Internal hernia through an iatrogenic defect in the falciform ligament: a case report

The incidence of internal hernia through a defect in the falciform ligament, mostly congenital, is very rare. In this era of minimally invasive laparoscopic surgeries, a few cases of internal hernia through an iatrogenic defect in the falciform ligament have also been reported. Here, we present a case of a 65-year-old patient who presented with acute small-bowel obstruction. The patient had undergone a laparoscopic fundoplication 4 years ago. On diagnostic laparoscopy, it was found that the cause of the intestinal obstruction was herniation of the small bowel through a window in the falciform ligament (which was probably created due to port insertion during the previous surgery of laparoscopic fundoplication). The obstruction was relieved by the division of the falciform ligament.     

Falciform ligament hernia after laparoscopic cholecystectomy: a rare case and review of the literature

The occurrence of an internal hernia through a congenital or iatrogenic defect in the falciform ligament is extremely rare. In the era of minimally invasive surgery, we present an unusual case of small bowel obstruction after laparoscopic cholecystectomy. An 85-year-old white male presented to the emergency room 2 weeks after an uneventful cholecystectomy and complaining of a colicky, nonradiating right upper quadrant abdominal pain. Hydroxyiminodiacetic acid (HIDA) scan and endoscopic retrograde cholangiopancreatography (ERCP) performed revealed an open ductal system. Abdominal computed tomography (CT) scan was suggestive of a high-grade small bowel obstruction. Exploratory laparotomy revealed a herniated loop of distal ileum, passing from right to left through a defect in the falciform ligament created by the subxyphoid trochar. The surgeon should consider dividing the inferior leaf of the free edge of the falciform ligament, including the round ligament, should an aperture be created during laparoscopic port placement.     

Internal herniation through the falciform ligament of the liver: a case report

Background: An internal abdominal hernia is defined as the protrusion of a viscus through a mesenteric or peritoneal aperture within the peritoneal cavity. A less common type of internal herniation is a small bowel herniation through a defect in the falciform ligament of the liver. This defect can be congenital or iatrogenic after penetration of the falciform ligament with a trocar during laparoscopic surgery.

Methods: We present a case report illustrating an internal herniation through an iatrogenic defect in the falciform ligament of the liver.

Results: A 78-year-old man comes to the emergency department with severe abdominal pain for several hours. Laparoscopic exploration shows a small bowel herniation through an iatrogenic defect of the falciform ligament after laparoscopic cholecystectomy. Reduction of the internal herniation is performed. Due to subsequently small bowel necrosis, a small bowel resection with primary anastomosis has to be performed too.

Conclusion: Small bowel herniation through an iatrogenic defect in the falciform ligament is very rare. However, it can lead to severe complications such as small bowel necrosis. To prevent internal herniation, we strongly suggest immediate repair or division of the falciform ligament when an iatrogenic defect is created during laparoscopic procedures.     

Laparoscopic repair of an iatrogenic intrapericardial diaphragmatic hernia using the falciform ligament flap

Iatrogenic intrapericardial diaphragmatic hernia after creation of a pericardial-peritoneal window is a very rare entity. We present the clinical case of an acute intestinal bowel obstruction due to herniation of small bowel into the pericardial sac. After laparoscopic reduction of the herniated small bowel, the diaphragmatic defect was successfully repaired using the hepatic falciform ligament.     

Internal hernia as a complication of laparoscopic nissen fundoplication

A rare case of strangulated small bowel through a defect in the falciform ligament is presented to emphasize the possibility of complication after the creation of a window in the falciform ligament during laparoscopic surgery.     

Internal Hernia as a Complication of Congenital Falciform Ligament Window

Commonly, small bowel obstruction (SBO) is caused by either postoperative adhesions or external hernias. Internal hernias are rare, accounting for less than 2% of all cases of intestinal obstruction. An internal hernia through the falciform ligament is extremely uncommon and is usually secondary to a congenital or iatrogenic defect caused by trocars insertion. In this article, we report a case of SBO in a virgin abdomen that appeared to be caused by a congenital defect in the falciform ligament. A search of the literature was done identifying all reported cases of internal hernias caused by falciform ligament defect in order to guide diagnosis and management as well as avoidance of hernias caused by iatrogenic defects.     

Congenital internal hernia through defect in the falciform ligament in adult: A case report and review of the literature

IntroductionThe incidence of occlusion syndrome caused by internal hernia is very rare, in particular when the defect is congenital discovered in adults with no previous abdominal surgery.Presentation of caseWe present a case of a 31 year-old female patient who presented with acute abdominal pain and mechanical obstruction. The patient had never undergone abdominal surgery.DiscussionOn diagnostic laparoscopy, it was found a herniation of a loop of small bowel through a hole in the falciform ligament. The obstruction was solved by the division of part of falciform ligament without intestinal resection.ConclusionInternal hernia is a very uncommon pathology, most often discovered in pediatric age because of congenital abnormalities, it must be included in the differential diagnosis in adults. Preoperative diagnosis is difficult. The diagnostic laparoscopic approach has shown to be the best.     

A case of internal hernia through a defect in the falciform ligament treated with laparoscopic surgery]

A 22-year-old male was admitted to our hospital with abrupt onset of upper abdominal pain. Abdominal US and CT revealed dilatation of the small intestine between the abdominal wall and a lateral segment of the liver. After a diagnosis of an internal hernia through a defect in the falciform ligament, emergency surgery was performed. Laparoscopic investigation showed incarceration of the small intestine in a defect of the falciform ligament. After releasing an incarceration, the hernia orifice was opened to prevent relapse. He was discharged on the 4th postoperative day. Internal hernia through a defect in the falciform ligament is extremely rare, with six reported cases including our own in Japan. Characteristic images of abdominal US and CT enable preoperative diagnosis of this condition. Surgery should be performed at an early stage after onset. In patients with no prior history of surgery, laparoscopic techniques may be useful.     

Internal herniation through a defect in the falciform ligament: a case report and review of the world literature

Summary Hernia through the falciform ligament accounts for 0.2% of internal hernias. A congenital etiology for these defects is probable. Contributing risk factors include visceral displacement into the upper abdomen and excessive visceral mobility. Patients present most commonly with symptoms of bowel obstruction. Chilaiditi Syndrome on abdominal roentgenograms and abdominal computed tomography may aid in diagnosis. Treatment consists of eliminating the hernia defect by suture ligation and division of the falciform and ligamentum teres as well as surgical management of secondary bowel ischemia if present. The existence of ‘parafalciform hernia’ and ‘bowel stringing falciform obstruction’ must also be recognized as possible etiologies for visceral obstruction or strangulation caused by the falciform ligament.     

Laparoscopic Management of Small Bowel Incarceration Caused by a Broad Ligament Defect: Report of a Case

We report the case of a 94-year-old woman who presented with signs of a small bowel obstruction many years after an appendectomy. Abdominal computed tomography (CT) scan showed discontinuity of the small bowel at a point next to the uterus. We made a provisional diagnosis of an internal hernia through a defect in the broad ligament and performed laparoscopic exploration, which revealed a viable ileal loop incarcerated through the broad ligament. Thus, CT scan may be useful for diagnosing this type of defect preoperatively, whereby open surgery can be avoided.     

An unusual cause of small bowel obstruction: herniation through a defect in the falciform ligament

Small bowel obstruction in children is most frequently seen secondary to postsurgical adhesions. In rare circumstances, obstruction may be the result of an internal hernia through or around the falciform ligament. We report the first case of a strangulated internal hernia around the falciform ligament in a young girl.     

Small bowel incarceration in a broad ligament defect

We report the case of a 33-year-old woman whose medical history included three normal pregnancies without previous abdominal or pelvic surgery. She presented with small bowel obstruction. An abdominal computed tomography (CT) scan study revealed air fluid levels in the pelvis. Laparoscopic exploration revealed a viable ileal loop incarcerated through the mesoligamentum teres. The intestinal loop was reduced and the broad ligament defect was closed with a laparoscopic absorbable clip. Among internal hernias, hernias through a defect in the broad ligament represent only 4-7%. Defects within the broad ligament can be either congenital (ruptured cystic structures reminiscent of the mesonephric or mullerian ducts) or secondary to operative trauma, pregnancy and birth trauma, or prior pelvic inflammatory disease. CT scan may be diagnostic by showing incarceration of a dilated intestinal loop in the Douglas pouch with air fluid levels. This is the first reputed case of a totally laparoscopic repair of a bowel incarceration through a broad ligament defect.     

Strangulated hernia through a defect in the broad ligament: a sheep in wolf’s clothing

Small bowel obstruction due to an internal hernia is an uncommon finding and, when caused by a defect in the broad ligament, it is exceptionally rare. This condition should be considered when evaluating all female patients presenting with de novo small bowel obstruction. We report an unusual case of intestinal obstruction from an internal hernia through the left broad ligament in a middle-aged patient with no prior surgical history and discuss the relevant literature and treatment. Although an oncologic diagnosis should be entertained, a small bowel obstruction arising in the pelvis may involve the broad ligament in parous patients. An internal hernia through the broad ligament should be considered in the differential diagnoses of female patients presenting with intestinal obstruction.     

Laparoscopic diagnosis and treatment of small bowel obstruction caused by postoperative intussusception

Small bowel obstruction is a common problem, especially for patients who have had previous abdominal surgery possibly complicated by postoperative adhesions. In contrast to adhesions, postoperative intussusception is an unusual cause of small bowel obstruction. We report a case of small bowel obstruction that occurred one month after antrectomy for duodenal ulcer with massive bleeding. Laparoscopic surgery was attempted after conservative treatment failed. A segment of jejunojejunal intussusception about 50 cm below the ligament of Treitz was identified and laparoscopic reduction of the intussusception was performed. The patient had an uneventful postoperative course and remained asymptomatic at 10-month follow-up. Although not frequently encountered, postoperative intussusception should be considered a possible etiology in patients with postoperative small bowel obstruction. In experienced hands, the laparoscopic approach offers a feasible option for correct diagnosis and appropriate treatment in this situation.     

Small bowel obstruction after laparoscopic donor nephrectomy

Background: Laparoscopic live donor nephrectomy has become the procedure of choice for kidney procurement at many centers worldwide. A decrease in postoperative pain and length of stay, a faster return to work, and no difference in morbidity and mortality compared to open nephrectomy have all been reported. However, few data exist regarding the complication of postoperative internal hernia and small bowel obstruction, which is unique to a laparoscopic/transperitoneal approach. Methods: We present three case reports of patients who developed small bowel obstruction from an internal hernia and mesenteric defect after laparoscopic donor nephrectomy. Results: A total of 635 patients underwent laparoscopic donor nephrectomy between March 1996 and August 2001 at our institution. Small bowel obstruction developed in three patients (0.47%) within 1 week postoperatively. Each case involved an internal hernia through a left colon mesenteric defect at the site of nephrectomy. Reoperation was necessary in each case and was associated with a prolonged hospital stay (mean, 22.3 days; range, 6–37). Two patients were managed with laparotomy; one patient underwent a laparoscopically assisted exploration. One patient required an additional open exploration for intraabdominal sepsis and cholecystectomy. Conclusions: Small bowel obstruction from internal hernia following laparoscopic donor nephrectomy is a rare event, but it can lead to significant morbidity in an otherwise healthy patient. These patients may be at higher risk for bowel obstruction given the soft tissue defect remaining after nephrectomy. Vigilance is required when mobilizing the colon to ensure that mesenteric defects are recognized and repaired.     

Internal herniation through a defect in the broad ligament

Internal hernias of a developmental nature are an uncommon cause of intestinal obstruction. Among the rarest of internal hernia is that which involves a defect in the broad ligament of the uterus. The case report of an elderly lady who had herniation of small bowel through a defect in the left broad ligament is presented.     

Incarceration of small bowel herniation through a defect of the broad ligament of the uterus: report of a case

Intestinal herniation through a defect in the broad ligament of the uterus is uncommon among internal herniations. We herein report a 59-year-old woman with intestinal obstruction, who had no previous history of surgical treatment except for an appendectomy. The laparotomy revealed an incarceration of the small bowel herniation through the defect of the right broad ligament. This possibility should therefore be considered in the differential diagnosis for female patients presenting with an intestinal obstruction without any history of a prior laparotomy. Received: August 21, 2000 / Accepted: March 5, 2002     

The laparoscopic repair of a morgagni hernia in a child

A 12-year-old female presented with the abnormal findings on the chest PA. The chest CT revealed a retrosternal defect of the diaphragm and a fatty opacity in the pleural cavity, resulting in a diagnosis of Morgagni hernia. It was decided to undergo a laparoscopic surgery. The retrosternal defect of the diaphragm measuring 3.5 cm in diameter was found, through which a portion of the greater omentum and the fatty tissue connected with the falciform ligament were herniated into the pleural cavity. The greater omentum was pushed back into the peritoneal cavity and the fatty tissue connected with falciform ligament was excised. The mediastinal pleura was plicated and the defect of the diaphragm was repaired primarily. Immediately after the operation, the patient developed a right pneumothorax for which a chest tube was inserted. She was discharged at the post-operative third day without any further complications.     

Mind the gap – Small bowel obstruction due to preperitoneal herniation following laparoscopic inguinal hernia repair – A case report

Introduction and importanceInguinal hernia repair is a very frequent operation in general and visceral surgery worldwide. The laparo-endoscopic approaches such as TAPP have gained increasing acceptance among specialists and many consider them as standard of care due to perioperative safety and excellent postoperative results. Knowledge of specific complications after minimally invasive inguinal hernia surgery, however, is important for the successful management of these patients.Case presentationWe herein present the case of a 75-year-old female patient who electively underwent laparoscopic repair of combined inguinal and femoral hernia. During the postoperative course a small bowel obstruction occurred requiring emergency re-laparoscopy revealing a preperitoneal herniation of small bowel through a peritoneal defect.Clinical discussionSmall bowel obstruction due to preperitoneal herniation of small bowel through a peritoneal defect after laparoscopic hernia repair is extremely rare. In such cases, emergency laparoscopic revision is necessary to avoid bowel ischaemia. Adequate closure of the peritoneum during the primary procedure along with the necessary attention to detail seems mandatory to avoid preperitoneal herniation after TAPP.ConclusionInadequate peritoneal closure after TAPP may lead to preperitoneal herniation of the small bowel leading to postoperative intestinal obstruction. All hernia surgeons should be aware of this rare, but potentially life-threatening complication and should close all peritoneal defects with greatest care and accuracy.     

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.