Left laparoscopic paraduodenal hernia repair

Background

An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Paraduodenal hernia is by far the most common form of congenital internal hernia, making up 53% of all reported cases. In recent years, as surgeons have become more comfortable with laparoscopic techniques, they are performing an increasing number of these procedures laparoscopically.

Methods

To highlight the technical steps of this technique, the case of a patient with a left paraduodenal hernia and a video of the laparoscopic repair are presented. Additionally, a PubMed search of the English medical literature was conducted using the search words “laparoscopic,” “paraduodenal,” and “hernia” as filters. The cases of laparoscopic paraduodenal hernia repair in the literature to date recording data on technique, complications, and hospital course were reviewed.

Results

In addition to the case described in this report, 14 cases of laparoscopic paraduodenal hernia were described in 10 published reports. Of the 15 cases, 11 (73%) were left-sided, likely representing the relative incidence of these cases. The hernia defect was closed in 10 (77%) of the 13 cases for which the repair method was described, whereas the defect was widely opened in the remaining cases. One report described an operative complication (6.7%), an internal mesenteric vein injury, and one recurrence (6.7%) occurred 18 months after surgery in the direct defect closure group.

Conclusion

The current data lead to the conclusion that laparoscopic paraduodenal hernia repair is a safe and feasible approach for selected patients. It can be expected that as surgeons become increasingly comfortable and facile with laparoscopic techniques, paraduodenal hernias and many other causes of acute small bowel obstruction will be increasingly managed laparoscopically.     

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.     

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.     

Paraduodenal hernia complicated with intussusception: case report

Background

The diagnosis of paraduodenal hernia is still a challenge in clinical practice due to lacking of specific symptoms. Case presentation: An 83-yr-old male patient presented to our department due to severe abdominal pain for 8?h. Abdominal contrast enhanced computerized tomography (CT) scan indicated intussusception in the duodenum and the upper segment of jejunum, as well as internal hernia. He complaint of progression in the abdominal pain, and then laparoscope was carried out, which indicated left-sided paraduodenal hernia. Subsequently, the patient was transferred to celiotomy, during which slight ischemic changes were noticed in the intestinal canal. Meanwhile, a hernial orifice was noticed in the left orifice of the duodenum. Conclusions: In this case, we presented our experiences on the diagnosis of paraduodenal hernia and intussusception. Our study contributed to the understanding, early diagnosis and selection of surgical options for the surgeons.

     

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 hernia: a report of two cases

Paraduodenal hernias are uncommon congenital herniations into the mesentery of the colon that present as small bowel obstruction. The diagnosis is elusive but may be made by CT scan or upper gastrointestinal series. There are three types: left, right, and transverse. The repair involves reduction of the hernia and closure of the mesenteric defect in accordance with the anatomy of the hernia. We present two cases of paraduodenal hernia that are representative of this unusual class of internal herniation.     

Characteristics of internal hernia after gastrectomy with Roux-en-Y reconstruction for gastric cancer

Background

Although the internal hernias have been a huge topic in the field of bariatric surgery, there were a few reports in gastric cancer. The purpose of this study was to analyze the incidence, clinical features, and prevention of internal hernia after gastrectomy for gastric cancer.

Methods

Twelve patients who underwent surgical treatment for internal hernia in our hospital after gastrectomy were analyzed. Features, including incidence, symptoms, and signs, were investigated in detail.

Results

The operative procedures for preceding gastrectomies were open distal gastrectomy in three patients, open total gastrectomy in three patients, laparoscopic-assisted distal gastrectomy in two patients, and laparoscopic total gastrectomy in four patients. The most frequent sites of internal hernias were jejunojejunostomy mesenteric defects (five patients) and Petersen’s defect (five patients), mesenterium of transverse colon (one patient), and esophagus hiatus (one patient). There was no significant difference between open and laparoscopic preceding gastrectomies. After closure of the mesenteric defect was introduced, no further internal hernias occurred. On CT examination, the whirl sign was present in ten patients on 3D images.

Conclusions

The present data suggest the importance of early recognition and treatment of internal hernia, as well as its prevention by closure of mesenteric defects.     

Transabdominal Preperitoneal Repair for Obturator Hernia

Background

A laparoscopic surgical approach for obturator hernia (OH) repair is uncommon. The aim of the present study was to assess the effectiveness of laparoscopic transabdominal preperitoneal (TAPP) repair for OH.

Methods

From 2001 to May 2010, 659 patients with inguinal hernia underwent TAPP repair at in our institutes. Among these, the eight patients with OH were the subjects of this study.

Results

Three of the eight patients were diagnosed as having occult OH, and the other five were diagnosed preoperatively, by ultrasonography and/or computed tomography, as having strangulated OH. Bilateral OH was found in five patients (63%), and combined groin hernias, either unilaterally or bilaterally, were observed in seven patients (88%), all of whom had femoral hernia. Of the five patients with bowel obstruction at presentation, four were determined not to require resection after assessment of the intestinal viability by laparoscopy. There was one case of conversion to a two-stage hernia repair performed to avoid mesh contamination: addition of mini-laparotomy, followed by extraction of the gangrenous intestine for resection and anastomosis with simple peritoneal closure of the hernia defect in the first stage, and a Kugel hernia repair in the second stage. There was no incidence of postoperative morbidity, mortality, or recurrence.

Conclusions

Because TAPP allows assessment of not only the entire groin area bilaterally but also simultaneous assessment of the viability of the incarcerated intestine with a minimum abdominal wall defect, we believe that it is an adequate approach to the treatment of both occult and acutely incarcerated OH. Two-stage hernia repair is technically feasible in patients requiring resection of the incarcerated intestine.     

Repair of recurrent ventral hernias using tissue expansion and porcine acellular dermal matrix

Background

Recurrent ventral hernias are often large and associated with loss of abdominal domain, hindering primary closure. One established intervention for patients with large ventral hernias is the component separation procedure that advances muscle from the lateral abdomen. This technique allows closure without creating tension; however, the relaxing incisions weaken the lateral abdominal wall by altering its natural architecture. We propose an approach to primary midline closure that does not compromise lateral abdominal wall stability and restores the architecture of the abdominal wall while allowing tension-free midline closure.

Methods

In three patients with recurrent ventral hernias who had failed two or more repair attempts, we used a two-stage reconstruction. Bilateral rectangular tissue expanders placed between the external and internal oblique muscles via subcostal incisions were expanded for 6–8 weeks. Second-stage surgery consisted of expander removal and primary closure of the abdominal defect reinforced by an underlay and overlay of noncross-linked intact porcine-derived acellular dermal matrix (PADM; Strattice? Reconstructive Tissue Matrix, LifeCell, Branchburg, NJ, USA).

Results

Primary closure of ventral hernias measuring 8?×?8, 12?×?8, and 8?×?6 cm was achieved with no need for component separation. At follow-up ranging from 10 to 17 months, all patients had structurally intact abdomens with no hernia recurrence and no abdominal wall weakness. All patients have resumed normal daily activities, including returning to work.

Conclusions

Expansion of the external and internal oblique muscles combined with an underlay and overlay of noncross-linked intact PADM allows strong and reliable primary closure of recurrent ventral hernias without the need for component separation. Level of evidence: Level V, therapeutic study     

Paramesocolic hernias: consequences of delayed diagnosis. Report of three new cases

Background

If internal hernias account for less than 1% of the causes of intestinal obstruction, the paraduodenal or paramesocolic hernias (PMH) represent 50% of the 500 published as of the year 2000. Despite their congenital character, they are diagnosed more frequently in adulthood, with a mean age of 38 years at diagnosis. In the last few years, diagnoses are being made earlier. With the goal of increased early diagnosis and decreased mortality associated with these internal hernias, the authors report on 3 young patients with PMH.

Methods

Three cases of paramesocolic hernias are reported, 2 right (RPMH) and 1 left (LPMH). They all had a history of symptoms of recurrent abdominal pain of variable frequency and intensity but of sufficient importance to justify previous diagnostic studies. The 2 patients with RPMH, a 3-year-old boy and a 17-year-old woman, presented symptoms of intestinal obstruction and had necrosis of the small intestine leading to short-bowel syndrome. The LPMH patient, a 13-year-old boy, suffered recurrent abdominal pain from the age of 3. Gastroesophageal reflux was diagnosed, and surgery was performed at the age of 4 years. A laparoscopy at 13 years of age found no pathology. A new upper gastrointestinal tract series found retroperitoneal and paraduodenal jejunum incarceration, partially obstructing the duodenum. During surgery, the adhered jejunal section was restored intraperitoneally, and the open Treitz arch was closed. The authors have not found the anatomic characteristics of this case in the literature.

Conclusions

Delays and errors in PMH diagnosis may result in irreparable damage. Differential diagnosis workups of patients with recurrent abdominal pain syndrome should always include PMH.     

Laparoscopic repair of iatrogenic diaphragmatic hernias after sternectomy and pedicled omentoplasty

Purpose

During sternectomy and pedicled omental flap transposition for the treatment of deep sternal wound infections, an ectopic diaphragmatic aperture is created. This may be the site of an iatrogenic diaphragmatic hernia, which may result in the herniation of intra-abdominal organs, and is difficult to repair. Although this complication was described as early as 1991, no effective treatment for this condition has been described previously.

Methods

The defect in poststernectomy diaphragmatic hernias has features similar to other incisional abdominal wall hernias, as well as to parastomal hernias and hiatal diaphragmatic hernias. We describe our laparoscopic approach developed from experience with these other types of hernias. We use an intraperitoneal flat mesh without keyhole. Fixation of the mesh to the anterior abdominal wall and to the diaphragm is done with a combination of sutures and spiral tackers. The omental pedicle is lateralised, fixed to the diaphragm and covered with the mesh. Special caution is needed when spiral tackers are applied to the diaphragm, because fatal complications of pericardial and cardiac injury have been described in laparoscopic hiatal diaphragmatic hernia repair.

Results

We used this technique in four patients who presented with a symptomatic poststernectomy diaphragmatic hernia. No procedure-related intra-operative or postoperative complications occurred. With a follow up of at least 12 months, no clinical or radiographic recurrence of diaphragmatic herniation has been encountered.

Conclusion

We describe a laparoscopic technique to repair this difficult diaphragmatic hernia used in four patients, with a good clinical and computed tomographic outcome at 12 months.     

A rare case of acute abdomen due to strangulated Waldayer's hernia

INTRODUCTIONAn internal hernia is the herniation of an intestinal segment into an intra-peritoneal fossa, is an uncommon cause for intestinal obstruction and is difficult to diagnose preoperatively.PRESENTATION OF CASEWe report a male patient 19 years old presenting with acute abdomen due to a strangulated Waldayer's hernia.DISCUSSIONThe paraduodenal hernias are more common in males (M:F ratio 3:1). The average age at diagnosis is 38.5 years clinically presenting with chronic intermittent post-parandial abdominal pain. An accurate incidence of paraduodenal hernias in infancy and childhood is unknown, but is quite rare.CONCLUSIONInternal complicated hernias are difficult to diagnose and once discovered intra-operative anatomical variations are present with special attribution to the management of the hernia sac.     

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 hernias through the falciform ligament: a case series and comprehensive literature review of an increasingly common pathology

Purpose

Internal hernias remain difficult to diagnose, despite advances in preoperative imaging. The anatomy of internal hernias varies widely, but herniation through the falciform ligament remains a rare entity. Sparse case reports are present, and no review has adequately synthesized all available information within the literature. Two patients presented to our institution with internal hernias through the falciform ligament over the span of 3 months.

Methods

A PubMed search was performed for any article containing both the terms “falciform” and “hernia.” These articles and their references were examined, identifying 35 cases in the world literature, in addition to the two at our institution. Reports were examined for demographics, mode of diagnosis, hernia etiology, hernia contents, need for resection, and survival.

Results

Five cases of falciform hernia were correctly diagnosed by preoperative imaging. Bowel resection was necessary in 43 % of patients, and mortality was 12 %. Incidence of falciform hernias is increasing.

Conclusion

This pathology is a rare, though increasingly frequent, phenomenon that must be considered in the differential diagnosis when a bowel obstruction without other identifiable cause is encountered, particularly in a patient with history of previous laparoscopy. However, preoperative studies have a poor sensitivity for accurately diagnosing a hernia through the falciform ligament. Failure to consider this etiology may result in delayed operative intervention and increased morbidity and mortality.     

Spigelian hernia in the right upper abdominal wall: a case report

Background

Spigelian hernia (SH) is rare and constitutes less than 2% of all hernias. It is reported that more than 90% of SHs lie in the “Spigelian belt”, but SH in the upper abdominal wall is extremely uncommon. Here, we report a case of SH in the right upper quadrant of abdomen.

Case presentation

A 38-year-old female was admitted to hospital with complaints of abdominal pain and right upper quadrant mass for 10?days. Contrast-enhanced computed tomography (CECT) of abdomen revealed the dilated small intestine between the swelling ventral muscles in the right upper abdominal wall which suggested a ventral hernia. The surgeons considered it was a spontaneous hernia because there was no history of surgery or trauma in the upper abdomen. About two hours later, the patient underwent emergency surgery. According to laparotomy, a diagnosis of SH with ileum herniation in the right upper abdominal wall was confirmed. The necrotic ileum segment was resected. Meanwhile the abdominal wall defect was repaired by suturing the internal oblique and transverse muscles to the rectus sheath. The patient had a favorable outcome for 1?year without recurrence.

Conclusion

A mass and pain in the upper abdominal wall may suggest an atypical SH. SH occurring in the upper abdominal wall is a rare condition with possibility of dire outcome if not managed early.

     

Emergency Repair of Giant Inguinoscrotal Hernia in a Septic Patient

Introduction

Giant inguinoscrotal hernias are rare but still exist even in developed countries. Although accompanied by a higher perioperative mortality, an elective surgical approach should be undertaken. In critically ill patients, however, the surgical intervention requires specific demands.

Methods

We report a case of a 45-year-old man who was referred to the hospital after perforation of the hernia with concomitant peritonitis and sepsis.

Results

After initial stabilization of the patient, a subtotal colectomy and a partial small bowl resection was performed. In a second step after stabilization of organ functions, the hernia sac was resected, and the abdominal cavity was reconstructed. The patient was discharged and is doing well until today but still refuses any plastic surgery.

Conclusion

Resection of giant inguinoscrotal hernia is feasible even in patients being administered in an emergency setting. Especially in case of an intra-abdominal infection, intestinal resection is the therapy of choice to allow the reconstruction of the abdominal cavity. A two-step approach should be considered to allow a successful recovery.     

Direct and Recurrent Inguinal Hernias Are Associated with Ventral Hernia Repair: A Database Study

Background

A systemically altered connective tissue metabolism has been demonstrated in patients with abdominal wall hernias. The most pronounced connective tissue changes are found in patients with direct or recurrent inguinal hernias as opposed to patients with indirect inguinal hernias. The aim of the present study was to assess whether direct or recurrent inguinal hernias are associated with an elevated rate of ventral hernia surgery.

Methods

In the nationwide Danish Hernia Database, a cohort of 92,457 patients operated on for inguinal hernias was recorded from January 1998 until June 2010. Eight-hundred forty-three (0.91 %) of these patients underwent a ventral hernia operation between January 2007 and June 2010. A multivariate logistic regression analysis was applied to assess an association between inguinal and ventral hernia repair.

Results

Direct (Odds Ratio [OR] = 1.28 [95 % CI, 1.08–1.51]) and recurrent (OR = 1.76, [95 % CI, 1.39–2.23]) inguinal hernias were significantly associated with ventral hernia repair after adjustment for age, gender, and surgical approach (open or laparoscopic).

Conclusions

Patients with direct and recurrent inguinal herniation are more prone to ventral hernia repair than patients with indirect inguinal herniation. This is the first study to show that herniogenesis is associated with type of inguinal hernia.     

The inheritance of groin hernia: a systematic review

Background

Groin hernia has been proposed to be hereditary; however, a clear hereditary pattern has not been established yet. The purpose of this review was to analyze studies evaluating family history and inheritance patterns and to investigate the possible heredity of groin hernias.

Methods

A literature search in the MEDLINE and Embase databases was performed with the following search terms: genetics, heredity, multifactorial inheritance, inheritance patterns, sibling relations, family relations, and abdominal hernia. Only English human clinical or register-based studies describing the inheritance of groin hernias, family history of groin hernias, or familial accumulation of groin hernias were included.

Results

Eleven studies evaluating 37,166 persons were included. The overall findings were that a family history of inguinal hernia was a significant risk factor for the development of a primary hernia. A family history of inguinal hernia showed a tendency toward increased hernia recurrence rate and significantly earlier recurrence. The included studies did not agree on the possible inheritance patterns differing between polygenic inheritance, autosomal dominant inheritance, and multifactorial inheritance. Furthermore, the studies did not agree on the degree of penetrance.

Conclusion

The literature on the inheritance of groin hernias indicates that groin hernia is most likely an inherited disease; however, neither the extent of familial accumulation nor a clear inheritance pattern has yet been found. In order to establish whether groin hernias are accumulated in certain families and to what extent, large register studies based on hernia repair data or clinical examinations are needed. Groin hernia repair (inguinal and femoral hernia) is among the most commonly performed gastrointestinal surgical procedures [1]. Emergency groin hernia surgery is associated with increased mortality, increased patient-related morbidity, and increased hospital stay compared with elective groin hernia procedures [2, 3]. Identifying patients at high risk of developing groin hernia would therefore provide the possibility of timely elective surgical intervention, thus reducing the rate of emergency procedures. It could also potentially make way for individualized surgical methods in the future.     

Retromuscular Preperitoneal Repair of Flank Hernias

Introduction

Flank hernias represent a challenging problem to reconstructive surgeons. Their anatomic proximity to the bony prominence and major neurovascular structures limits fixation options and restricts mesh overlap. We present our technique and outcomes of a preperitoneal repair with wide mesh overlap.

Methods

This study is a retrospective analysis of patients undergoing open flank hernia repair with a retromuscular preperitoneal approach.

Results

Between September 2007 and April 2011, 16 patients, mean age 55?years (range 34?C80) and BMI 33?kg/m² (range 26?C46), underwent open flank hernia repair. Eight were recurrent hernias; six previously had mesh placed; nine were incarcerated. Mean hernia defect size was 232?cm² (range 25?C800). Mean operative time was 178?min (range 105?C245). One intraoperative complication, ureteral injury in a transplant recipient, occurred and was primarily repaired without sequela. Two patients developed wound complications, one requiring superficial debridement and another requiring partial excision (<5?%) of the mesh with secondary healing. With a mean follow-up of 16.8?months (range 2?C49), no recurrent hernias were noted.

Conclusion

Open retromuscular preperitoneal repair of flank hernias with iliac bone fixation is technically feasible, allowing wide mesh overlap for a durable repair. This approach may offer advantages of treating abdominal wall laxity and repair of larger defects when compared to laparoscopic approaches.