Internal supravesical hernia repaired via the anterior approach alone: A case report

IntroductionInternal supravesical hernia is one of the rarest types of inguinal hernia. The hernial orifice is surrounded by the transverse vesical fold, median umbilical fold, and medial umbilical fold.Presentation of caseA 75-year-old male presented with lower abdominal pain and nausea. Plain abdominal CT showed that the bladder was suppressed by small bowel near the left internal inguinal ring. A part of the small bowel wall seemed to be inlaid, and so the patient was diagnosed with a strangulated left inguinal hernia. The hernia repair operation was performed via the anterior approach. There was no internal hernial sac found, but there was a walnut-sized mass in the properitoneal space. A diagnosis was made intraoperatively of internal supravesical hernia with strangulated small bowel. Small bowel resection and hernial orifice closure were performed.DiscussionAlthough internal supravesical hernia can present with distinctive CT findings, preoperative diagnosis is extremely difficult. Internal supravesical hernia in previous reports has been repaired via open laparotomy or laparoscopic surgery; however, we successfully repaired this intraoperatively-diagnosed internal supravesical hernia by the anterior approach alone.ConclusionThe patient with internal supravesical hernia diagnosed intraoperatively could be treated via the anterior approach alone successfully. Depending on the situation, the anterior approach can be an option.     

Inguinal mass due to an external supravesical hernia and acute abdomen due to an internal supravesical hernia: A case report and review of the literature

Although supravesical hernias were described as early as 1804, there have been fewer than 100 cases reported in the literature. The supravesical fossa is a triangular area bounded laterally and above by median and medial umbilical ligaments, and below by the peritoneal reflection that passes from the anterior abdominal wall to the dome of the bladder. A hernia starting in this fossa usually protrudes through the abdominal wall as a direct inguinal hernia (external supravesical hernia). Less commonly, it remains within the abdomen, passing into spaces around the bladder (internal supravesical hernia). A 43-year-old mill worker presented with an enlarged painful mass in the left groin. He underwent a surgical repair of a direct inguinal hernia without addressing an unrecognized supravesicular component. Eight hours after his discharge next morning, he presented with acute abdomen, nausea, vomiting, and abdominal distention. The second surgery revealed the presence of a left lateral internal supravesical hernia with incarcerated small bowel. This was also repaired, and the patient was discharged in stable condition. This report aims to review and discuss the surgical anatomy of these rare supravesical hernias and calls attention to this type of hernia as an unusual cause of small bowel obstruction.     

Laparoscopic paracecal hernia repair

The diagnosis and treatment of internal abdominal hernia usually require laparotomy. We report a case of preoperative diagnosis and laparoscopic repair of paracecal hernia. A 90-year-old woman was referred with features of a well-established small bowel obstruction (SBO). Computed tomography and a small bowel contrast examination showed a paracecal hernia. With the patient under general anesthesia, laparoscopic surgery was carried out with the use of pneumoperitoneum, and an easy reduction of the incarcerated intestinal loop was achieved by gentle traction of the intestine. The bowel was assessed for viability and showed no evidence of nonviability. The abnormal orifice in the paracecal region was observed. The orifice was closed with 3-0 PDS II (polydiaxonone) sutures laparoscopically. A laparotomy was avoided, and the patient recovered without significant complications. We conclude that laparoscopy can play a useful role in the treatment of internal hernia causing SBO when an obstructive lesion has been detected and decompression accomplished preoperatively.     

Sciatic hernia clinically mimicking obturator hernia, missed by ultrasonography: case report

Sciatic hernia is a rare pelvic floor hernia that occurs through the greater or lesser sciatic foramen. Sciatic hernias often present as pelvic pain, particularly in women, and diagnosis can be difficult. Sciatic hernia is one of the rarest forms of internal hernia, which can present as signs and symptoms of small bowel obstruction, swelling in the respective gluteal region or pelvic pain. Transabdominal and transgluteal operative approaches, including laparoscopic repair, have been reported. We present a case of left-sided sciatic hernia with incarcerated small bowel as its contents. The hernia was missed by ultrasonography and plain abdominal radiography, but the clinical features were suggestive of an obturator hernia.     

Laparoscopic management of left paraduodenal hernia

Internal herniation of small bowel accounts for about 1% of all the patients with intestinal obstruction. Fifty percent of the patients with paraduodenal hernia will have bowel obstruction. Left paraduodenal hernia resulting from abnormal rotation of the midgut during embryonic development is the most common form of congenital internal hernia. A case of a young male presenting with chronic abdominal pain due to left paraduodenal hernia is being reported. A correct preoperative diagnosis of left paraduodenal hernia was made on computerised tomography (CT), and the patient was managed by laparoscopic surgery. The role of imaging in preoperative diagnosis is being highlighted with a brief review of literature.     

Left laparoscopic paraduodenal hernia repair

Background

An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Paraduodenal hernia is by far the most common form of congenital internal hernia, making up 53% of all reported cases. In recent years, as surgeons have become more comfortable with laparoscopic techniques, they are performing an increasing number of these procedures laparoscopically.

Methods

To highlight the technical steps of this technique, the case of a patient with a left paraduodenal hernia and a video of the laparoscopic repair are presented. Additionally, a PubMed search of the English medical literature was conducted using the search words “laparoscopic,” “paraduodenal,” and “hernia” as filters. The cases of laparoscopic paraduodenal hernia repair in the literature to date recording data on technique, complications, and hospital course were reviewed.

Results

In addition to the case described in this report, 14 cases of laparoscopic paraduodenal hernia were described in 10 published reports. Of the 15 cases, 11 (73%) were left-sided, likely representing the relative incidence of these cases. The hernia defect was closed in 10 (77%) of the 13 cases for which the repair method was described, whereas the defect was widely opened in the remaining cases. One report described an operative complication (6.7%), an internal mesenteric vein injury, and one recurrence (6.7%) occurred 18 months after surgery in the direct defect closure group.

Conclusion

The current data lead to the conclusion that laparoscopic paraduodenal hernia repair is a safe and feasible approach for selected patients. It can be expected that as surgeons become increasingly comfortable and facile with laparoscopic techniques, paraduodenal hernias and many other causes of acute small bowel obstruction will be increasingly managed laparoscopically.     

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.     

Internal hernia formation after laparoscopic Roux-en-Y gastric bypass for morbid obesity

There is mounting concern that internal hernia formation after laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity remains unrecognized until complications develop. In this report we present our experience with this complication. Out of 100 patients who underwent LRYGB we identified five patients who were diagnosed with postoperative internal hernia formation. The medical records and operative details of these patients were reviewed. Of the five patients four were female and the average age was 36 years (range 30-43). All Roux limbs were placed in a retrocolic position. The average time interval to presentation was 104 days (range 4-305). All patients had abdominal pain and four patients experienced vomiting. One patient had obstipation. Only one patient had fever (38.1 degrees C) and the highest white cell count was 14,500. The average loss in body-mass index was 5.21 kg/m2 (range 2.5-14.8). Plain abdominal films revealed dilated bowel in the upper abdomen in three patients. Contrast bowel series was diagnostic in only one patient. One patient had a CT scan, which was diagnostic of small bowel obstruction. All patients underwent operative reduction of the internal hernia; two of these were completed laparoscopically. All hernias had occurred at the mesocolic window and were caused by sutures that had pulled through tissue at the dorsal and lateral aspect of the initial repair. One patient had a nonviable segment of small bowel. There were no deaths. Patients who undergo LRYGB are at a 5 per cent risk for developing small bowel obstruction secondary to internal hernia formation at the mesocolic window. Clinical evaluation and traditional study modalities may not be effective diagnostic tools. A high index of suspicion and low threshold to explore these patients may be the best way to avoid serious sequelae. Modification of operative techniques may reduce the occurrence of internal hernia formation.     

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.     

Laparoscopic repair of an incarcerated obturator hernia

Obturator hernia is a rare cause of bowel obstruction. Occurring primarily in elderly women, it has a high incidence of incarceration and a high mortality rate. This report describes the successful laparoscopic reduction and repair of an incarcerated obturator hernia. Using open laparoroscopy, an incarcerated obturator hernia was diagnosed intraoperatively. After laparoscopic reduction, a transabdominal preperitoneal repair was completed using polypropylene mesh. The patient recovered uneventfully with no recurrence at 6 months. Laparoscopic techniques have been successfully applied to diagnose, reduce, and repair an incarcerated obturator hernia.     

A pseudo-TEP repair of an incarcerated obturator hernia

Introduction

Obturator hernia (OH) is a rare condition and difficult to diagnose. While they account for as few as 0.073% of all hernias, mortality can be as high as 70%. The typical clinical presentation for OH is small bowel obstruction. Computed tomography is the diagnostic tool of choice. Surgical repair is mandatory in virtually all cases of OH and traditionally consists of performing an exploratory laparotomy.

Presentation of case

A 90-year-old female was admitted to our surgical service with signs of small bowel obstruction and a CT scan revealing incarcerated fatty tissue and small bowel within a left OH.

Discussion

The role of laparoscopic surgery in the management of OH has been limited to elective repairs; most reports detail that the OH was found serendipitously during laparoscopic inguinal hernia operations or other pelvic procedures. A few reports describe the use of laparoscopy to treat OH associated with bowel obstruction in an emergency setting using a TAPP approach. A strict TEP hernia repair is not indicated for all patients with OH, and should rarely be performed in emergency situations given its limitation to assess or resect bowel if necessary. In selected cases, a formal exploratory laparoscopy that is negative for compromised bowel can be safely followed by a TEP repair using the same umbilical access as shown in our patient.

Conclusion

A 90-year-old female with a small bowel obstruction related to an incarcerated OH was treated effectively with an extraperitoneal laparoscopic approach.     

Early intervention in intersigmoid hernia may prevent bowel resection-A case report

INTRODUCTION

Intersigmoid hernia is a rare internal hernia presenting with symptoms of bowel obstruction. Preoperative diagnosis is uncommon but computerised tomography (CT) may show signs to suggest internal hernia.

PRESENTATION OF CASE

A 63-year-old female presented with abdominal pain, vomiting and absolute constipation. Examination revealed a tense distended abdomen. A plain abdominal radiograph showed features of small bowel obstruction. Conservative management was initiated without success and a CT scan was performed which showed a dilated distal oesophagus, stomach and small bowel with a non-dilated length of distal ileum and large bowel. Internal hernia was suggested as a possible cause and the patient underwent a laparotomy where a loop of small bowel was found to be strangulated and gangrenous within the intersigmoid fossa. The gangrenous bowel was resected, an end-to-end anastamosis was performed and the fossa was closed. The patient made an uneventful recovery.

DISCUSSION

Hernias of the sigmoid mesocolon account for 6% of internal hernias with internal hernias themselves causing between 0.2 and 4.1% of intestinal obstruction. This report presents a case of intersigmoid hernia, a rare internal hernia which should be suspected in patients presenting with acute obstruction, no past surgical history and no external hernia. Patients with these symptoms should receive an urgent CT scan to facilitate early surgery and minimise strangulation and prevent bowel resection.

conclusion

Intersigmoid hernia presents with acute obstruction, no past surgical history and no external hernia. Urgent CT scanning and early surgery may minimise strangulation, conserve bowel and reduce patient morbidity and mortality.     

Internal hernia through the mesenteric opening after laparoscopy-assisted transverse colectomy

We report a case of a rare complication in laparoscopic colectomy. A 55-year-old woman underwent a laparoscopy-assisted transverse colectomy for transverse colon cancer. On the 5th postoperative day, she developed bowel obstruction. Decompression by a long intestinal tube failed to resolve the bowel obstruction. She underwent operative intervention. Abdominal exploration showed jejunal loop caused by a strangulation forming on an internal hernia through the mesenteric opening at the anastomotic colonic stumps, which had not been sutured during the previous operation. Our experience might indicate the need for closure of small mesenteric opening after laparoscopic colectomy.     

Internal and external supravesical hernia.

Two cases of supravesical hernia are described. One was a rare posterior internal supravesical hernia discovered only at exploratory laparotomy after exhaustive but fruitless diagnostic procedures. The surgical anatomy of anterior and posterior internal supravesical hernia is discussed and a simplified terminology is proposed.     

Elective laparoscopy for small bowel obstruction

We performed elective laparoscopic adhesiolysis in 21 patients with small bowel obstruction. The procedure was completely laparoscopic or laparoscopy assisted in 17 patients, but 4 patients required full laparotomy due to internal hernia in 2, perforation of the small bowel associated with dense adhesions in 1, and carcinoma of the cecum in 1. In patients with a laparoscopic or laparoscopy-assisted procedure, the mean operating time, mean time until the return of bowel function, and mean postoperative stay were 94 minutes, 3.3 days, and 9.9 days, respectively. During follow-up for 14 to 44 months, 3 patients developed recurrent obstruction, 1 patient suffered from catheter-induced thrombosis, and 1 patient died from lung cancer. Elective laparoscopy can be performed safely and effectively in selected patients with intermittent small bowel obstruction.     

Ileal strangulation by a secondary perineal hernia after laparoscopic abdominoperineal rectal resection: A case report

IntroducitonWe report a recent case of strangulated bowel obstruction due to an incarcerated secondary perineal hernia that developed after laparoscopic rectal resection.Presentation of caseA 75-year-old man undergoing treatment for alcoholic cirrhosis underwent laparoscopic abdominoperineal resection of the rectum (APR) for lower rectal cancer after preoperative chemoradiotherapy. Lung metastases were diagnosed 2 months postoperatively. Ten days after chemotherapy initiation, the patient was hospitalized on an emergency basis due to hepatic encephalopathy. Ten days thereafter, we observed perineal skin protrusion. Moreover, the skin disintegrated spontaneously, resulting in ascetic fluid outflow. Pain and fever developed, with inflammatory reactions. Contrast-enhanced computed tomography showed strangulated small bowel obstruction due to perineal hernia. We performed an emergency surgery, during which we found small intestine wall incarcerated in the pelvic dead space, with thickening and edema; no necrosis or perforation was observed. We performed internal fixation by introducing an ileus tube into the ileocecum and fixing its balloon at the cecal terminus.DiscussionSecondary perineal hernia is rare and can develop after APR. Its prevalence is likely to increase in future because of the increasing ubiquity of laparoscopic APR, in which no repair of peritoneal stretching to the pelvic floor is performed. However, only two case of secondary perineal hernia causing strangulated bowel obstruction has been reported in the literature. The follow-up evaluation of our procedures and future accumulation of cases will be important in raising awareness of this clinical entity.ConclusionWe suggest that the pelvic floor and the peritoneum should be repaired.     

Laparoscopic treatment of left paraduodenal hernia in two cases of children

IntroductionThe paraduodenal hernia is an internal hernia that might cause a small bowel obstruction. The laparoscopic repair of paraduodenal hernia is sporadically reported for its safety, convenience, and patient's satisfaction.Presentation of caseWe performed the laparoscopic treatment of the left paraduodenal hernia in two children, a 3-months old boy and 12-year old girl. The girl had a left upper quadrant pain for one month with postprandial nausea after eating. The 3-months boy presented with an intermittent severe irritability. Small bowel series and computed tomography showed the left paraduodenal hernia in two patients. We successfully did the laparoscopic paraduodenal hernia repair using 5 mm and 3 mm laparoscope. They discharged within 5 days, uneventfully.DiscussionDespite of technical difficulties in pediatrics such as small working space and less pneumoperitoneum, the laparoscopic repair for paraduodenal hernia leads to patient's earlier intake of diet and rapid recovery with cosmetic satisfaction. The 3 mm laparoscopic repair needs longer operation time, but it is feasible in infants.ConclusionLaparoscopic repair of paraduodenal hernia in children and infants is safe and feasible. We recommend the laparoscopic repair as the first surgical option for paraduodenal hernia.     

Adult transmesenteric hernia: report of two cases

Transmesenteric hernia is a rare cause of bowel obstruction in adults. We herein describe two cases that occurred in adult women, ages 27 and 19. Both cases presented with abdominal pain without muscular defense signs. Computed tomography of both cases showed features of small bowel obstruction by an internal hernia. A laparotomy showed mesenteric defects of the mesentery of the ileum in the former case and the mesentery of the transverse colon in the latter case, with a herniating ileum. The involved small bowel was viable in both cases, and the bowel was pulled out of the mesenteric defect without resection. The mesenteric defects were then successfully repaired.     

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.     

Intestinal obstruction after totally extraperitoneal laparoscopic inguinal hernia repair.

Laparoscopic hernia repair is a frequently performed operation. Although it has many advantages over open inguinal hernia repair, laparoscopic surgery is not without complications. Small bowel obstruction is a complication unique to laparoscopic repair of inguinal hernias. It is reported following transabdominal preperitoneal repairs. We present a case of small bowel incarceration through a peritoneal defect after a totally extraperitoneal inguinal hernia repair. Techniques to avoid this complication are presented. The literature is reviewed.