Littre's hernia: a systematic review of the literature

Littre's Umbilical Hernia in a Child: A Case Report and Scoping Review

Littre's umbilical hernia (UH) is a rare disease, the third most common Littre hernia. Most case reports interest adult patients. We reported the case of a four-year-old girl with anemia and symptomatic UH, with an incidentally diagnosed Meckel's diverticulum (MD) containing pancreatic ectopic tissue. We reviewed case reports on Littre's umbilical hernia without a date or language restriction. Including our patient, 21 cases were reviewed, of whom 15 (71.4%) were adults and 13 (61.9%) were males. Complicated umbilical hernia occurred in 13 patients (61.9%) and symptomatic MD in two children (9.5%). Investigations preoperatively diagnosed two patients (9.5%). Eighteen patients (85.7%) underwent open surgery, Meckel's diverticulum removal was performed in 18 patients (85.7%), and primary umbilical hernia repair was performed in 16 (76.2%). Ectopic tissue was present in four patients (19.1%), and long-term outcomes were excellent in all patients.

Umbilical Littre hernia: A rare case report of an acute abdomen

INTRODUCTION

Littre's hernia (LH) is due to the presence of a Meckel's diverticulum (MD) in a hernial sac. It is an extremely rare condition in less than 1 % of all MD cases. It is often asymptomatic and is diagnosed incidentally during routine surgery for hernia repair. Surgery is the main treatment. Although the management of uncomplicated MD remains controversial, MD's management in the setting of either bowel obstruction or of Littre's hernia is done according to the clinical principles combined with the availability of local expertise.

PRESENTATION OF CASE

We report a case of an 11-year-old boy presented to the emergency room with a diagnosis of acute obstructive syndrome. Radiological exams were inconclusive. Intra-operatively findings showed a strangulated MD trapped in a small umbilical hernia. A simple wedge resection, followed by a primary closure of the remaining defect was performed. During 12 months of observation the patient remains in good condition.

DISCUSSION

LH is an uncommon type of abdominal wall hernia. Preoperative diagnosis is difficult. Even abdominal ultrasound and computed tomography (CT) cannot reveal the right diagnosis and it is generally performed intraoperatively. The main treatment is surgery. Repair of a Littre hernia requires both management of Meckel's diverticulum and repair of the hernia with sutures or mesh.

CONCLUSION

LH is a very rare type of hernia. Diagnosis is very difficult. All surgeons should be aware of this type of hernia to avoid life-threatening complications. The application of hernia repair recommendations for children may anticipate the happening of complicated LH.

An unusual form of incisional hernia: A case report of Littre's hernia

INTRODUCTION

Littre's hernia (LH) is a rare condition involving Meckel's diverticulum within a hernia sac, with an incidence of <0.1 % of all complicated hernias. To this day, only a few case reports have been published concerning this entity.

CASE PRESENTATION

A 48-year-old patient with a history of four midline C sections and an incarcerated incisional midline hernia was admitted to the emergency department for small bowel obstruction evolving for 12 h. Examination revealed an incarcerated midline incisional hernia. An abdominal CT scan was performed, showing a multi-orifice incisional hernia with a small bowel loop and a 3 cm abscess. The patient underwent an urgent midline laparotomy. During surgery, we found a small bowel loop with a perforated Meckel's diverticulum, located 50 cm from the ileocaecal valve, associated with a 3 cm abscess. Surgical drainage of the abscess, resection of 20 cm of small bowel, including the diverticulum, and an appendicectomy were performed. The incisional midline hernia was managed by herniorrhaphy. The post-operative course was uneventful.

CLINICAL DISCUSSION

Surgeons need to keep in mind the possibility of discovering Meckel's diverticulum in a hernia sac in every incarcerated hernia. Complete history intake and careful physical examination are important to uncover signs prompting clinical suspicion. Littre's hernia is rare and difficult to diagnose, with no distinguishing clinical features or physical signs.

CONCLUSION

Managing LH involves treating the symptomatic Meckel's diverticulum with various resection methods and the hernia itself, with mesh application being a controversial topic. Prophylactic resection remains debatable among experts.

Incidental Meckel's Diverticulum in Umbilical Hernia

The presence of a Meckel's diverticulum in the hernial sac is called a Littre's hernia. It is a rare complication of Meckel's diverticulum. We present a 56-year-old male patient who complained of swelling in the umbilical region. After the clinical examination and imaging studies, we diagnosed the patient with a partially reducible umbilical hernia. The patient underwent exploration and was found to have omentum, Meckel's diverticulum, and part of the ileum within the sac. The patient underwent segmental resection of the bowel, primary repair of the hernial defect, and onlay meshplasty. Postoperatively, the patient did not develop any complications.

Management of Littre Hernia-Case Report and Systematic Review of Case Reports

Littre hernia is a rare type of hernia in which a Meckel diverticulum is found in the hernia sac. Given the rare nature of this disease, little data on demographics and surgical management exists. In this article, we provide a case report of a strangulated inguinal Littre hernia and perform a systematic review of the literature. The PubMed database was searched on 5 March 2022, and all cases of Littre hernia in adults that had English abstracts or full-text were analyzed. Our primary objective was to evaluate the surgical management and outcomes of this particular type of hernia, and our secondary objectives were to assess demographic characteristics, presentation particularities, and recurrence rates. We identified 89 articles with 98 cases, including our own. Results show a high prevalence of complications described intraoperatively, with strangulation being present in up to 38.46% of patients. The laparoscopic approach was utilized in patients with femoral, inguinal, and umbilical hernias. The most commonly performed type of resection was MD resection, followed by bowel resection, while a minority of cases (5.48%) remained unresected. Mesh repair was more frequently performed in patients with MD resection. A mortality rate of 8.7% in patients who underwent bowel resection was found. A relatively high number of reports of ectopic tissue (21.21%), ulceration (12.12%), and tumors (9.09%) were found. The average follow-up was 19.5 ± 10.29 months, with no hernia recurrence. In conclusion, most cases are admitted in an emergency setting, and intestinal obstruction is frequently associated. A minimally invasive approach can be an option even for complicated hernias. MD resection or bowel resection is usually employed, depending on the extent of ischemic lesions. Patients undergoing bowel resection may be prone to worse outcomes.

A case report of an asymptomatic necrotic Meckel's diverticulum in an inguinal hernia during elective surgery in a resource limited setting: Littre's hernia

INTRODUCTION AND IMPORTANCE

Although the common complications of Meckel's diverticulum (MD) are well known, that these congenital intestinal outpouchings may become involved as the content of abdominal hernia sacs is not well appreciated. MD is the most prevalent congenital abnormality of the gastrointestinal tract, but involvement in a hernia, known as Littre's hernia (LH), accounts for less than 1 % of MD cases. Incarcerated LH has been reported sporadically in the literature, with MD found in the sacs of paraumbilical, femoral, inguinal, and incisional hernias.

PRESENTATION OF CASE

We report a LH in a 3-year-old male child who was scheduled for elective herniotomy for a reducible left inguinal hernia. Intraoperatively we found the hernia sac contained a necrotic and perforated MD with viable associated bowel loop. The patient was successfully managed by diverticulectomy and primary repair through a trans-inguinal incision and herniotomy was performed.

CLINICAL DISCUSSION

LH is a rare presentation of MD, and preoperative diagnosis of LH is challenging. Even in the case of a strangulated MD, a patient may not present with the typical signs and symptoms associated with compromised viscous. Once identified, repair of Littre hernia consists of resection of the diverticulum, or segmental bowel resection if necessary, and herniotomy.

CONCLUSION

The finding of a perforated MD during elective hernia repair emphasizes the importance of awareness of unusual variants of inguinal hernia, and the necessity of identifying a MD given the risk of sequelae in the case of necrosis or perforation, if not repaired.

Littre's hernia-a reason for resection

Littre's hernias are exceedingly rare, with an estimated incidence of 0.09% in strangulated or incarcerated hernias. It may present as a complication of Meckel's diverticulum in less than 1%. In the adult population, it presents as an inguinal (50%), femoral (20%) and umbilical (20%) hernias. Management of Meckel's diverticulum when encountered during a routine repair of hernia in literature is generally resection. We present a case of a healthy 68-year-old gentleman who was found to have a Meckel's diverticulum in the indirect hernia sac during routine elective open right inguinal hernia repair.

A new hernia: Meckel's diverticulum within a parastomal hernia

A Meckel's diverticulum is a true diverticulum containing all layers of bowel wall. An infrequently encountered sequela of this is a Littre's hernia, typically inguinal or femoral. This is the first description of a Meckel's diverticulum within a parastomal hernia. When encountered incidentally at surgery, resection should be considered on a case-by-case basis to prevent future complications of bleeding, obstruction or perforation.

Bowel obstruction secondary to gallstone ileus within a strangulated inguinal hernia: Report of a rare diagnosis

INTRODUCTION

Gallstone ileus is rare and inguinal hernias are common causes of intestinal obstruction but combination of them is a very rare cause of intestinal obstruction. It is accepted that in patients with severe comorbidities surgeons can manage inguinal hernias and gallstone conservatively. In this article we report a patient with gallstone and inguinal hernia that managed with conservatively management because of heart failure but admitted with complication of gallstone and hernia and treated successfully.

CASE PRESENTATION

An 80-year-old woman with a history of heart failure and two bouts of acute cholecystitis, who presented with pain and swelling in the inguinal region and obstructive symptoms. And due to the urgent nature of the condition, she underwent surgery.

CONCLUSION

One of the rare complications of gallstones is cholecystoduodenal fistulas, especially in patients whose episodes of cholecystitis are treated medically. Early diagnosis and appropriate surgical management in these circumstances reduce the mortality and morbidity.

Management of inflamed sigmoid diverticulum inside an incarcerated right inguinal hernia: Case report of a rare discovery

Introduction

Incarcerated inguinal hernia is one of the most common emergencies in surgery. The diagnosis is usually made by physical examination, but the contents of the hernia sac may vary.

Case presentation

We present a rare case of inflamed diverticulum of the sigmoid colon found within an incarcerated right inguinal hernia sac in a 77-year-old man. The inflamed diverticulum was resected, and the hernia was repaired with synthetic mesh. No postoperative complication occurred. No previous study has reported a similar approach.

Discussion

It is most unusual for an uncomplicated inflamed sigmoid colon diverticulum to be found in the hernia sac when performing acute repair of an incarcerated inguinal hernia. Resection of the diverticulum and subsequent repair of the hernia with synthetic mesh is an attractive alternative.

Conclusion

Acute diverticulitis should always be considered in patients with an acute abdomen, this includes those with a painful hernia. Emergency surgery should not be delayed, and local resection of the inflamed diverticulum may be an option if no perforation is apparent, and the surrounding colon is unaffected.

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Acute sigmoid diverticulitis presenting as incarcerated inguinal hernia is rare.

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This condition may mimic herniation of a saccular protrusion of the sigmoid colon.

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Local resection of the diverticulum is safe if there is no perforation and the remaining colonic wall is unaffected.

A Strangulated Meckel's Diverticulum in an Inguinal Hernia: A Case Report and Literature Review

Background

Meckel's diverticulum is an embryologic remnant of the vitelline duct, occurring in approximately 2% of the adult population. A hernia containing a Meckel's diverticulum is called a Littré's hernia and is rarely reported in the medical literature. Clinically, a Littré's hernia is indistinguishable from a hernia containing small bowel and is often discovered incidentally during a repair.

Case Presentation

Herein, we report a rare case of strangulated Littré's hernia in a patient's right groin. The sac contained a long segment of small bowel in addition to a large Meckel's diverticulum. The bowel was irreducible through the groin incision, and a lower midline laparotomy was made. Necrotic bowel including the Meckel's diverticulum was resected. Given the presence of necrotic bowel and potential for infection, the hernia was repaired with a Bassini herniorrhaphy, reinforced with absorbable mesh. The patient recovered uneventfully.

Conclusion

Littré's hernia is a rare clinical entity. Treatment is similar to any bowel-containing hernia. Repair of the hernia defect with permanent mesh should be weighed against the risk of implant infection.

Complicated Littre's umbilical hernia with normal Meckel's diverticulum: A case report and review of the literature

Introduction and importance

A Littre's hernia (LH) is defined by the presence of Meckel's diverticulum (MD) in any kind of hernia sac. Preoperative diagnosis of LH is a challenge because of its rarity and the absence of specific radiological findings and clinical presentation. Surgery is the appropriate treatment of complicated LH that is an extremely rare condition with approximately 50 cases reported in the literature over the past 300 years.

Case presentation

A 46-year-old Caucasian female was admitted to the Emergency Department with a two-day history of abdominal pain. Physical examination revealed an irreducible and painfull mass in umbilical region. Abdominal computed tomography scan showed the protrusion of greater omentum and small bowel loop through the umbilical ring. Laboratory tests were unremarkable. After diagnosis of strangulated umbilical hernia, the patient underwent exploratory laparotomy: the irreducible umbilical hernial sac was opened with presence of incarcerated and strangulated omentum and uncomplicated MD. Resection of incarcerated and ischemic greater omentum alone was performed. The postoperative course of patient was uneventful.

Clinical discussion

Meckel's diverticulum (MD) is a vestigial remnant of the omphalomesenteric duct, representing the most common congenital malformation of the gastrointestinal tract. Preoperative diagnosis of LH is very difficult and surgery represents the correct treatment of complicated LH.

Conclusion

LH represents an extremely rare complication of MD difficult to diagnose and suspect because of the lack of specific radiological findings and clinical presentation. Surgery represents the appropriate treatment of abdominal wall hernias and complicated MD.

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A Littre's hernia (LH) is defined by the presence of Meckel's diverticulum (MD) in any kind of hernia sac.

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LH is an extremely rare complication of MD and its preoperative diagnosis is very difficult.

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Surgery represents the appropriate treatment of abdominal wall hernias and complicated MD.

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Routine resection of uncomplicated MD is not advised and it should be based on identified MD’ s risk factors.

Incarcerated gallbladder in inguinal hernia: a case report and literature review

Background

Treating hernias is one of the oldest challenges in surgery. The gallbladder as content in the case of abdominal hernias has only been reported in a few cases in the current literature. Cholecyst has only been described in the content of an inguinofemoral hernia in one case to date.

Case presentation

A 73-year-old female patient was admitted to the Emergency Department due to complaints in the right inguinal area, which had started 1 day earlier. The patient complained of cramp-like abdominal pain and nausea. Physical examination confirmed an apple-sized, irreducible hernia in the right inguinal region. Abdominal ultrasound confirmed an oedematous intestinal loop in a 70-mm-long hernial sac, with no circulation detected. Abdominal X-ray showed no signs of passage disorder. White blood cell count and C-reactive protein level were elevated, and hepatic enzymes were normal in the laboratory findings. Exploration was performed via an inguinal incision on the right side, an uncertain cystic structure was found in the hernial sac, and several small abnormal masses were palpated there. The abdominal cavity was explored from the middle midline laparotomy. During the exploration, the content of the hernial sac was found to be the fundus of the significantly ptotic, large gallbladder. Cholecystectomy and Bassini’s repair of the inguinal hernia were performed safely.

Conclusions

Following a review of the literature, it can be concluded that the finding of incarcerated gallbladder in the content of an inguinal hernia is a rare finding. No other similar emergency case and successful surgical intervention have been reported before.

Two-stage laparoscopic surgery for incarcerated umbilical Littre's hernia in severely obese patient: a case report

Background

Littre's hernia containing Meckel's diverticulum is an extremely rare disease. We report an adult case of two-stage laparoscopic surgery for incarceration of Meckel's diverticulum in an umbilical hernia.

Case presentation

The case involved a 23-year-old, severely obese man with BMI 36.5 kg/m². After experiencing effusion from the umbilicus for 2 months, and was referred from a local dermatologist. We diagnosed an infected urachal remnant, and antibiotic therapy was performed first. Surgery was planned for after the infection disappeared. During follow-up, effusion from the umbilicus took on an intestinal fluid-like character, so we diagnosed small intestinal cutaneous fistula and performed surgery. Under laparoscopy, we found a Meckel's diverticulum incarcerated in an umbilical hernia. The diverticulum was resected first, and the incarceration was released. The umbilicus was infected, so we planned repair of the umbilical hernia in a second surgery. The postoperative course was uneventful and the patient was discharged on postoperative day 5. One month after the initial operation, we confirmed that there were no signs of infection, and performed umbilical hernia repair using the laparoscopic intraperitoneal onlay mesh (IPOM) repair. Postoperative progress was uneventful and he was discharged on postoperative day 4. No recurrence or infection was observed until 8 months postoperatively.

Conclusions

We performed dissection of the diverticulum and umbilical hernia repair for the incarcerated umbilical Littre's hernia under laparoscopy in a severely obese patient. The risk of mesh infection seems to be avoidable using a two-stage surgery, and the risk of recurrence can be reduced using the IPOM repair compared with simple suture closure.

Re-do surgery after prosthetic abdominal wall repair: intraoperative findings of mesh-related complications

INTRODUCTION

Mesh repair is one of the most popular technique for the treatment of abdominal wall hernias, resulting in lower recurrence rates. However, it is associated with a high risk of mesh-related complications. The aim of the present study is to assess the impact of biomaterials on the intra-abdominal organs, in terms of adhesions and visceral complications, in a series of patients undergoing re-do surgery at our abdominal wall unit.

MATERIALS AND METHODS

We reviewed the clinical records of 301 patients who undergone laparotomy between June 2008 and May 2018, selecting 67 patients with one or more previous prosthetic abdominal wall repair (AWR).

RESULTS

The average number of previous repairs was 1.6 with a mean time interval of 66 months from the last repair. Clinical presentation included hernia recurrence (69%), mesh infection (26%), infection and recurrence (10%), and fistula (1%). Adhesions were intraoperatively observed in all patients, except for eight cases. Mesh was completely removed in 43 patients, partially in four. Postoperative complications were observed in 39% of cases, including wound dehiscence, hematoma, seroma, and mesh infection.

CONCLUSIONS

Long-term implant results in abdominal wall repair and are not completely known, and literature is still lacking on this topic. Re-do surgery for subsequent pathological events may represent a way to increase our knowledge.

Meckel's diverticulum and the eponymous legend

Johann Friedrich Meckel (1781-1833) was a 19th century anatomist born into an eminent dynasty. He was a professor of anatomy, pathology, and zoology at the University of Halle, in Central Germany. The diverticulum, a congenital remnant of the vitellointestinal duct was named after him. Other eponyms include Meckel's cartilage, Meckel syndrome, and Meckel-Serres law of recapitulation. His concepts in comparative anatomy, embryology, and teratology anticipated Darwin. This review is a short tribute to this legend and his prolific contributions. LEVEL: Historic review, level V.

A Rare Case of Acquired Transthoracic Littre's Hernia

Introduction  The Littre hernia is a rare complication of Meckel's diverticulum. Meckel's diverticulum is vestigial remnant of the omphalomesenteric duct occurring in approximately 2% of the general population with an estimated 4 to 16% risk of complications. Usual sites of the Littre hernia include inguinal (50%), umbilical (20%), and femoral (20%). We report a case of an acquired transthoracic Littre's hernia occurring through the left part of the diaphragm triggered by a history of traumatic rib fractures associated with alcohol abuse. Case Report  A 71-year-old man presented with 4-day history of worsening shortness of breath, colicky lower abdominal pain, and inability to open bowels despite passing flatus, without nausea or vomiting. His past medical history was remarkable for multiple traumatic rib fractures caused by falls which were associated with excessive alcohol consumption. A noncontrast computed tomography (CT) scan of the abdomen and pelvis showed distended jejunal loops containing air/fluid levels likely resulting from herniated jejunum between the left chest wall and left diaphragm. An urgent laparotomy was performed which revealed small bowel and omentum herniating through a small defect in the left posterior hemidiaphragm. The contents of the sac were reduced and a Meckel's diverticulum was found inside the sac, characteristic of Littre's hernia. The diaphragmatic defect was closed and the Meckel diverticulum stapled and excised. Discussion  Herniation of Meckel's diverticulum through the diaphragm most commonly occurs in the pediatric population. Acquired transthoracic Littre's hernia is rare and may arise following thoracobdominal trauma caused by surgery, motor vehicle accidents, and falls from height. Left-diaphragmatic tears are characteristically more clinically apparent and symptomatic than the right since the liver often has a protective effect on the right part of the diaphragm. Herniation of abdominal contents in the chest cavity causes respiratory distress and requires urgent surgical correction. Diagnosis is often delayed since diaphragmatic hernia tends to present very late after the initial trauma, subjecting the patient to possible life-threatening complications. While it is easier to reduce the herniated contents and repair the diaphragm via a thoracic approach, laparotomy is often preferred in cases of acute trauma associated with intra-abdominal injuries. Repair of Littre's hernia then consists of resection of the diverticulum and herniorraphy. Conclusion  Internal Littre's hernia is usually of congenital origin. This is the first case of a transthoracic Littre's hernia caused by traumatic rib fractures. Hence, it is of utter importance that a clinician is aware of such uncommon pathology.

Intestinal obstruction due to incarcerated Meckel’s diverticulum (Littre’s hernia)

Meckel's diverticulum it is the most common malformation of the gastrointestinal tract. Femoral hernia is the second most common inguinal hernia, and is characterized by incarceration and strangulation. We present a case of 90-year-old woman wiht strangulation of Meckel’s diverticulum in a left-sided femoral hernia. The diverticulum was resected and hernia was repared wihtout complications. A Littre’s hernia is a complication of Meckel’s diverticulum and it is a result of its protrusion through a herniary orifice. Surgical resection is recommended for this type of hernia due to possible vascular complications, intestinal obstruction and herniation. Although usually Littre’s hernia appears in the early ages of the life, we must not ignore their possible appearance in people who are aged. We present in this case a Littre’s hernia in a very old woman.