Misdiagnosed Meckel's diverticulum with internal hernia mimicking appendicitis:A case report

BACKGROUND Meckel's diverticulum is a common congenital anomaly of the gastrointestinal tract,with a higher incidence rate in children under 7 years old.The condition is characteristically asymptomatic but may become a clinical concern when complications such as intestinal obstruction,bleeding,perforation,or diverticulitis precipitate acute abdominal presentations.CASE SUMMARY This report describes the case of a middle-aged man initially suspected of having acute appendicitis,which rapidly progressed to acute peritonitis with concomitant intestinal obstruction observed during preoperative assessment.Surgical exploration confirmed the diagnosis of Meckel's diverticulum-induced internal hernia,accompanied by intestinal obstruction and necrosis.In addition,the hernial ring base exhibited entrapment resembling a surgical knot.CONCLUSION Meckel's diverticulum is a rare cause of small bowel obstruction in adults,and it should be considered in a differential diagnosis.

Stranched Internal Hernia Revealed by Occlusion of the Large Libra: A Propos of a Case

The left para-duodenal internal hernia, whose origin is generally embryological, is a rare etiology of intestinal obstruction found mainly in young adults. We report here the case of acute intestinal obstruction by left para-duodenal internal hernia in a 36-year-old young man. It was a patient who consulted urgently for occlusive syndrome with cessation of materials and gases. Abdominal percussion noted abdominal tympanism and pre-hepatic dullness was preserved. The flow and icicle signs were negative. Palpation did not objectify hepatosplenomegaly and did not find any organomegaly either. On the other hand, she found an epigastric defense. The abdominal X-ray without preparation showed water levels that were wider than high, hail-like. We performed a median above and below umbilical laparotomy and intraoperatively, it was an internal hernia with incarceration of small loops in a voluminous left paraduodenal sac of 12 cm. They were not necrotic and quickly recolored after extrication. We resected the hernial sac and closed the hernial orifice with separate stitches with absorbable suture 0. The postoperative course was simple. The patient was discharged from the hospital on the 4th postoperative day. After 18 months of hindsight, he is doing well.

Interest of Computed Tomography in the Diagnosis of Intestinal Obstruction Due to an Internal Hernia of Unusual Location: The Falciform Ligament

Pathological implications of the falciform ligament are rare and internal hernias are exceptional. The origin of the falciform ligament defect can be congenital or inflammatory (a satellite of acute cholecystitis) or even post-surgical. The internal hernias of the falciform ligament are most often revealed by an acute intestinal obstruction syndrome with an ischemic component. The scanner provides the benchmarking examination allowing us to conduct a positive diagnosis and see also the inherent complications, which drives us to take the appropriate and fast surgical procedures. It is an entity that must be known.

Intestinal infarction by internal hernia in Petersen's space after laparoscopic gastric bypass

Intestinal occlusion by internal hernia is not a rare complication(0.2%-5%)after Laparoscopic Roux-en-Y-GBP(LGBP)with higher morbidity and mortality related to mesenteric vessels involvement.In our Center,from October 2009 to April 2013 we have had 17 pts treated for internal hernia on 412 LGBP(4.12%).Clinical case:28-year-old woman,operated of LGBP(BMI=49;comorbidity:diabetes mellitus and arthropathy)about 10mo before,was affected by recurrent abdominal pain with alvus alteration lasting for a week.After vomiting,she went to first aid Unit of a peripheric hospital where she made blood tests,RX and US of abdomen that resulted normal so she was discharged with flu like syndrome diagnosis.After 3 d the patient contacted our Center since her symptoms got worse and was hospitalized.Blood tests showed an alteration of hepatic enzymes and amylases.The abdominal computed tomography(CT)showed the presence of fluid in perisplenic,peri-hepatic areas and in pelvis and a"target like imagine"of"clustered ileal loops"with a superior mesenteric vein(SMV)thrombosis involving the Portal Vein.During the operation,we found a necrosis of80 cm of ileus(about 50 cm downstream the jejuno-jejunal anastomosis)due to an internal hernia through Petersen’s space causing a SMV thrombosis.The necrotic bowel was removed,the internal hernia was reduced and Petersen’space was sutured by not-absorbable running suture.An anticoagulant therapy was begun in the post-operative time and the patient was discharged after 28 d.Conclusions:The internal hernia diagnosis is rarely confirmed by preoperative exams and it is obtained in most cases by laparoscopy but the improvement of technologies and the discover of"new"CT signs interpretation can address to an early laparoscopic treatment for high suspicion cases.

Protein-losing enteropathy caused by a jejunal ulcer after an internal hernia in Petersen's space: A case report

BACKGROUND The incidence of internal hernias has recently increased in concordance with the popularization of laparoscopic surgery.Of particular concern are internal hernias occurring in Petersen's space,a space that is surgically created after treatment for gastric cancer and obesity.These hernias cause devastating sequelae,such as massive intestinal necrosis,fatal Roux limb necrosis,and superior mesenteric vein thrombus.In addition,protein-losing enteropathy(PLE)is a rare syndrome involving gastrointestinal protein loss,although its relationship with internal Petersen’s hernias remains unknown.CASE SUMMARY A 75-year-old man with a history of laparotomy for early gastric cancer developed Petersen's hernia 1 year and 5 mo after surgery.He was successfully treated by reducing the incarcerated small intestine and closure of Petersen’s defect without resection of the small intestine.Approximately 3 mo after his surgery for Petersen’s hernia,he developed bilateral leg edema and hypoalbuminemia.He was diagnosed with PLE with an alpha-1 antitrypsin clearance of 733 mL/24 h.Double-balloon enteroscopy revealed extensive jejunal ulceration as the etiology,and it facilitated minimum bowel resection.Pathological analysis showed extensive jejunal ulceration and collagen hyperplasia with nonspecific inflammation of all layers without lymphangiectasia,lymphoma,or vascular abnormalities.His postoperative course was unremarkable,and his bilateral leg edema and hypoalbuminemia improved after 1 mo.There was no relapse over the 5-year follow-up period.CONCLUSION PLE and extensive jejunal ulceration may occur after Petersen's hernia.Doubleballoon enteroscopy helps identify and resect these lesions.

Internal Hernia of Broad Ligament： ACT Scan Suspicion and Laparoscopic Treatment

Internal hernia of the broad ligament is rare. Computerized tomography is the key tool of the diagnosis. The treatment is surgical and takes advantage of the use of laparoscopy. We report a case of internal hernia of right broad ligament suspected on computerized tomography and treated by laparoscopy. The following was uneventful.

Transverse mesocolic hernia with intestinal obstruction as a rare cause of acute abdomen in adults:A case report

BACKGROUND Internal hernia is a rare cause of acute abdomen and intestinal obstruction in adults.Internal abdominal hernias include paraduodenal,perigastric,foramen of Winslow,intersigmoid,and post-anastomotic hernias and can be congenital or acquired.Internal hernias occur in 1%-2%of patients,and transmesocolic hernias are extremely rare.This report presents a patient with a transverse mesocolic hernia with a preoperative diagnosis of small intestinal obstruction.CASE SUMMARY A 45-year-old Chinese woman was admitted to the hospital with middle and upper abdominal pain for 2 d,abdominal distension,and vomiting.After abdominal computed tomography,she was diagnosed with an internal abdominal hernia complicated by small intestinal obstruction and underwent emergency laparoscopic surgery.The patient recovered well and was discharged 6 d postoperatively.CONCLUSION Transmesocolic hernias must be considered in adult patients with signs and symptoms of intestinal obstruction,even without a history of abdominal trauma or surgery.

Easy fixation effects the prevention of Peterson’s hernia and Roux stasis syndrome

BACKGROUND Laparoscopic distal gastrectomy(LDG)for gastric cancer has been progressed and popular in Japan,since it was first described in 1994.Several reconstruction methods can be adopted according to remnant stomach size,and balance of pros and cons.Roux-en-Y(R-Y)reconstruction is a one of standard options after LDG.Its complications include Petersen’s hernia and Roux stasis syndrome.Here we report our ingenious attempt,fixation of Roux limb and duodenal stump,for decreasing the development of Petersen’s hernia and Roux stasis syndrome.AIM To develop a method to decrease the development of Petersen’s hernia and Roux stasis syndrome.METHODS We performed ante-colic R-Y reconstruction after LDG.After R-Y reconstruction,we fixed Roux limb onto the duodenal stump in a smooth radian.Via this small improvement in Roux limb,Roux limb was placed to the right of the ligament of Treitz.This not only changed the anatomy of the Petersen’s defect,but it also kept a fluent direction of gastrointestinal anastomosis and avoided a cross-angle after jejunojejunostomy.31 patients with gastric cancer was performed this technique after R-Y reconstruction.Clinical parameters including clinicopathologic characteristics,perioperative outcomes,postoperative complication and follow-up data were evaluated.RESULTS The operative time was(308.0±84.6 min).This improvement method took about 10 min.Two(6.5%)patients experienced pneumonia and pancreatitis,respectively.No patient required reoperation or readmission.All patients were followed up for at least 3 year,and none of the patients developed postoperative complications related to internal hernia or Roux stasis syndrome.CONCLUSION This 10 min technique is a very effective method to decrease the development of Petersen’s hernia and Roux stasis syndrome in patients who undergo LDG.

Left paraduodenal hernia presenting as recurrent small bowel obstruction

Internal hemiation of the small bowel is a relatively rare cause of intestinal obstruction. Left paraduodenal hernia resulting from abnormal rotation of the midgut during embryonic development is the most common form of congenital internal hernia. We report our experience in the diagnosis and management of a young male with left paraduodenal hernia presenting as recurrent intestinal obstruction. Correct preoperative diagnosis of left paraduodenal hernia had been difficult due to non-specific clinical presentations, but the advent of modern imaging technology makes early and correct diagnosis possible, Due to the risk of obstruction and strangulation, surgical treatment is indicated; however, timely intervention increases the likelihood of a favorable outcome.

Strangulated hernia through a defect of the broad ligament and mobile cecum: A case report

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 endto-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.

Left paraduodenal hernia in an adult complicated by ascending colon cancer: A case report

Paraduodenal hernia is the most common internal hernia. The clinical symptoms of paraduodenal hernia may be intermittent and nonspecific. Therefore, it is difficult to diagnose preoperatively. Abdominal computed tomography （CT） scan currently plays an important role in the evaluation and management of paraduodenal hernia before surgical operation. We report one unique case of preoperatively diagnosed left paraduodenal hernia complicated by advanced ascending colon cancer and reviews of Japanese literature.

Transmesosigmoid hernia:Case report and review of literature

Transmesosigmoid hernia has previously been considered as a rare condition.The clinical symptoms can be nonspecific.Here,we report a case of acute intestinal obstruction because of transmesosigmoid hernia.In addition,after a comprehensive review of PubMed and China National Knowledge Infrastructure,we present a review of 22 cases of transmesosigmoid hernia.We summarize several valuable clinical features that help early recognition of transmesosigmoid hernia.As a result of easy strangulation,in patients without a history of surgery or abdominal inflammation who present with symptoms of progressive or persistent small bowel obstruction(SBO),surgeons should consider the possibility of transmesosigmoid hernia.In addition,based on our data,in patients with SBO because of transmesosigmoid hernia,the defect is usually 2-5 cm in diameter.Furthermore,because of the high risk of strangulation with transmesosigmoid hernia,it is mandatory to reassess the condition timely and periodically when patients receive conservative treatment.

Closed loop ileus caused by a defect in the broad ligament:A case report

BACKGROUND Closed loop ileus caused by entrapment of bowel in a defect of the broad ligament is a rarity.Only a few cases have been reported in the literature.CASE SUMMARY We present the case of a 44-year-old,healthy patient with no prior history of abdominal surgery who developed a closed loop ileus due to an internal hernia secondary to a defect in the right broad ligament.She first presented to the emergency department with diarrhea and vomiting.As she had had no previous abdominal surgery,she was diagnosed with probable gastroenteritis and discharged.The patient subsequently returned to the emergency department due to a lack of improvement in her symptoms.Blood tests showed an elevated white blood cell count and a closed loop ileus was diagnosed on an abdominal computer tomography scan.Diagnostic laparoscopy revealed an internal hernia entrapped in a 2 cm large defect in the right broad ligament.The hernia was reduced and the ligament defect was closed using a running,barbed suture.CONCLUSION Bowel incarceration through an internal hernia may present with misleading symptoms and laparoscopy may reveal unexpected findings.

Abdominal separation in an adult male patient with acute abdominal pain

We report a male patient with prolonged post-prandial abdominal distension and a sudden onset of epigastric pain initially diagnosed as acute abdomen. The patient had no history of surgery. Physical examination revealed peritonitis and abdominal computed tomography scan showed upper abdominal mesentery intorsion. The patient then underwent surgical intervention. It was found that the descending mesocolon dorsal root was connected to the ascending colon and formed a membrane encapsulating the small intestine. The membrane also formed an orifice in the ileal pars caeca, from which a 30 cm herniated ileum formed a "C"-shaped loop which was strangulated by the orifice. An abdominal separation was diagnosed after surgery. We liberated the membranous peritoneum which incarcerated the intestinal canal from the root ofileocecal junction to Treitz ligament, and reduced the small intestinal malrotation. The patient had an uneventful recovery after opera-tion with his abdominal distention disappeared during the follow-up. Abdominal separation is a rare situation, which may be related with embryo development. Surgery is a choice of treatment for it.

Right paraduodenal hernia:report of two cases and review of literature

Paraduodenal hernia(PDH),a rare congenital anomaly,is a type of internal hernia which occurs due to a defect in the reduction and rotation of the midgut.On anatomical and embryological basis,PDH can be broadly divided into right-and Left PDH.Right PDH is rarer than its counterpart.We present two cases of Right PDH.The patientsy presented with a history of recurrent intestinal obstruction since childhood,which was managed conservatively,without a definitive diagnosis.Once they presented to us,a detailed clinical history and a barium meal follow-through clinched the diagnosis of PDH.Intra-operative findings correlated well with the clinical diagnosis.The jejunal loops had herniated through the fossa of Waldeyer.Reduction of hernia contents and excision of the hernia sac was carried out.Post-operatively,the patients are healthy and symptom-free at 4 and 3 years follow-up,respectively.The rarity of this condition and the need for early diagnosis,to prevent the high risk of bowel obstruction and strangulation,makes PDH one of the difficult challenges for the clinicians.

A new concept and classification of corona morris and its clinical significance

Purpose： The obturator artery and its accessory （aberrant） arising from different origins and crossing the pubic rami are vascular variations. The internal iliac artery usually provides the obturator artery which may communicates with the external iliac artery through either the accessory obturator or inferior epigastric artery. A collateral circulation between the external and internal lilac system is known as corona mortis. The aim of current study is to provide sufficient data of vascular variability crossing the pubic rami for clinical field. Methods： Present study includes 208 hemipelvises dissected in the Institution of Anatomy, Medical University of Graz. During dissection, the obturator artery and its accessory crossing the superior rami of pubic bone were found to have different origins. Results： The obturator artery arising from the external lilac artery and from the femoral artery accounts for 9.8% and 1.1% respectively. Therefore, it passes over the superior pubic rami in 10.9%. Further, the accessory （aberrant） artery arises only from the femoral artery in 1.1%. In present study, the vascular variation crossing the superior pubic rami with or without collateral circulation between external and internal iliac system referred as corona mortis is addressed. This study includes new classification of obturator and accessory obturator arteries as well as the corona mortis. It includes a comparison of corona mortis incidence in Austria population and other populations. The corona mortis found to be in 12% of Austrian population. Conclusion： A great attention of clinicians, radiologists, surgeons, orthopedic surgeons, obstetricians and gynecologists has to be considered before pubic surgical procedures such as internal fixation of pubic fracture, an inguinal hernia repair. Further, traumatic pubic rami fracture may lead to massive hemor- rhage due to laceration of the obturator artery.