Littre's hernia, an incarcerated ventral incisional hernia containing a strangulated meckel diverticulum: report of a case

Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract. Any hernia containing Meckel’s diverticulum is classified as a Littre hernia. Littre hernias typically occur in the inguinal region, and they may cause bowel obstruction secondary to strangulation or incarceration of the diverticulum within the hernial sac. This case appears to be the second reported of an incarcerated incisional hernia due to Littre’s hernia.     

Laparoscopic repair of a Littre’s hernia with porcine dermal collagen implant (Permacol)

Background Littre’s hernia was originally defined as “the presence of a Meckel’s diverticulum in any hernia sac” by Rieke in 1841. It is a rare finding at any age, and its true incidence is unknown. The conventional treatment for Littre’s hernia is wedge resection of the diverticulum and repair of the hernia from within the sac. However, the advent of laparoscopic surgery has altered the management of all abdominal hernias, including Littre’s hernia. Case report We present a case of a 55-year-old woman who presented as an emergency with right iliac fossa pain and tenderness. A CT scan demonstrated a 46 × 25 × 25 mm lesion related to the distal ileum extending towards the inguinal canal. At laparoscopy she was found to have a Meckel’s diverticulum herniating through the deep inguinal ring into the right inguinal canal. We report the laparoscopic excision of the Meckel’s diverticulum using an endoscopic stapling device and repair of this hernia with Permacol, an acellular porcine collagen mesh. The patient made a quick recovery and was discharged 5 days post-operatively. A complication of an umbilical port site infection was treated 2 weeks post-operatively with oral antibiotics. To date there has been no recurrence of the hernia and no right inguinal pain. Laparoscopic repair of Littre’s hernia using Permacol has not been reported previously. Conclusions Laparoscopy is a safe, inexpensive and efficient method for the diagnosis and treatment of Littre’s hernia. Permacol is a strong yet supple material for hernia repair.     

Littré’s femoral hernia causing intestinal fistula

Abstruct Littré’s hernia is one of the rarest forms of hernia, characterized to contain the Meckel’s diverticulum as its sole content. The Meckel’s diverticulum in the hernial sac can be involved by those complications which occur in the diverticulum in the free abdominal cavity. A case of Littré’s femoral hernia in a 75 years old man with formation of an intestinal fistula as a result of inflammation of the Meckel’s diverticulum, probably, following mechanical trauma exerted by a phytogenic fibre, was reported, and the previous literatures were reviewed. Consequently, it was confirmed that signs and symptoms of Littré’s hernia with complications are less severe and non-characteristic compared to ordinary types, and hence its preoperative diagnosis is very difficult.     

Bilateral femoral hernia in a male cadaver with vascular variations: case report and review of the literature

Femoral hernia, which is a less common occurrence than inguinal hernia, is not congenital in most cases and is uncommon in young males. It is considered to be more common in females than in males due to an enlarged femoral ring in the former. A case of bilateral femoral hernia in a 64-year-old male cadaver is described within the framework of an anatomical approach. On the right side, the protrusion of the viscus appeared as a small intestine coil, whereas on the left side the protruded viscus appeared as a pelvic colon’s appendix appiplocae. On both sides, the protruded viscus was located in front of an aberrant obturator artery, which oriented from the external iliac artery and not from the internal iliac artery as should be the case. The puberal branch of the inferior epigastric artery was absent. The cadaver’s medical history and his skin examination excluded an abdominal surgery. In the literature, case reports of bilateral femoral hernia appear only seldom, especially those of male patients who had not undergone inguinal hernia repair surgery. In femoral hernias more often than in other types of hernia, the protruded viscus is strangulated and undergoes a tissue necrosis. Morbidity and mortality for complicated femoral hernia is high. Knowledge of vascular variation such as presented by the cadaver under study is extremely useful to the surgeon because any iatrogenic injury of the aberrant obturator artery during a laparoscopic repair may result in dangerous hemorrhage.     

Littré meets de garengeot: meckel’s diverticulum and appendix in a femoral hernia

Littre’s and de Garengeot hernias are rare operative findings, the former describing the presence of a Meckel’s diverticulum in a hernia sac and the latter describing the presence of the vermiform appendix in a femoral hernia. The finding of both of these anatomical structures in the same hernia is exquisitely rare and infrequently described. In the following report such a case is described and the current knowledge surrounding these unusual hernias is discussed.     

Incarceration of Meckel’s diverticulum through a ventral incisional defect: a rare presentation of Littre’s hernia

Meckel’s diverticulum is the most common congenital abnormality of the gastrointestinal tract and is the result of the incomplete obliteration of the omphalomesenteric duct. Herniation of Meckel’s diverticulum is called Littre’s hernia and is a rare occurrence. Herein is described an extremely rare case of incarcerated and strangulated Meckel’s diverticulum through an incisional ventral defect in a 59-year-old female patient, who presented with manifestations of acute surgical abdomen. At emergency laparotomy, a strangulated small-bowel loop containing a Meckel’s diverticulum was found, which had migrated through the subcutaneous tissues to the right iliac fossa, where a painful mass was palpated on admission. Segmental resection of the ischemic ileum was performed and the abdomen was closed without the use of a prosthetic mesh. Histopathological findings were suggestive of a true diverticulum containing heterotopic gastric mucosa.     

Amyand’s hernia with adenocarcinoid tumor

The contents of an incarcerated inguinal hernia sac usually consist of small bowel or omentum. Amyand’s hernia, the situation in which appendicitis is noted in the hernia sac, is a rare occurrence. Also, neoplasms of the appendix is quite uncommon. The occurrence of these two conditions together is even more rarely reported. We report the case of a 62-year-old male with these two diseases simultaneously. Incarcerated inguinal hernia was noted before operation. Amyand’s hernia was noted during the operation. Adenocarcinoid tumor of the appendix was noted after the operation. Operative decisions were changed during the medical course.     

“Tension-free” herniorrhaphy for groin hernias in patients with cirrhosis: Report of four cases

Tension-free herniorraphies were carried out using either the Mesh Plug repair (M-P) or Perfix plug technique (P-P) in four patients with cirrhosis. Three patients had a lateral inguinal hernia, and the other had bilateral inguinal and femoral hernias. The patients’ ages ranged from 55 to 80 years. The Child-Pugh classifications showed that one was A, two were B, and one was C. The main complaint in two patients was a difficult reduction and the others had discomfort. An M-P was performed in the three patients with inguinal hernias and an M-P was performed for the femoral hernias and a P-P for the inguinal hernias in the patient with both inguinal and femoral hernias. Two patients had fluid collection under the incision and one of them required a single puncture. However, the others had no related complications after the operation. One patient died due to liver failure without recurrence of the groin hernias 31 months after the operation. The others had no recurrence and no related symptoms from 5 to 52 months after the operation.     

Uncommon content in groin hernia sac

Groin hernia may have very unusual sac content. Vermiform appendix, acute appendicitis, ovary, fallopian tube and urinary bladder have been rarely reported. We aimed to present our experience with these unusual hernia contents. Records of 1,950 groin hernia patients were retrospectively analyzed. Vermiform appendix was found in 0.51% and acute appendicitis was found in 0.10% of groin hernia sacs. The incidence of appendix in femoral hernia was 5%, while inguinal hernia sac contained ovary and fallopian tube in 2.9% of the cases. The incidence of groin hernias containing urinary bladder was 0.36%. We also had 1 patient with incarcerated bladder diverticula in an indirect hernia sac. Iatrogenic bladder injury occurred in 2 patients. Although rare, a groin hernia sac may contain vermiform appendix and exceptionally acute appendicitis. Tubal and ovarian herniation in inguinal hernias can be found in adult and perimenopausal women with an incidence as high as in children. Urinary bladder hernia occurs with a similar incidence of tuba-ovarian hernia, however, it requires special attention because of a high risk of iatrogenic bladder injury during the inguinal dissection. Every effort should be made to preserve the organ found in hernia sac for an uneventful postoperative period.     

Perforated appendix and periappendicular abscess within an inguinal hernia

We report an extremely rare case of complicated Amyand’s hernia. A 61-year-old male patient was admitted with clinical signs of incarcerated right inguinal hernia and localised tenderness in the right iliac fossa. He underwent emergency surgery and the operative findings included perforated appendix and periappendicular abscess within a right inguinal hernia sac. Appendectomy and Shouldice’s herniorrhaphy without prosthetic mesh placement were performed. Histology revealed the presence of a villous adenoma near the base of the appendix. We point out that although Amyand’s hernia is a very rare clinical entity, it should always be considered in the differential diagnosis in cases with clinical signs of incarcerated right inguinal hernia, especially when there are no pathological findings on the abdominal X-rays.     

Femoral hernia with strangulated Meckel's diverticulum (Littre's hernia): Case report and review of the literature

An unusual complication of a Meckel's diverticulum, a strangulated Littre's femoral hernia, is presented. The incidence and complications of Meckel's diverticulum are discussed. It is emphasized that most complications occur before age 30. Thus in an adult an incidentally discovered Meckel's diverticulum should not be resected.     

Diagnosis and operative management of a perforated de Garengeot hernia

IntroductionA de Garengeot hernia, a femoral hernia containing the appendix, is a difficult diagnosis often made intra-operatively when the hernia sac is opened. It is a rare finding, and complications are more frequent with a de Garengeot hernia.Presentation of caseA 92 year-old female presented to the emergency department (ED) complaining of abdominal pain. A computed tomographic (CT) scan of the abdomen and pelvis demonstrated a hernia anterior to the inguinal ligament without strangulation. Two weeks later the patient returned to the ED with worsening abdominal pain in the right lower quadrant. Repeat CT scan demonstrated a 7 × 4 cm complex fluid collection in the right inguinal region, and the patient was taken to the operating room for exploration. The hernia sac was entered and found to contain the appendix with evidence of distal perforation. The appendix was taken out, and the hernia defect was repaired. The patient tolerated the procedure well.DiscussionFemoral hernias have a high risk of incarceration due to the tightness of the femoral canal (Talini et al. 2015 [4]). Due to anatomic location of the appendix, de Garengeot hernias are most often seen on the right. Incarceration of the appendix is a clear etiology for appendicitis secondary to ischemia.ConclusionFull preoperative workup for a femoral hernia often fails to diagnose the presence of the appendix within the hernia. It is important to have a high clinical suspicion for a de Garengeot’s hernia in patients with incarcerated or strangulated right femoral hernias.     

Laparoscopic management of complicated Meckel’s diverticulum in children: a 10-year review

Background  Meckel’s diverticulum, the most common congenital anomaly of the gastrointestinal tract, is prone to develop complications in the pediatric population. The authors report their 10-year experience with the management of complicated Meckel’s diverticulum in children using laparoscopy. Methods  A retrospective review of all complicated Meckel’s diverticulum cases involving children from 1998 to 2007 was performed. The efficacy and safety of laparoscopy used to manage complicated Meckel’s diverticulum were assessed. Results  Over a 10-year period, 20 children (17 boys and 3 girls) with a mean age of 5 years (range, 7 months to 13 years) were included in the study. Of the 20 children, 12 presented with gastrointestinal bleeding, 2 had intestinal obstruction, 3 had abdominal pain mimicking acute appendicitis, 2 had inguinal hernia, and 1 had intussusception. Diagnostic laparoscopy was performed for all the patients. Laparoscopically assisted transumbilical Meckel’s diverticulectomy was performed successfully for 18 of the children. The operative time ranged from 50 to 190 min (mean, 115 min). All the children had an uneventful recovery except one, who experienced a postoperative wound infection. Ectopic gastric mucosa was found in 14 cases. Conclusions  Diverse pediatric surgical conditions result from Meckel’s diverticulum. Laparoscopy is a safe and effective method for the management of complicated Meckel’s diverticulum.     

Bilateral laparoscopic inguinal hernia repair in patients with occult contralateral inguinal defects

Background A high incidence of bilateral inguinal defects found on laparoscopic evaluation during hernia repair has been reported. However, expectation of bilateral inguinal defects in patients who are diagnosed with pure unilateral hernia might be underestimated. A prospective clinical study was performed to reveal a rate of contralateral occult defects in patients who were diagnosed with unilateral inguinal hernia prior to primary laparoscopic totally extraperitoneal (TEP) repair. Methods One hundred consecutive male patients with primary unilateral inguinal hernias were included in the study. Patients with known bilateral inguinal hernias as well as femoral, giant and combined hernias were excluded. All patients underwent TEP with exploration and evaluation of the contralateral groin. Results Median follow-up was 24 (4–46) months. Median age was 48 (18–73). Mean operative time was 42.2 (18–167) min. There were 78 (78%) patients with pure unilateral hernias and 22 (22%) patients with bilateral hernias whose contralateral inguinal defect or hernia was revealed only intraoperatively. Of those, 19 (86%) had right and 3 (14%) left occult defects. Minor complications occurred in 17 (17%) patients. There were no major complications. Two patients required a 23-hour stay in the hospital for urinary retention and hypoxia. Median period of returning to normal activity was 7 (5–14) days. There were two (2%) recurrences. Median period of returning to normal activity was 6.2 days after unilateral repair and 8.4 days after bilateral TEP. Conclusion This study revealed 22% occurrence of bilateral inguinal defects in the patients who are diagnosed with pure inguinal hernia before surgery, with higher incidence for those with left inguinal hernia. It appears that routine contralateral groin exploration and evaluation during TEP is valuable. Patients with occult bilateral hernias are benefit from bilateral TEP.     

Amyand’s hernia in premature neonates: report of two cases

The finding of a normal or inflamed vermiform appendix within an inguinal hernia is termed Amyand’s hernia. It is extremely rare in children, especially in infants and neonates. When it occurs, it is usually misdiagnosed as an irreducible or strangulated inguinal hernia, and the accurate diagnosis is made intraoperatively. We report two cases of Amyand’s hernia in premature neonates. Both patients presented on admission with signs and symptoms indicating a strangulated right inguinal hernia, and the accurate diagnosis was made intraoperatively. One of them had progressed to local peritonitis. Appendicectomy and hernia repair were made at the same time through an inguinal transverse incision, and the postoperative course was uneventful in both. We point out the need to consider acute appendicitis in the differential diagnosis of strangulated right inguinal hernia.     

Laparoscopic diagnosis and repair of pediatric femoral hernia

Femoral hernias are often misdiagnosed and treated as inguinal hernias. Thus, laparoscopic groin exploration may be a valuable means of evaluating children with presumed recurrent inguinal hernias. This study describes the feasibility of laparoscopic groin exploration and femoral hernia repair in children. Four children (aged 2, 2, 3, and 17 years) with reported unilateral recurrent inguinal hernias underwent diagnostic laparoscopy via a 4-mm pediatric laparoscope. Contralateral defects were visualized in all four patients; there were three femoral hernias and one direct inguinal hernia. None of the contralateral defects had been suspected clinically. Of the seven femoral defects, five were repaired laparoscopically. One patulous defect was repaired by reapproximating the iliopubic tract to Cooper's ligament and overlaying a preperitoneal Teflon felt(R) patch. The other four defects were repaired using a Teflon felt(R) plug and preperitoneal patch. A total of three ports were required in each patient (umbilical, suprapubic, and one in between). Two femoral defects in one patient required open repair because a large lipoma prevented adequate visualization and diagnosis. The direct inguinal hernia was also repaired using the open technique. Laparoscopic groin exploration and femoral hernia repair in pediatric patients is safe and technically feasible. Its advantages, however, such as superior diagnostic ability and simultaneous bilateral tension-free repair, need to be validated with a larger study and longer follow-up.     

Amyand’s hernia: a report of 18 consecutive patients over a 15-year period

Aim The presence of a vermiform appendix in an inguinal hernia sac is termed Amyand’s hernia. It may present as a tender inguinal or inguino-scrotal swelling and is often misdiagnosed as an incarcerated or strangulated hernia. The purpose of this study was to review the management of Amyand’s hernia at a single institution since 1991. Material and methods A retrospective analysis was undertaken of 18 consecutive patients with an Amyand’s hernia operated upon at our institution from 1991 to 2005. Patients’ demographics, treatment and postoperative outcome were analysed. Results There were 17 men and one woman. Their median age was 42 years. None of the patients was diagnosed preoperatively. The commonest presenting symptom was painful inguinal or inguino-scrotal swelling (83%). All patients, therefore, underwent emergency surgery with a presumptive diagnosis of either incarcerated or strangulated inguinal hernia. Operative findings included 11 normal appendices, four inflamed appendices and three perforated appendices in the inguinal hernial sac. Patients with a normal appendix (n = 11) had a mesh hernia repair without an appendicectomy. The rest of the patients (n = 7) with an abnormal appendix underwent emergency open appendicectomy followed by Bassini’s sutured hernia repair. One patient died in the postoperative period of pneumonia. Only one recurrent hernia has been detected, with a median follow-up time of 6.4 years. Conclusion The inflammatory status of the appendix determines the type of hernia repair and the surgical approach. Incidental appendicectomy in the case of a normal appendix is not favoured.     

Littre's hernia in infancy presenting as undescended testicle

Littre's hernia is defined as any hernial sac which contains a Meckel's diverticulum. It has been reported in association with inguinal, umbilical, femoral, sciatic, ventral, and lumbar hernias. This hernia is rare, particularly in children, in whom the umbilical variety is reported by some to be most common. Littre's hernia is difficult to diagnose, but should be suspected in patients with gastrointestinal bleeding, incompletely reducible hernias, and fecal hernial fistulas. It may be confused with cryptorchidism when Meckel's diverticulum adheres to and envelops the testicle making palpation of the gonad difficult. Recommended treatment is resection of the Meckel's diverticulum from within the opened hernial sac followed by herniorrhaphy.     

Adult right-sided Bochdalek hernia with ileo-cecal appendix: Almeida-Reis hernia

INTRODUCTIONBochdalek hernia is one of the most common congenital abnormalities manifested in infants. In the adult is a rarity, with a prevalence of 0.17–6% of all diaphragmatic hernias. Right-sided Bochdalek hernias containing colon are even more rare, with no case described in the literature with ileo-cecal appendix.PRESENTATION OF CASEThe authors present a case of a right-sided Bochdalek hernia in an adult female of 49 years old, presented with severe respiratory failure. During laparotomy for hernia correction, were found in an intrathoracic position the cecum and ileo-cecal appendix, the right colon and the transverse colon.DISCUSSIONAlthough useful in patient evaluation, clinical history and physical examination are not helpful in making diagnosis because of their nonspecific character. CT scan is the most accurate exam for making diagnosis. Most of the times there is no hernial sac. Surgery is the treatment of choice, and it is always indicated even if asymptomatic. In general suture of the defect is possible. Due to patient's weak respiratory function we chose laparotomy by Kocher incision.CONCLUSIONBeing the first case of a right-sided Bochdalek hernia in the adult with a herniated ileo-cecal appendix, we name it Almeida-Reis hernia.