Presence of vermiform appendix (non-inflamed or inflamed) in inguinal hernia is called Amyand's hernia in honor to surgeon C. Amyand who published the first case of perforated appendicitis within inguinal hernia in a boy caused by ingested pin. This presentation of foreign body Amyand's hernia appendicitis is very rare, and here we present such a case.
A 6-year-old boy, white Kosovar ethnicity, presented with right groin pain, swelling and redness. Two days before admission the patient was injured by football during a children game in the right lower abdomen and the next day he complained of pain in the right inguinal area.
On admission patient had a painful non-reducible mass in the right inguinal region and cellulitis. Plain abdominal x-ray showed no fluid-air levels, but a metallic foreign body (pin) under right superior pubic ramus was apparent. With preoperative diagnosis of suspect incarcerated inguinal hernia with cellulitis the patient was operated on under general anaesthesia in December 2, 2006. Intraoperatively we found the inflamed vermiform appendix perforated by a pin in the hernial sac. Appendectomy and herniotomy were performed. The wound was primary closed, without any post-operative complications and follow up for the patient is three years long.
Foreign body (pin) Amyand's hernia appendicitis seems to be extremely rare, maybe once in a century (Amyand 1735, Hall 1886, and our case in 2006). In patients with clinical signs of incarcerated inguinal hernia, with locally inflammatory signs, but without signs of intestinal obstruction Amyand's hernia appendicitis in differential diagnosis must be considered. In our case, it is possible that the injury during the football game might have induced perforation of the vermiform appendix with the foreign body in it.
Richter’s hernia is an abdominal hernia in which part of the circumference of bowel entrapped in the hernial sac. The segment of the entrapped bowel is nearly always the distal ileum but any part of gastrointestinal tract from the stomach to the colon may become incarcerated. The most common sites for Richter’s hernia are the femoral ring (71%), deep inguinal ring (23%) and ventral or umbilical hernias (6%). The growing popularity of laparoscopic surgery has led to a new possible site for development of Richter’s hernia. In most cases as less than two thirds of the circumference of the bowel wall is involved, the lumen of the gut remains free and thus features of intestinal obstruction are often absent. Richter’s hernia is a deceptive entity whose high death rate can be reduced by accurate diagnosis and early surgery. We report a case of strangulated Richter’s umbilical hernia in a 36 years old male.
Richter’s umbilical hernia; Strangulated
We report a case of 28-year-old woman presenting with small bowel obstruction. She had neither prior surgery nor delivery. An upright abdominal radiograph revealed several air-fluid levels in the small bowel in the midabdomen and the pelvic cavity. Computed tomography demonstrated a dilated small bowel loop in the Douglas’s fossa, but no definite diagnosis could be made. Supportive therapy with draining the intestinal fluid by a long intestinal tube did not result in improvement, which suggested the possibility of a strangulated hernia. Exploratory laparotomy revealed mobile cecum and a 20-cm length of the ileum herniated into a defect of the right broad ligament. As a gangrenous change was recognized in the incarcerated bowel, its resection was carried out, followed by end-to-end anastomosis and closure of the defects of the broad ligament. The postoperative course was uneventful. Intestinal obstruction is a very common cause for presentation to an emergency department, while internal hernia is a rare cause of obstruction. Among internal hernias, those through defects of the broad ligament are extremely rare. Defects of the broad ligament can be either congenital or secondary to surgery, pelvic inflammatory disease, and delivery trauma. In conclusion, we emphasize that hernia of the broad ligament should be added to the list of differential diagnosis for female patients presenting with an intestinal obstruction. Early diagnosis and surgical repair reduce morbidity and mortality from strangulation.
Internal hernia; Broad ligament; Intestinal obstruction; Mobile cecum
Acute inguinal hernias are a common presentation as surgical emergencies, which have been routinely managed with open surgery. In recent years, the laparoscopic approach has been described by several authors but has been controversial amongst surgeons. We describe the laparoscopic approach to incarcerated/strangulated inguinal hernias based on a review of the literature with regards to its feasibility in laparoscopically managing the acute hernia presentation.
A systematic literature search was carried out including Medline with PubMed as the search engine, and Ovid, Embase, Cochrane Collaboration, and Google Scholar databases to identify articles reporting on laparoscopic treatment, reduction, and repair of incarcerated or strangulated inguinal hernias from 1989 to 2008.
Forty-three articles were found, and 7 were included according to the inclusion criteria set. Articles reporting on the use of laparoscopy for the evaluation of the hernia but not reducing and repairing it, the use of the open technique, elective hernia repairs, pediatric series, review articles, and other kinds of hernias were excluded after title and abstract review. This resulted in 16 articles that were reviewed in full. Of these 16 articles, 7 reported on the use of the laparoscopic approach exclusively. From these 7 studies, there were 328 cases reported, 6 conversions, average operating time of 61.3 minutes (SD±12.3), average hospital stay of 3.8 days (SD±1.2), 34 complications (25 of which were reported as minor), and 17 bowel resections performed either laparoscopically or through a minilaparotomy incision guided laparoscopically.
The laparoscopic repair is a feasible procedure with acceptable results; however, its efficacy needs to be studied further, ideally with larger multicenter randomized controlled trials.
•Occasionally unusual abdominal structures may be found within the hernia sacs.•Abdominal malignancies have the potential to seed any part of the peritoneum.•Surgeons should be vigilant where there is a known intra-abdominal malignancy & the presence of an incarcerated hernia.
Incarcerated femoral hernias usually contain a simple loop of bowel. Occasionally other abdominal structures may be found within the hernial sac. Rarely femoral hernias may contain metastatic tumour deposits.
Presentation of case
We report the case of an 82 year old lady with a background of ovarian carcinoma, who presented with acute small bowel obstruction and an irreducible right groin mass. CT imaging revealed an incarcerated loop of small bowel within a femoral hernia sac. The patient proceeded to theatre for hernia repair. Upon opening the hernial sac an adherent incarcerated small bowel loop was discovered. Interestingly, the sac itself was lined with metastatic deposits, which were later histologically proven to be ovarian in origin. The sac was reduced and the hernia was repaired. The patient’s post-operative course was uneventful.
As abdominal wall hernias communicate with the abdominal cavity there is the potential for malignant cells to seed the peritoneal lining of the hernia sac. If the sac also contains bowel wall, this may become involved in the tumour mass. This may result in small bowel incarceration & obstruction.
In cases, where there is a known intra-abdominal malignancy & the presence of an incarcerated hernia, there should be a high index of suspicion for the presence of tumour within the hernial contents.
Femoral hernia; Incarcerated; Cancer; Ovarian; Bowel obstruction; Strangulated
Obturator hernia is a rare condition that may present in an acute or subacute setting in correlation with the degree of small-bowel obstruction. Pre-operative diagnosis is difficult, as symptoms are often non-specific. A high index of suspicion should be maintained for emaciated elderly women with small-bowel obstruction without a previous abdominal operation and a positive Howship–Romberg sign. When diagnosis is in doubt, computed tomography scan of the abdomen and the pelvis (if available) or laparotomy should be performed immediately, as high mortality rate is related to the perforation of gangrenous bowels. We present 2 cases of strangulated obturator hernia, managed differently with both open and laparoscopic approaches. The diagnostic accuracy of computed tomography scan is highlighted followed by a brief literature review with an emphasis placed on surgical management.
digestive system surgical procedures; gut; intestinal obstruction; laparoscopy; obturator hernia; X-ray computed tomography scanners
Lumbar hernias are rare conditions and about 300 cases have been reported since the first description by Barbette in 1672. Therefore strangulation or incarceration are also exceptionally encountered. We present a 62 -year-old-man who had strangulated left lumbar hernia and consequent mechanical small-bowel obstruction, alongside with a non strangulated right lumbar hernia. Through a median laparotomy, an intestinal necrosis was found. A bowel resection with end to end anastomosis was performed and the lumbar hernias were repaired on both sides. The recovery was uneventfull. To the best of our knowlwdge thanks to the litterature review presented here, this is the 19th case of incarcerated or strangulated spontaneous lumbar hernia described in the surgical litterature since 1889.
Lumbar hernia; Strangulation; Incarceration; Review
Port site hernia develops through a fascial or peritoneal layer that was inadequate or not repaired. It is a rare complication of laparoscopic surgery which may lead to serious problems. Here, we present a 77-year-old female, diagnosed with a small bowel hernia through a 10-mm port site. We had performed ten cases of laparoscopy-assisted distal gastrectomy before this case. The patient complained of left lower abdominal pain with a palpable mass. Abdominal CT showed an incarcerated small bowel hernia and the patient underwent segmental resection of the strangulated small bowel through a minimally extended port site incision.
Port site hernia; Strangulated small bowel; Minimally extended port site incision
Intersigmoid hernia is a rare form of internal hernia. Here, we report a case of intersigmoid hernia and provide a brief review of the 62 cases involving the mesosigmoid reported in Japan from 2000 to 2013. In the current case, a 26-year-old man with no previous history of abdominal surgery presented with abdominal pain and vomiting. Abdominal computed tomography revealed an extensively dilated small bowel and a closed loop of small bowel in the mesosigmoid. The patient was diagnosed with an intestinal obstruction due to an incarcerated internal hernia involving the mesosigmoid. There was no blood flow obstruction at the incarcerated bowel. An elective single-incision laparoscopic surgery was performed after decompression of the bowel using ileus tube. As the ileum herniated into the intersigmoid fossa, the patient was diagnosed with an intersigmoid hernia. The incarcerated small bowel was reduced in order to make it viable, and the hernial defect was closed with interrupted sutures. The patient had an uneventful recovery and was discharged on postoperative day five.
Incarcerated inguinal hernia is often encountered by surgeons in daily practice. Although rare, hernial reduction en masse is a potential complication of manual reduction of an incarcerated hernia. Manual reduction was performed in a case of Zollinger classification type VII (combined type) hernia in which the indirect hernia portion included an incarcerated small intestine. This procedure caused hernial reduction en masse, but this went unnoticed, and the remaining portion of the direct hernia in the inguinal region was treated surgically by the anterior approach. Because the incarcerated small bowel that had been reduced en masse was not completely obstructed, the patient's general condition was not greatly affected, and he was able to resume eating. Twenty days after surgery, he developed sudden abdominal pain as a result of gastrointestinal perforation. When performing manual reduction of an incarcerated hernia in cases after self-reduction over a long period, the clinician should always be aware of the possibility of reduction en masse.
Transomental hernias are among the rarest type of all internal hernias which overall account for less than 6% of small bowel obstructions. Most transomental hernias occurring in adults are either iatrogenic or post-traumatic. More rarely, a spontaneous herniation of small bowel loops may result from senile atrophy of the omentum. We report a case of an 86-year-old male who presented with signs and symptoms of small bowel obstruction but had no past surgical or traumatic abdominal history. At contrast-enhanced multi-detector row computed tomography (CT), a cluster of fluid-filled dilated small bowel loops could be appreciated in the left flank, with associated signs of bowel wall ischemia. Swirling of the mesenteric vessels could also be appreciated and CT findings were prospectively considered consistent with a strangulated small bowel volvulus. At laparotomy, no derotation had to be performed but up to 100 cm of gangrenous small bowel loops had to be resected because of a transomental hernia through a small defect in the left part of the greater omentum. Retrospective reading of CT images was performed and findings suggestive of transomental herniation could then be appreciated.
Small bowel obstruction; Internal hernias; Transomental hernia; Multi-detector row computed tomography; Strangulation
We report a case of small bowel obstruction with strangulation caused by a port site hernia following a laparoscopic appendicectomy and the successful management of the problem by employing a laparoscopy assisted technique. The aim of this report is to emphasize the importance of fascial closures of trocar sites in order to significantly decrease postoperative morbidity.
A 31 years old female presented with a classic clinical picture of acute appendicitis. She underwent an uneventful laparoscopic appendicectomy. A 12 mm trocar was used at the umbilical port. On Postoperative day three, the patient developed abdominal distension, crampy abdominal pain, nausea and bilious vomiting. Her white cell count increased to 16,500/mm3, and CRP was 145. X-ray abdomen showed dilated small bowel with multiple air fluid levels. CT scan showed a herniated loop of small bowel into the trocar site with small bowel obstruction. Laparoscopy was done to confirm the Richter's hernia into trocar site with small bowel obstruction. The bowel loop could not be reduced laparoscopically. Limited exploration of the trocar site confirmed findings with necrosis of the antimesenteric portion of the small bowel. A limited bowel resection and anastomosis was performed. The patient had an uneventful recovery.
Most port site hernias present within 10 days of the primary procedures, delayed hernias have been reported. CT scan is a helpful adjunct to differentiate port site hematoma from incarcerated small bowel. The knowledge of such a complication and its early diagnosis are important to avoid complications.
Laparoscopy; Complications; Port site; Hernia
Strangulated Inguinal hernia is one of the most common surgical emergencies dealt with by surgeons worldwide. Usually the narrow internal inguinal ring or the external inguinal ring is the site of constriction of the viscus, which forms the content of the hernia resulting in strangulation. We report a rare case of strangulated inguinal hernia where the constricting element is not the internal or external inguinal ring, but an omental band adhesion causing closed loop small bowel obstruction and gangrene within the hernial sac in the inguinal canal.
A 56-year-old Caucasian gentleman presented to us with a 6 hours history of non-reducible tender lump in his right groin. His groin was explored urgently under general anaesthesia and was found to have an omental band adhesion causing closed loop small bowel obstruction with gangrene within the hernial sac in the inguinal canal with a wide internal inguinal ring. Gangrenous small bowel was resected and primary anastomosis was performed through the same inguinal incision.
Strangulation of the inguinal hernial content is usually due to the tight constriction at the level of internal inguinal ring or at external inguinal ring. Uncommonly strangulation of the contents can occur due to other causes like omental band adhesion. Anyone presenting with clinical features of strangulated inguinal hernia with small bowel obstruction mandates prompt exploration of the inguinal canal. Although it may not change the treatment approach, one should be aware about this special entity. Resection of the gangrenous small bowel and primary anastomosis can be safely performed through the same inguinal incision.
“Reduction en masse of inguinal hernia” means reduction/migration of a hernial sac into the properitoneal space. We report the CT findings in a case of reduction en masse with strangulated obstruction. CT scan demonstrated a hernial sac with fibrous constriction band at the neck, situated in the properitoneal space superior to the inguinal region, causing closed-loop obstruction. The hernial sac contained thickened bowel loop with wall enhancement and fluid suggestive of incarceration/strangulation. We propose to call this, ‘The properitoneal hernial sac sign’, defined as “Presence of a hernial sac in the properitoneal space (and not in the inguinal/femoral canal) containing an obstructed/incarcerated bowel loop and causing small bowel obstruction” to identify “reduction en masse of inguinal hernia”.
Inguinal hernia; hernial sac; reduction en masse; properitoneal space; closed-loop obstruction
We describe an unusual case of ileal atresia, resulting from antenatal strangulation of a Meckel’s diverticulum in an exomphalos minor. This is a rare antenatal complication of Littre’s hernia, which has not been previously described. A small exomphalos minor at the base of umbilical cord and late onset vascular accident at the narrow defect leading to ileal atresia may be missed in the prenatal diagnosis. The triad of exomphalos minor, Meckel's diverticulum and terminal ileal atresia secondary to antenatal strangulation of Littre's hernia is very rare to find in the same patient. A small exomphalos minor at the base of the umbilical cord can be missed even in the postnatal period. Our case lends direct evidence of vascular accident as a cause of ileal atresia and supports vascular theory. Whenever possible umbilicus should be preserved naturally and exomphalos sac should be opened higher up for excellent cosmetic results.
The incidence of diaphragmatic hernias caused or exacerbated by diagnostic colonoscopy is not well elucidated at this time, and is believed to be very rare.
We present the case of a 57 year old man with remote history of traumatic injury who first presented with vague left shoulder pain for two weeks, mild anemia, and tested positive for fecal occult blood. Four days post colonoscopy the patient was found to have a strangulated loop of bowel herniated through the diaphragm into the left hemithorax.
In patients with previous history of serious traumatic injury and particularly those with previous splenectomy, a thorough history and physical examination before routine colonoscopy is important. A high level of suspicion for post-operative complications should also be maintained when assessing such patients.
Omental hernias are rare and difficult to diagnose preoperatively due to a lack of specific symptoms.
Presentation of case
We report a case of adhesional omental hernia diagnosed at laparoscopy. A 38 year-old female patient with evidence of a previous caesarean section presented with an acute abdomen. We found there were omental bands stuck onto the anterior wall of the uterus, and a loop of small bowel passing through the subsequent omental defect was dilated proximally without oedema. We performed laparoscopic exploration. We saw that there were omental bands stuck onto the anterior wall of the uterus, this was partially narrowing a segment of ileum. We also saw that the proximal bowel loop occupying the omental defect was dilated without oedema.
This is an uncommon cause of an acute abdomen, but should be kept in mind as a differential diagnosis, especially in patients with a surgical history.
Omental hernia; Acute abdomen; Adhesion; Ileus; Laparoscopy
We describe a case of strangulated umbilical hernia in a girl aged 5 years. She presented with an acute inflammatory lesion at the umbilicus which was initially thought to be due to cellulitis with possible abscess formation. Exploration revealed an umbilical hernia containing necrotic greater omentum.
Laparoscopic incisional and ventral hernia (LVIH) repair is becoming more popular throughout the world. Although individual series have presented their own information, few data have been collected to identify the risk of the most serious complication, enterotomy. A literature review has identified this to occur in 1.78% of patients who undergo this procedure. Large bowel injury represents only 8.3% of these injuries. Eighty-two percent of the time, these injuries will be recognized and repaired. In the majority of published series in which this occurred, the hernia repair was completed with a laparoscopically placed prosthesis, as only 43% were converted to the open procedure. Complications related to this approach are infrequent. The mortality rate of this operation was noted to be 0.05%. However, if an enterotomy occurred, it increased to 2.8%. A recognized enterotomy was associated with a mortality rate of 1.7%, but an unrecognized enterotomy had a rate of 7.7%. Careful technique and close inspection of the intestine at the completion of the adhesiolysis and the herniorrhaphy is recommended. If the hernia repair proceeds as planned following repair of enterotomy, continuation of antibiotics and the placement of an antimicrobial impregnated prosthesis are recommended. More study is necessary before firm recommendations can be made, as the majority of these events are most likely unreported. Safety concerns may require postponement of the hernia repair if an enterotomy occurs.
Hernia; Laparoscopy; Enterotomy; Mesh
Foreign body ingestion is a common complaint in gastrointestinal clinics. It is usually not difficult to diagnose because most of the patients report a definitive history of accidental foreign body ingestion. However, in rare cases, patients do not have a clear history. Thus, the actual condition of the patient is difficult to diagnosis or is misdiagnosed; consequently, treatment is delayed or the wrong treatment is administered, respectively. This report describes a fatal case of esophageal perforation caused by an unknowingly ingested fishbone, which resulted in lower esophageal necrosis, chest cavity infection, posterior mediastinum fester, and significant upper gastrointestinal accumulation of blood. However, his clinical symptoms and imaging data are very similar with esophageal hiatal hernia. Unfortunately, because the patient was too late in consulting a physician, he finally died of chest infection and hemorrhage caused by thoracic aortic rupture. First, this case report underlines the importance of immediate consultation with a physician as soon as symptoms are experienced so as not to delay diagnosis and treatment, and thus avoid a fatal outcome. Second, diagnostic imaging should be performed in the early stage, without interference by clinical judgment. Third, when computed tomography reveals esophageal hiatus hernia with stomach incarceration, posterior mediastinal hematoma, and pneumatosis caused by esophageal, a foreign body should be suspected. Finally, medical professionals are responsible for making people aware of the danger of foreign body ingestion, especially among children, those who abuse alcohol, and those who wear dentures, particularly among the elderly, whose discriminability of foreign bodies is decreased, to avoid dire consequences.
Esophageal hiatus hernia; Foreign body; Esophageal perforation; Gastrointestinal accumulation
Single incision laparoscopic inguinal hernia repair appears to be a safe and efficient alternative to multiport laparoscopic inguinal hernia repair.
Almost 20 years after the first laparoscopic inguinal hernia repair was performed, single incision laparoscopic surgery (SILS™) is set to revolutionize minimally invasive surgery. However, the loss of triangulation must be overcome before the technique can be popularized. This study reports the first 100 laparoscopic total extraperitoneal hernia repairs using a single incision. The study cohort comprised 68 patients with a mean age of 44 (range, 18 to 83): 36 unilateral and 32 bilateral hernias. Twelve patients also underwent umbilical hernia repair with the Ventralex patch requiring no additional incisions. A 2.5-cm to 3-cm crescentic incision within the confines of the umbilicus was performed. Standard dissecting instruments and 52-cm/5.5-mm/300 laparoscope were used. Operation times were 50 minutes for unilateral and 80 minutes for bilateral. There was one conversion to conventional 3-port laparoscopic repair and none to open surgery. Outpatient surgery was achieved in all (except one). Analgesic requirements were minimal: 8 Dextropropoxyphene tablets (range, 0 to 20). There were no intraoperative or postoperative complications with a high patient satisfaction score. Single-incision laparoscopic hernia repair is safe and efficient simply by modifying dissection techniques (so-called “inline” and “vertical”). Comparable success can be obtained while negating the risks of bowel and vascular injuries from sharp trocars and achieving improved cosmetic results.
Inguinal hernia; Total extraperitoneal; Laparoscopy; SILS™
Background and Objectives:
Laparoscopic-assisted surgery has been applied for a variety of colonie surgery. The objective of this paper is to demonstrate a possible and avoidable complication of laparoscopic colonie surgery.
A 47-year-old woman underwent gasless laparoscopic-assisted sigmoid colectomy. On the 20th postoperative day, she developed bowel obstruction. Decompression with a long tube failed to resolve the bowel obstruction. Open laparotomy was performed. Abdominal exploration revealed a loop of the small bowel incarcerated in the mesenteric defect caused by the previous operation. Adhesiolysis was performed, and the post-operative course was uneventful.
Despite technical difficulty, complete closure of the mesentery after bowel resection is strongly recommended for prevention of transmesenteric incarcerated hernia after laparoscopic surgery.
Laparoscopic surgery; Hernia; Complication; Mesentery
Hernia is one of the commonest complications of peritoneal dialysis. It is recommended that patients undergo surgical repair of hernias immediately after the diagnosis. We report a patient on continuous ambulatory peritoneal dialysis presenting with strangulated umbilical hernia. He underwent resection of the gangrenous ileum and end-to-end anastomosis. He was shifted to hemodialysis on second postoperative day and was continued on hemodialysis for 2 weeks. In the third week, he was initiated on low volume PD exchanges and by the fourth week, he returned to normal CAPD exchanges.
Peritoneal dialysis; strangulation; umbilical hernia
Traumatic Spigelian hernia is a rare clinical entity with variable clinical presentation and requires a high index of suspicion for prompt diagnosis and the management. Delay in the diagnosis can lead to incarceration or strangulation of bowel loops and subsequent morbidity.
Here, we are reporting a case of traumatic Spigelian hernia followed by blunt trauma to the right lower abdomen. The herniated bowel loop was gangrenous and perforated. There was spillage of fecal matter into the adjoining parietal layer. Patient underwent exploratory laparotomy with resection of gangrenous bowel loop and ileostomy was performed. Post-operative course was uneventful.
Traumatic; Spigelian hernia; Abdominal wall hernia
Background and Objective:
We present the case of a female patient 29 years of age with antecedents of laparoscopic laser ablation for endometriosis, laparoscopic appendectomy, and umbilical hernioplasty.
The patient was admitted to the hospital's emergency room for abdominal pain in the epigastrium, transfixing, irradiating to both upper quadrants and to the lumbar region, accompanied by nausea and gastrobiliary vomiting. Lipase determination was 170 mg/dL. Other laboratory findings were normal. Plain abdominal films on the patient's admission were normal, and computed tomography (CT) showed data compatible with acute pancreatitis. Without improvement during the patient's hospital stay, pain and vomiting increased in intensity and frequency.
New abdominal x-rays revealed dilatation of small bowel loops. Management was begun for intestinal obstruction, with intravenous hydration and placement of a nasogastric tube without a good response. At 48 hours, a diagnostic laparoscopy was performed, revealing a 3-cm internal hernia in the left broad ligament in which a 20-cm segment of terminal ileum was encased. We performed liberation of the ileal segment and closed the hernial orifice by using the laparoscopic approach.
The patient's evolution was excellent.
Small bowel obstruction; Internal hernia; Broad ligament; Laparoscopy