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.     

Volvulus of the small intestine caused by right paraduodenal hernia: a case report

This report describes a very rare case of right paraduodenal hernia presenting as volvulus of nonherniated small intestine. A 12-year-old boy presented with sudden onset of lower abdominal pain, and emergency laparotomy was performed on a diagnosis of small intestinal obstruction. Laparotomy confirmed right paraduodenal hernia and volvulus of the small intestine out of the hernia sac.     

Recurrent intestinal volvulus in midgut malrotation causing acute bowel obstruction: A case report

Intestinal malrotation occurs when there is a disruption in the normal embryological development of the bowel. The majority of patients present with clinical features in childhood, though rarely a first presentation can take place in adulthood. Recurrent bowel obstruction in patients with previous abdominal operation for midgut malrotation is mostly due to adhesions but very few reported cases have been due to recurrent volvulus. We present the case of a 22-year-old gentleman who had laparotomy in childhood for small bowel volvulus and then presented with acute bowel obstruction. Preoperative computerised tomography scan showed small bowel obstruction and features in keeping with midgut malrotation. Emergency laparotomy findings confirmed midgut malrotation with absent appendix, abnormal location of caecum, ascending colon and small bowel. In addition, there were small bowel volvulus and a segment of terminal ileal stricture. Limited right hemicolectomy was performed with excellent postoperative recovery. This case is presented to illustrate a rare occurrence and raise an awareness of the possibility of dreadful recurrent volvulus even several years following an initial Ladd’s procedure for midgut malrotation. Therefore, one will need to exercise a high index of suspicion and this becomes very crucial in order to ensure prompt surgical intervention and thereby preventing an attendant bowel ischaemia with its associated high fatality.     

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.     

An unusual cause of small bowel obstruction caused by a Richter's-type hernia into the urinary bladder

INTRODUCTION

The authors present an unusual case of small bowel obstruction in a 62-year-old man.

PRESENTATION OF CASE

A 62-year-old man with a background of transitional cell carcinoma (TCC) of the bladder presented to the emergency department with abdominal pain, distension, vomiting and had not opened his bowels for three days. 3 weeks previously he had a repeat Transurtheral resection of bladder tumour (TURBT), during which there was an iatrogenic perforation of the bladder. A CT scan of the abdomen and pelvis revealed small bowel obstruction but did not identify a cause. At laparotomy the cause of the obstruction was identified as a section of the small bowel that had partially herniated into the bladder, via the perforation. The defect was repaired and the patient made an uneventful recovery.

DISCUSSION

Herniation of the bowel into a defect in the bladder wall is a rare event with only 6 previous cases reported in the literature. It can cause signs and symptoms of bowel obstruction.

CONCLUSION

In patients with known bladder perforations who present with symptoms and signs of bowel obstruction, bowel herniation into the bladder should be considered. Early surgical intervention may be necessary if the patient is clinically unwell with appropriate symptoms and signs and imaging does not provide conclusive answer.     

A massive hiatal hernia that mimics a congenital diaphragmatic hernia. An unusual presentation of hiatal hernia in childhood: report of a case

A massive hiatal hernia containing the colon, intestine, and stomach with organoaxial volvulus is an uncommon entity in childhood. This clinical form of a hiatal hernia may mimic congenital diaphragmatic hernia and chest pathologies. In this paper, we describe a patient who presented with a massive hiatal hernia that mimicked a congenital diaphragmatic hernia, and discuss the pitfalls in diagnosing this clinical entity.     

Retrocecal hernia preoperatively diagnosed by computed tomography: A case report

IntroductionRetrocecal hernia is a rare type of pericecal hernia. Because it is difficult to diagnose preoperatively, it is often treated with emergency operation.Case presentationAn 83-year-old male patient experienced sudden abdominal pain. Marked small bowel dilatation and intestinal obstruction were detected by abdominal computed tomography (CT). An enhanced CT scan also revealed a trapped cluster of small bowel loops behind the cecum and ascending colon. We preoperatively diagnosed small bowel ileus as a result of retrocecal hernia. After conservative therapy with a long intestinal tube, an emergency operation was performed. During the surgery, a portion of the ileum was found to be incarcerated in the retrocecal fossa. Intestinal resection was not necessary because the incarcerated ileum appeared viable, and the orifice to the hernia was opened. The patient was discharged without postoperative complications.DiscussionThe diagnosis of retrocecal hernia can often be confirmed intraoperatively. This disease is identified based on a minimal error in rotation with incarceration behind the cecum during the final phase of descent and fixation of the right colon or failure of cecal and retroperitoneal fixation. Early preoperative diagnosis is important to prevent intestinal ischemia, necrosis, and perforation and to reduce resection rates.ConclusionEarly preoperative diagnosis is important to avoid resection of the small intestine. CT scans are useful for preoperative diagnosis in case of retrocecal hernia.     

Transmesosigmoid hernia: report of a case

Sigmoid mesocolon hernia is an uncommon type of internal hernia. A 63-year-old man who presented with pain in the left side of the abdomen and nausea was referred to our department for treatment of ileus. He was initially managed conservatively, but as his symptoms became progressively worse, a laparoscopy was done, which revealed hemorrhagic ascites and necrosis of the small intestine in the lower abdomen. An open laparotomy was subsequently performed and the intraoperative findings were consistent with a transmesosigmoid hernia. There was an abnormal defect in the sigmoid mesocolon and protrusion of about 30 cm of small bowel through this abnormal opening, which had resulted in strangulation of the bowel. The necrosed part of the intestine was resected and the defect was closed. Received: November 9, 2001 / Accepted: May 7, 2002 Reprint requests to: T. Sasaki     

Intestinal obstruction caused by a foramen of Winslow hernia

Hernias occurring through the foramen of Winslow are extremely rare (accounting for only 8% of all internal hernias and 0.08% of all hernias) and are seldom diagnosed preoperatively. A delay in treatment is responsible for high mortality rates of around 36% to 49%. Successful management requires prompt diagnosis and surgical treatment.     

Left paraduodenal hernia causing small bowel obstruction in an adolescent patient

Internal hernias are an uncommon cause of bowel obstruction, accounting for less than 1% of cases. Paraduodenal hernias, the most common type of internal hernias, are believed to be congenital in origin. They can be asymptomatic, cause chronic abdominal pain, or present with acute intestinal obstruction with strangulation and ischemia. We describe a case of left paraduodenal hernia found in a patient who presented with acute intestinal obstruction.     

Strangulated transmesosigmoid hernia as a late complication of a fall from a height: A case report

IntroductionA transmesosigmoid hernia is defined as small bowel herniation through a complete defect involving both layers of the sigmoid mesentery. Blunt trauma injury to the sigmoid mesocolon has been reported only rarely. We herein report a case of a strangulated transmesosigmoid hernia associated with a history of a fall from a height.Presentation of caseA 43-year-old woman presented to our hospital for evaluation of vomiting. She had no history of abdominal surgery but had sustained a complete spinal cord injury and pelvic fracture secondary to a fall from a height 25 years earlier. A computed tomography scan of her abdomen and pelvis demonstrated a closed loop of small bowel in the pelvis, with a zone of transition in the left lower abdomen. Although the cause of the obstruction was difficult to establish, ischemia was strongly suspected; therefore, the decision was made to perform emergency exploratory laparoscopy. During laparoscopy, a loop of ileum was observed to have herniated through a full-thickness defect in the sigmoid mesocolon, consistent with a transmesosigmoid hernia. The herniated loop was strangulated but not gangrenous and was successfully reduced using laparoscopic graspers. The incarcerated small bowel appeared viable and was therefore not resected. The defect was closed with a running suture. The patient had an uneventful postoperative course with no recurrence.Discussion and conclusionAbdominal blunt trauma can cause sigmoid mesenteric rupture resulting in a transmesosigmoid hernia. In the management of transmesosigmoid hernias, laparoscopic herniorrhaphy has the advantage of facilitating simultaneous diagnosis and surgical intervention.     

Delayed presentation of congenital diaphragmatic hernia manifesting as combined-type acute gastric volvulus: a case report and review of the literature

Acute gastric volvulus associated with congenital diaphragmatic hernia is an unusual surgical emergency. We describe a case of an 11-year-old girl who presented with a 4-day history of abdominal pain, nonproductive retching, cough, and shortness of breath. A chest radiograph revealed a large air-fluid level in left hemithorax and the presence of intestinal loops with marked mediastinal deviation. Nasogastric decompression was unsuccessful. Via a thoracoscopic approach, the large fluid-filled stomach was percutaneously decompressed but could not be reduced. Through a left subcostal incision, a left-sided diaphragmatic defect about 4 × 5 cm was encountered. A large portion of small intestines, ascending and transverse colon, strangulated but viable stomach, and a large spleen herniated through the defect. The contents were reduced, revealing a combined gastric volvulus. Once the diaphragmatic defect was repaired primarily, there was insufficient space in the abdominal cavity to contain all the viscera reduced form the chest. Therefore, we placed an AlloDerm patch on the fascia and closed with a wound V.A.C (Kinetic Concepts Inc, San Antonio, TX). Two weeks later, the wound was definitively closed; she recovered uneventfully and was discharged home 3 days later. To our knowledge, only 26 previous cases of acute gastric volvulus complicating a congenital diaphragmatic hernia in children have been reported in the literature. Our patient represents the 27th case and the first combined type acute gastric volvulus case.     

Late-onset congenital diaphragmatic hernia: A case report

INTRODUCTIONA Bochdalek hernia is a posterior congenital defect of the diaphragm, usually on the left hemidiafragm, caused by a lack of closure of the pleuroperitoneal canal between the eighth and tenth week of fetal life during the embryonic development. It typically presents in the neonatal period with severe respiratory failure.PRESENTATION OF CASEIn this paper we present a 35 year old man with a 5-year history of episodes of severe dyspnea who arrived to the emergency room, during his medical work-up we incidentally found an intrathoracic gastric bubble, a laparoscopy was performed, founding a necrotic stomach and for defect correction.DISCUSSIONThis pathology is infrequent in adults, among this age group, there are two different clinical presentations: asymptomatic patients who are diagnosed incidentally when abdominal organs are found in the thorax in a chest X-ray, and symptomatic patients due to side effects of incarceration, strangulation, hemorrhage and visceral perforation in the chest cavity.CONCLUSIONDiaphragmatic hernias are rare among adult population, and they are usually asymptomatic, in this case we presented a symptomatic patient, diagnosed with a chest X-ray and treated surgically. The surgical approach for the resolution of this pathology is variable and it depends on the presence and severity of visceral complications.     

A rare presentation of midgut malrotation as an acute intestinal obstruction in an adult: Two case reports and literature review

INTRODUCTIONMidgut malrotation is a congenital anomaly presenting mainly in the childhood. Its presentation as an acute intestinal obstruction is extremely rare in adults usually recognized intra-operatively, therefore a high index of suspicion is always required when dealing with any case of acute intestinal obstruction.PRESENTATION OF CASEWe report two cases of young adults who presented with symptoms of acute intestinal obstruction and were diagnosed intra-operatively as cecal volvulus and paraduodenal hernia, respectively, caused by midgut malrotation. Post-operative CT scan confirmed these findings.DISCUSSIONMalrotation of the intestinal tract is a product of an aberrant embryology. The presentation of intestinal malrotation in adults is rare (0.2–0.5%). Contrast enhanced CT can show the abnormal anatomic location of a right sided small bowel, a left-sided colon and an abnormal relationship of the superior mesenteric vein (SMV) situated to the left of the superior mesenteric artery (SMA) instead of to the right.CONCLUSIONAnomalies like midgut malrotation can present as an operative surprise and awareness regarding these anomalies can help surgeons deal with these conditions.     

Internal hernia with triple hiatus of congenital origin: Report of a case

We report herein the case of a 65-year-old woman who was referred to our department with prolonged ileus symptoms despite conservative therapy. A plain abdominal radiograph showed intestinal gas shadows with an air-fluid level in the lesser curvature of the stomach. As no improvement was achieved by the insertion of a short tube, a long tube was inserted. A loop formation of the long tube in the subphrenic region was detected on an abdominal radiograph, and an enterogram showed an interruption in the ileum in the lower abdomen. The patient was diagnosed as having an adhesional ileus and a strangulated ileus due to a lesser sac hernia. A laparotomy was performed which revealed that the small intestine had herniated into the lesser sac space through a hiatus of Treitz' fossa and a hiatus in the transverse mesocolon. Furthermore, part of the small intestine had herniated through an omental hiatus. The herniated intestine was manually reduced and the hiatus was closed. However, as the right ovary was found to have adhered to the ileum and stenosis was seen, we were forced to perform partial resection of the ileum. Considering that this patient had no history of laparotomy in the upper abdomen, abdominal injury, or acute abdomen, it was surmised that the three abnormal hiatuses were congenital. Received: June 25, 1999 / Accepted: May 30, 2000     

腹内疝致肠梗阻42例临床分析

目的 探讨腹内疝导致肠梗阻的临床特点、诊断及治疗方法.方法 对42例经手术证实为腹内疝导致肠梗阻的临床资料进行回顾性分析.结果 42例均行手术治疗,确诊为原发性(先天性)腹内疝8例,继发性(后天性)腹内疝34例;术后死亡2例,痊愈出院40例.结论 腹内疝导致肠梗阻术前早期病因诊断困难,以肠梗阻为主要临床症状,病情进展快,非手术治疗效果不明显,大多需要手术治疗.