择期闭孔疝的临床特征分析及治疗方法探讨

目的分析择期闭孔疝的临床特征并探讨其治疗方法。 方法回顾性分析2013年8月至2018年8月,四川大学华西医院收治的11例择期行无张力闭孔疝修补患者的临床资料。分析其临床特征,探讨手术治疗方法,记录术后并发症发生及复发情况。 结果11例患者均为女性,确诊为闭孔疝,病程2个月至14年,平均体质量指数（17.62±2.16）kg/m²,平均年龄（76.63±9.15）岁,合并心肺疾病4例。均有反复下腹痛。术前诊断为双侧闭孔疝4例;术前诊断为单侧闭孔疝,术中探查后证实为双侧闭孔疝6例;1例术前及术中证实为单侧,仅行右侧闭孔疝无张力修补,半年后出现新发左侧闭孔疝。所有患者术后随访无闭孔疝复发,无再腹痛,无肠梗阻及腹股沟区慢性疼痛,无大腿及膝部放射性疼痛。所有患者术后切口均无感染。 结论择期闭孔疝常见于高龄消瘦女性,病程长,往往并发心肺基础疾病,临床表现反复下腹疼痛,通常不伴肠梗阻,腹部CT对诊断有重要价值。临床上误诊率高,通常是双侧并发,采用无张力修补复发率低,并发症少,可供借鉴。     

Obturator hernia: a diagnostic challenge

We describe a case of an 82-year-old lady with groin pain secondary to an obturator hernia. She was a diagnostic challenge, and 6 years passed before the obturator hernia was discovered. She presented to hospital with symptoms of bowel obstruction, and a computer tomography (CT) scan of her pelvis revealed an incarcerated obturator hernia. Her surgical management included reinforcement of the obturator foramen with sutures. A recurrence of the obturator hernia 2 years later required an extra-peritoneal mesh repair of the defect in the obturator foramen with a good outcome.     

Laparoscopic trans-peritoneal hernioplasty (TAPP) is useful for obturator hernias: report of a Case

A 71-year-old female presented to our hospital due to pain from the right hip joint to the lower abdomen. The pain had suddenly appeared and spontaneously disappeared more than 10 times during the past 2 years. She had visited many hospitals, but remained undiagnosed. The patient underwent a computed tomography (CT) scan of the pelvis, and a soft tissue shadow was seen between the external obturator and pectineal muscles. She was diagnosed with a right obturator hernia and underwent elective repair by laparoscopic trans-peritoneal hernioplasty (TAPP). 1 year has passed since the surgery, without any recurrence of the abdominal pain. Obturator hernias are rare, and most cases are found as incarcerated hernias. It is rare to find an obturator hernia without intestinal obstruction, or with the recurrent pain as in our case. We herein report a case in which an obturator hernia was undiagnosed and intermittent pain was experienced for 2 years prior to TAPP, which appears to have successfully treated the hernia.     

Diagnosis and laparoscopic repair of type I obturator hernia in women with chronic neuralgic pain.

BACKGROUND: We performed a pilot study review of 7 female patients suffering with obturator neuralgia produced by a type I obturator hernia. Diagnosis and laparoscopic treatment of this rare hernia are presented. METHODS: Patients with chronic pelvic pain and signs of obturator neuralgia were identified retrospectively by chart review. These patients had been referred to our chronic pelvic pain clinic. Outcomes of their surgery from February through November 2001 were analyzed. Median length of follow-up was 11 months (range, 6 to 16). A new technique using Cooper's ligament and arcus tendineus fasciae pelvis was used for the tension-free mesh hernia repair. RESULTS: In this pilot study, 6 of 7 patients (86%) received greater than 50% relief of their chronic pelvic pain, which leads to the conclusion that we have at least 95% confidence that the pain reduction achieved is greater that 50%. Due to the small sample size, no statistically meaningful conclusions could be reached. All of the patients have reported some pain relief and increased function since surgery. CONCLUSION: Symptomatic type I obturator hernias may be more common than previously thought. Patients with obturator neuralgia, persisting longer than 6 months despite conservative therapy, may respond to laparoscopic reduction of the pilot fat tag and mesh overlay of the obturator canal.     

Internal hernias in pregnant women with history of gastric bypass surgery: Case series and review of literature

INTRODUCTIONGastric bypass surgery is the most common obesity surgery procedure in women. Decreased weight loss favors fertility and leads to pregnancy sometimes just months after surgery, raising the risk of developing gastric bypass-related complications during pregnancy, including the formation of internal hernias.PRESENTATION OF CASEThe first patient presented at 37 weeks of gestation with abdominal pain, nausea and vomiting. X-ray revealed multiple air-fluid levels and absence of gas in colon. She underwent a cesarean section and exploratory laparotomy without complications. A Petersen's space internal hernia was found. The second patient presented at 25 weeks of gestation with abdominal pain and nausea. X-ray revealed multiple air–fluid levels and a “U-shaped” intestinal loop. She underwent exploratory laparotomy with reduction of an internal hernia also in Petersen's space.DISCUSSIONPregnant patients with internal hernias after gastric bypass are usually of young age and with a several-day history of abdominal pain. Surgical exploration is safe and should not be delayed. The literature review showed that maternal death (9%) and fetal death (13.6%) rates are considerably high.CONCLUSIONThe possibility of an internal hernia should always be considered in pregnant women with history of gastric bypass who present with abdominal pain, in order to prevent catastrophic outcomes such as maternal and/or fetal death.     

A rare cause of intestinal obstruction: incarcerated femoral hernia, strangulated obturator hernia

Obturator hernia may occur bilaterally in association with another hernia, which is usually of the femoral type. We present a 77-year-old-woman who had abdominal pain with nausea and vomiting together with swelling of the right groin for 3 days. Incarcerated right femoral hernia and consequent mechanical small-bowel obstruction was diagnosed, and urgent operation was undertaken. As the incarcerated femoral hernia reduced spontaneously during the induction of anesthesia, a lower median incision was performed. During exploration, the real cause of mechanical intestinal obstruction was found to be a small intestinal loop strangulated in the left obturator hernia. Right femoral and left obturator hernia were repaired with preperitoneal polypropylene mesh. If there is enough time and general condition of the older patient is suitable, further diagnostic techniques for concomitant obturator hernias may be useful in patients who present with signs of incarcerated inguinal hernia and intestinal obstruction.     

A Left Paraduodenal Hernia Causing Acute Bowel Obstruction: a Case Report

We present the case of a 54-year old woman who presented twice at our emergency department with progressive abdominal pain. Over the last few years, multiple short periods of abdominal pain had occurred: the pain always resolved spontaneously after a few hours. She had no past medical history. CT scan revealed a sac-like mass of small bowel loops to the left of the ligament of Treitz, consistent with the diagnosis of a left paraduodenal hernia. On laparotomy, a left paraduodenal hernia with incarceration of small bowel loops was found; the herniated loops were reduced and the hernia orifice closed. The anatomy, treatment and importance of considering this uncommon diagnosis when examining a patient with acute small bowel obstruction are discussed.     

Incisional Intercostal Hernia With Prolapse of the Colon After Right Partial Nephrectomy

A 75-year-old woman with a history of myocardial infarction, gallstones, and right renal cancer was referred to our department because of right flank pain. She had a surgical scar on the right abdomen between the 10th and 11th ribs; computed tomography demonstrated intercostal herniation of the colon. Recognizing the possibility of adhesions of the hernia and colon, we used a median skin incision and patched a polyester mesh coated with absorbent collagen. The patient had an uneventful postoperative course, with no pain for 6 months postoperatively. Transdiaphragmatic intercostal hernias with abdominal contents commonly develop after trauma or thoracic surgery. Incisional intercostal hernias seldom develop after nephrectomy; the present case is only the fourth report. We conjecture that a costochondral incision can induce subluxation of the costotransverse joint, intercostal nerve injury, and atrophy of the intercostal and abdominal oblique muscles. Surgeons must therefore recognize the potential, albeit rare, for intercostal hernia after nephrectomy.     

A case of obturator hernia leading to right thigh abscess in China

The purpose of this case is to investigate a case of obturator hernia leading to right thigh abscess on 68-year-old woman of China. A 68-year-old Chinese woman was referred to China-Japan Friendship Hospital of Jilin University with abdominal pain, bloating, exhaust, stop defecation in 2011. She had chronic bronchitis, emphysema with a history of 20 years. This patient did not have any bad habits, such as smoking, alcohol consumption, etc. In this surgery, CT was used to diagnose the basic condition of the patient. Surgery was used for treatment of patients with diseases. In addition, this operation was performed by the china-Japan Friendship Hospital of Jilin University. The results of this case showed that the cervix of rectal right anterior wall can hit a funicular neoplasm, toughening, smooth, with tenderness, considering for the external pressure bowel loops. The inside of the right thigh showed obvious swelling, skin slightly bruising, and tenderness. Chest radiographs showed that patients had emphysema, multiple planes of fluid and air in the abdomen. Patients had been successfully operated, but she died because of severe infection.     

Small intestinal strangulation due to a primary internal paracecal hernia

The discovery of a paracolic hernia is an unusual event, even for an experienced specialist in colorectal surgery. We report a case of a 59-year-old woman with no previous history of abdominal surgery, who presented to the Emergency Department complaining of episodic abdominal pain and distension accompanied by a palpable mass in the right lower quadrant. At laparotomy, a paracecal hernia with small bowel volvulation was found. The prime objective of this report is to draw the clinician's attention to the necessity of making a rapid diagnosis of internal hernias.     

Appendicitis in incarcerated femoral hernia

Background: Femoral hernia can rarely present with the content of appendicitis. We report on an elderly female who was admitted to our emergency department with a painful groin mass. Methods: An 85-year-old woman presented with a 7-day history of right groin pain and swelling. She also had complaints of nausea, vomiting, and right lower quadrant abdominal pain. Physical examination revealed a right groin mass in the femoral region, which was painful on examination. Abdominal examination ended with normal findings except bilateral lower quadrant tenderness. Ultrasonographic examination revealed a hernia sac containing suspected aperistaltic bowel segment with edematous wall. Results: The patient underwent surgery. During exploration of the right groin region, a strangulated femoral hernia sac containing appendicitis was detected. Conclusion: Surgeons should be aware of the existence of this kind of atypical presentation of appendicitis.     

Obturator Hernia: Laparoscopic Diagnosis and Repair

Objective:

Review of international literature reveals eight reported cases of laparoscopic obturator hernia repair. Non-specific signs and symptoms make the diagnosis of an obturator hernia difficult. Laparoscopic intervention provides a minimally invasive method to simultaneously diagnose and repair these hernias.

Methods and Procedures:

A 35 year old woman presented with lower abdominal pain, vaginal bleeding, and dyspareunia. During gynecological diagnostic laparoscopy, a pelvic floor hernia was suspected, and a general surgical evaluation was sought. At a subsequent laparoscopy, the diagnosis of a left direct inguinal and a right obturator hernia was made. Both were repaired laparoscopically with polypropylene mesh.

Results:

At follow-up at one and six weeks postoperatively, the patient''s complaints of pain had completely resolved.

Conclusion:

The diagnosis of obturator hernia is problematic. The usual presenting signs and symptoms are non-specific. Without conclusive historical or physical findings, laparoscopy is an excellent method for diagnosing obturator hernia. This entity, once diagnosed laparoscopically, can be repaired simultaneously via laparoscopic mesh technique.     

闭孔疝的临床诊断与外科治疗

目的探讨闭孔疝的临床特点、诊断方法及外科治疗经验。 方法回顾性分析2014年1月至2017年8月,扬州大学附属医院收治的6例闭孔疝患者的临床资料,分析病例特点。 结果6例患者均痊愈出院。平均手术时间（77.5±29.2）min,术中平均出血量（42.5±30.9）ml,平均住院时间（11.5±2.4）d。1例术后切口脂肪液化,1例术后出现肺部感染,对症处理后均愈合。 结论闭孔疝是临床少见疾病,临床误诊、漏诊率极高,CT检查可早期明确诊断。     

OBTURATOR HERNIA

Four cases of strangulated obturator hernia are presented with a brief review of the literature up to 1980. All four patients were emaciated women over 50 years old and in all instances the hernia was on the left side. None of the cases was diagnosed preoperatively and all had Howship-Romberg's sign absent. A diagnosis of strangulated obturator hemia should always be considered in any elderly, thin female with clinical features of intestinal obstruction and without any history of previous abdominal operations. Three of the patients died due to delayed presentation, delayed operative interference and rupture of the gangrenous loop leading to septicaemia.     

Endoscopic totally extraperitoneal repair for occult bilateral obturator hernias and multiple groin hernias

INTRODUCTION: An obturator hernia is a rare hernia that is bilateral in about 6% of patients. Most patients present with chronic pelvic pain although a few patients may present with features of intestinal obstruction. Only about 10% of obturator hernias are diagnosed preoperatively. METHODS: A 65-year-old female patient with chronic obstructive pulmonary disease presented with bilateral groin swellings associated with local pain and heaviness. She also suffered from recurrent episodes of abdominal distension. She was diagnosed to have bilateral direct inguinal hernias and a left femoral hernia. At endoscopy under epidural anesthesia she was found to have a direct inguinal, an indirect inguinal, and a femoral hernia on the left side and an indirect inguinal hernia on the right side. Additionally, the endoscopic totally extraperitoneal approach to inguinal hernias identified hitherto undiagnosed bilateral obturator hernias. The hernias were reduced and polypropylene mesh was placed bilaterally covering the myopectineal orifice and pelvic floor bilaterally. RESULTS: The patient was discharged the next day and is symptom-free on followup at eight months. CONCLUSION: Endoscopic repair of groin hernias allows the surgeon not only to diagnose and treat unsuspected groin hernias but also allows identification, dissection, and repair of coincidental occult pelvic hernias like obturator hernias at the same time.     

Intercostal hernia and spontaneous pneumothorax in a liver transplant recipient: a case report

Intercostal hernia can occur after blunt trauma and can also complicate thoracotomy. This report describes a 13-year-old liver transplant recipient with chronic asymptomatic intercostal hernia at site of thoracotomy. This hernia became manifest upon development of spontaneous pneumothorax. She presented with pleuritic pain and radiographic evidence of spontaneous pneumothorax. Her history included liver transplantation at age 19 months for tyrosinemia, posttransplant lymphoproliferative disorder at age 7 years with thoracotomy for lung biopsy, and prolonged corticosteroid administration. Examination and computed tomography revealed an intercostal hernia. She underwent repair of hernia, stapled resection of apical blebs, and pleurodesis. Reconstruction of chest wall involved rib fracture and intercostal approximation with nonabsorbable sutures covered by serratus muscle advancement. She is symptom free with intact repair 2 years and 9 months after surgery and is able to participate in vigorous physical activity. This is the first report of an intercostal hernia detected upon development of spontaneous pneumothorax. The hernia occurred at the site of a prior thoracotomy, possibly because of impaired healing from corticosteroid administration. This case suggests that nonabsorbable sutures should be used for intercostal approximation after thoracotomy in patients with impaired wound healing.     

De Garengeot’s Hernia: a Diagnostic Challenge

Surgical literature defines the case of acute appendicitis in a sac of femoral hernia as de Garengeot’s hernia. The diagnosis remains a very hard challenge for surgeon because the symptoms are aspecific and the most effective tools for preoperative evaluation (as abdominal computed tomography and abdominal ultrasound scan) can often be indeterminate or misinterpreted. We report the case of an 85-year-old white male admitted to our unit complaining of a 1-day history of vague abdominal pain, nausea, vomiting, and painful swelling in the right groin. Preoperatively, an incarcerated right femoral hernia was supposed and patient underwent surgery via oblique inguinal incision. The intraoperative finding was a de Garengeot’s hernia and an appendectomy with hernia repair was performed. Patient had a regular course and was discharged on the second postoperative day.     

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.     

Incisional hernia after extreme lateral interbody fusion on the lumbar spine: A case report

IntroductionExtreme lateral interbody fusion is a minimally invasive lateral transpsoas approach for spine surgery. We herein report a case of an incisional hernia after an extreme lateral interbody fusion on the lumbar spine that was successfully treated by laparoscopic surgery with intraperitoneal onlay mesh repair.Presentation of caseA 78-year-old woman was referred to our hospital with a complaint of left abdominal bulge and pain. She had undergone an extreme lateral interbody fusion for a lumbar spinal canal stenosis from L1 to L4 a year prior. Abdominal computerized tomography showed a left lumbar incisional hernia, and laparoscopic surgery was performed. The hernia orifice was sutured closed and covered with mesh. The patient was discharged five days after the operation with no complications.DiscussionWhen performing XLIF for a spinal disorder, the muscles should be separated bluntly along their fibers to prevent muscle atrophy, and the incised fascia should be securely sutured closed. Abdominal wall incisional hernias can occur after spinal surgeries such as extreme lateral interbody fusion.ConclusionLaparoscopic repair for abdominal wall incisional hernia after spine surgery is safe and feasible.     

Large congenital transmesenteric hernia: a missed small-bowel atresia?

Internal hernias are uncommon diagnoses and represent rare causes of intestinal obstruction. Diagnoses are frequently made perioperatively. We present herein an illustrated case of transmesenteric hernia diagnosed in a pregnant woman who consulted for severe abdominal and dorsal pains. As CT scan was not possible because of the obstetric history, a decision to perform surgery was made because of acute pain, no history of previous surgery, and a plain erect X-ray disclosing early signs of intestinal obstruction. Perioperative findings were an ileal volvulus through a transmesenteric fossa circled by a unique ileocolic branch. This particular vascular disposition suggests transmesenteric hernias may be the first step in the constitution of congenital small-bowel atresia.