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
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
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
“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
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.
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.
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.
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
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.
Intra-abdominal drains have been widely used in order to prevent intra-abdominal fluid accumulation and detection of anastomotic leakage.
Presentation of case
We herein report a case of small bowel herniation followed by strangulation in an 82 year old woman who had undergone sigmoidectomy for colorectal cancer.
Although several complications related to drain usage such as drainsite infection, hemorrhage and intestinal perforation may occur, intestinal incarceration through drain site is rarely reported.
Drains must be used with caution and only if indicated. Careful insertion, regular post-operative or post-removal inspection is strongly recommended.
Abdominal drain; Small bowel herniation; Small bowel incarceration
Internal hernia is a rare entity which can cause intestinal obstruction. The most common type of internal hernia is the paraduodenal hernia which accounts for 53% of cases, and the internal hernia within the pelvis account for 7%. Perineal hernia, which is classified as pelvic hernia, usually occurs due to weakening of the pelvic floor musculature and thus, should be distinguished from the internal hernia caused by peritoneal defects in the pelvic cavity.
PRESENTATION OF CASE
We present a case of 28-year-old female who presented intestinal obstruction. Conservative therapies failed and she required emergency laparotomy. The operative findings revealed a peritoneal defect of 2 cm in diameter in the pouch of Douglas, through which the ileum was incarcerated and strangulated. The incarcerated bowel was reduced, and the intestinal color quickly returned to normal. Therefore a primary closure of the peritoneal defect was performed and the postoperative course was uneventful.
A PubMed search for the case of internal hernia through a defect in the pouch of Douglas revealed only three, making this an extremely rare condition.
Because of rarity of this hernia, the etiology is unknown. However, our patient is a young female with no history of pregnancy, abdominal surgery, or trauma, therefore the cause of the peritoneal defect is considered congenital.
Pouch of Douglas; Internal hernia; Peritoneal defect; Intestinal obstruction
Pericaecal hernias are a rare subgroup of internal abdominal hernias that present with abdominal pain and occasionally with features of bowel obstruction.
PRESENTATION OF CASE
A 72 year old female presented with a 24-h history of sharp, localised right iliac fossa pain, and no other symptoms. Clinical examination confirmed localised peritonism in the right iliac fossa. A tentative diagnosis of acute appendicitis was considered but in view of age a CT scan was performed. An area of abnormality in the right iliac fossa region was noted. At laparoscopy a macroscopically normal appendix and caecum was found. A smooth non-indentable mass in the lateral right iliac fossa contained loops of distal ileum, passing through a retro-caecal mesenteric defect consistent with a paraceacal hernia, with entrapment of the right ovary and fallopian tube. A right salpingectomy as performed and subsequent histopathological examination confirmed infarction of the fallopian tube.
Internal abdominal hernias are reported to have a post mortem incidence ranging between 0.2 and 0.9% of which only 10–15% are accounted for by pericaecal hernias. Types of pericaecal hernias include: ileocolic, retrocaecal, ileocaecal and paracaecal. These hernias are predisposed by the embryological development of the caecum retracting to the posterior abdominal wall and forming potential fossae.
This case highlights the need to consider a pericaecal hernia as a differential cause of right iliac fossa peritonism, and an indication for radiological imaging such as CT scan when the history is atypical for acute appendicitis.
Paracaecal hernia; Appendicitis; Salpingo-ovarian; Ileum entrapment
We report an incarcerated internal hernia in a huge irreducible parastomal hernia-"hernia within hernia." A 70-year-old obese woman with diabetes who underwent an abdomino-perineal resection 20 years ago was admitted to our hospital with 20 years history of a huge irreducible bulge, 25 cm in diameter. An internal hernia due to an adhesive band extending from the sac wall to proximal colon was found in the parastomal hernia sac during an emergency laparotomy. We cut off the distal colon and relocated the colostomy stoma. The patient was discharged uneventfully 2 weeks after the surgery and was readmitted to have a further laparoscopic hernia repair 8 months later. Unfortunately, an unrecognized enterotomy occurred during the secondary surgery that led to an additional laparotomy during which the mesh was not contaminated by the bowel contents and was kept in place. At 22-month follow-up, there were no evidences of recurrence.
Ventral hernia; Incarceration; Intestinal obstruction; Herniorrhaphy
We report a rare case of a giant ovarian tumor presenting as an incarcerated umbilical hernia. A 61-yr-old woman was admitted to the hospital with severe abdominal pain, an umbilical mass, nausea and vomiting. On examination, a large, irreducible umbilical hernia was found. The woman underwent an urgent operation for a possible strangulated hernia. A large, multilocular tumor was found. The tumor was excised, and a total abdominal hysterectomy and bilateral salphingo-oophorectomy were performed. The woman was discharged 6 days after her admission. This is the first report of incarcerated umbilical hernia containing a giant ovarian tumor within the sac.
Granulosa Cell Tumor; Hernia, Umbilical; Surgery
Internal herniation of a small bowel behind pelvic vessels is a rare complication seen after pelvic lymphadenectomy.
PRESENTATION OF CASE
A 56-year-old woman was operated due to a gynecological cancer. 4 years thereafter she presented with a 2 days history of abdominal pain and vomiting. Clinical and radiological findings indicated a small bowel obstruction. A loop of small bowel had herniated behind the left external iliac artery. Using laparoscopic technique the herniated bowel was reduced. Due to limited peritoneum around the area and skeletonized vessel, we decided not to do any repair of the hernia orifice. The postoperative recovery was uneventful, bowel activity returned to normal and she was discharged the next day.
Follow-up was done at 1 month and the latest at 10 months. She didn’t experience pain or discomfort after the operation.
Due to limited peritoneum around the skeletonized vessel, we decided to leave the hernia orifice unrepaired. We found it hazardous to do any direct suture of the orifice or use a free peritoneal graft to repair the defect as the fibrosis and inflammatory process might have compromised the artery or the vein. A longer follow-up of the patient is needed to clearly conclude if this simple procedure has been sufficient. We agreed that if the patient would experience any sign of recurrence and need another operation we would close the defect at that time.
4 years after pelvic lymphadenectomy a small bowel herniation behind an external iliac artery occurred. The patient was successfully treated with reduction of the small bowel using laparoscopic technique. A quick recovery with minimal discomfort and no sign of recurrence after 10 months made our approach an acceptable surgical option.
Hernia; Iliac artery; Intestinal obstruction; Lymphadenectomy
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.
A 27-year-old man presented with a 5 day history of abdominal pain and distension, with associated constipation and vomiting. He had presented 8 years earlier following a traumatic injury to the left side of the chest, and no diaphragmatic injury was reported at that time. On this admission, a computed tomography scan showed herniation of the splenic flexure of the colon into the left hemithorax. Subsequently, he had an emergency laparotomy for resection, with formation of a loop ileostomy. The various imaging techniques all have advantages and disadvantages when diagnosing a traumatic diaphragmatic hernia. It is the clinician’s role to maintain a high index of suspicion when a patient initially presents with trauma where a traumatic diaphragmatic hernia may be a possibility.
Intra luminal hypopharyngeal and oesophageal foreign bodies are common. Among these the incidence of open safety pin is relatively uncommon and the occurrence of multiple open safety pins in the same ’ individual is a very rare phenomenon. Removal of one open safety pin itself is a surgical enigma, as inadvertant attempts at removal may cause the pointed end to get impacted submucosally or intramurally or may cause oesophageal tear and calls for the assistance of a thoracic surgeon. This article intends to highlight the occurrence of multiple open safety pins in the lumen of the oesophagus and its difficulty in successful retrieval.
Multiple open safety pins; Foreign body — oesophagus
Post traumatic diaphragmatic hernia is very often missed particularly in polytrauma patients. We present case of an isolated post traumatic diaphragmatic hernia with strangulation, a very rare finding.
PRESENTATION OF CASE
A 35 year old man presented with features of intestinal obstruction with past history of a seemingly trivial blunt thoracic injury 15 years back. Findings of X-ray abdomen and chest with high leukocyte count raised suspicion of obstructed diaphragmatic hernia which on exploration revealed obstructed diaphragmatic hernia with gangrenous bowel segment.
Blunt injury of diaphragm is relatively common and is considered as a marker of severe trauma and it can clinically be occult as other violent injuries may mask and disguise its initial clinical presentation1 resulting in late presentation with obstruction and/or rarely strangulation. An early diagnosis of the condition is prudent to avoid morbidity and mortality associated with late presentations.
In a patient of intestinal obstruction with history of even trivial throraco- abdominal injury, diagnosis of diaphragmatic hernia should be kept in mind.
Strangulation; Traumatic diaphragmatic hernia
Internal hernia (IH) is a rare cause of small bowel obstruction occurs when there is protrusion of an internal organ into a retroperitoneal fossa or a foramen in the abdominal cavity. IH can be presented with acute or chronic abdominal symptom and discovered by accident in operation field. However, various kinds of imaging modalities often do not provide the assistance to diagnose IH preoperatively, but computed tomography (CT) scan has a high diagnostic accuracy. We report a case of congenital IH in a 6-year-old boy who experienced life threatening shock. CT scan showed large amount of ascites, bowel wall thickening with poor or absent enhancement of the strangulated bowel segment. Surgical exploration was performed immediately and had to undergo over two meters excision of strangulated small bowel. To prevent the delay in the diagnosis of IH, we should early use of the CT scan and take urgent operation.
Intestinal obstruction; Hernia; Child
Internal hernias of the abdomen are uncommon. They represent less than 1% of bowel obstruction cases. The left Paraduodenal hernia (PH) is the most frequent type of internal hernias. We report a case of 77 year- old woman consulting for bowel obstruction evolving since two days. The abdominal computed tomography revealed a retroperitoneal small bowel contained in a peritoneal sac. The surgical exploration confirmed the diagnosis of a left internal PH by showing incarcerated jejunal loops in a PH through a narrow opening to the left of the angle of Treitz. A surgical reduction of the hernia and closure of the hernia neck were performed. The follow-ups were uncomplicated. Through this observation and a literature review, we try to recall the clinical and radiological characteristics of this disease and to clarify the therapeutic modalities.
Computed tomography; internal hernia; paraduodenal hernia; small bowel obstruction
The incidence of hernias is increased in patients with alcoholic liver disease with ascites. To the best of our knowledge, this is the first report of an acute rise in intra-abdominal pressure from straining for stool as the cause of a ruptured umbilical hernia.
An 81-year-old Caucasian man with a history of alcoholic liver disease presented to our emergency department with an erythematous umbilical hernia and clear, yellow discharge from the umbilicus. On straining for stool, after initial clinical assessment, our patient noted a gush of fluid and evisceration of omentum from the umbilical hernia. An urgent laparotomy was performed with excision of the umbilicus and devitalized omentum.
We report the case of a patient with a history of alcoholic liver disease with ascites. Ascites causes a chronic increase in intra-abdominal pressure. A sudden increase in intra-abdominal pressure, such as coughing, vomiting, gastroscopy or, as in this case, straining for stool can cause rupture of an umbilical hernia. The presence of discoloration, ulceration or a rapid increase in size of the umbilical hernia signals impending rupture and should prompt the physician to reduce the intra-abdominal pressure.
Obturator hernia is a rare pelvic hernia that occurs primarily in multiparous, elderly (>70 years of age), thin females. This case highlights the successful laparoscopic mesh repair of an incarcerated obturator hernia in an octogenarian.
The authors report a case of an incarcerated obturator hernia in an elderly female with subsequent high-grade small bowel and its successful laparoscopic operative management. A review of the relevant literature was also performed following a search on the online literature databases such as PUBMED and EMBASE. Laparoscopic mesh repair of the incarcerated obturator hernia and an ipsilateral femoral hernia found incidentally was successfully performed. A review of the literature showed a significant burden of morbidity and mortality associated with obturator hernias. Laparoscopic mesh repair has been previously shown to be a safe therapeutic modality. Small bowel obstruction and leg pain in a thin elderly lady should arouse suspicion for an incarcerated obturator hernia. Laparoscopic management of an incarcerated obturator hernia is a feasible and safe therapeutic option.
Femoral hernias are relatively uncommon, however they are the most common incarcerated abdominal hernia, with strangulation of a viscus carrying significant mortality. Classically three approaches are described to open femoral hernia repair: Lockwood's infra-inguinal, Lotheissen's trans-inguinal and McEvedy's high approach. Each approach describes a separate skin incision and dissection to access the femoral sac. The decision as to which approach to adopt, predominantly dependent on the suspicion of finding strangulated bowel, is often a difficult one and in our opinion an unnecessary one.
We propose a technique for open femoral hernia repair that involves a single skin incision 1 cm above the medial half of the inguinal ligament that allows all of the above approaches to the hernia sac depending on the operative findings. Thus the repair of simple femoral hernias can be performed from below the inguinal ligament. If found, inguinal hernias can be repaired. More importantly, resection of compromised bowel can be achieved by accessing the peritoneal cavity with division of the linea semilunaris 4 cm above the inguinal ligament. This avoids compromise of the inguinal canal, and with medial retraction of the rectus abdominis muscle enables access to the peritoneal cavity and compromised bowel.
This simple technique minimises the preoperative debate as to which incision will allow the best approach to the femoral hernia sac, allow for alteration to a simple inguinal hernia repair if necessary, and more importantly obviate the need for further skin incisions if compromised bowel is encountered that requires resection.