injury in this patient.

Conclusion

Spontaneous TIH should be suspected in patients presenting with a sudden palpable chest wall bulge and associated thoracoabdominal symptoms in the absence of preceding injury.