Parastomal gallbladder hernia in a septic patient

Parastomal Gallbladder Herniations: A Systematic Review

Parastomal hernias (PSHs) are a common complication following stoma placement. The presence of the gallbladder within a PSH is a rare and unusual occurrence, posing a significant management challenge for surgeons once encountered. We conducted a systematic review of the literature to evaluate the management and outcomes of parastomal gallbladder herniations. A comprehensive search was performed across the PubMed, Embase, and Medline databases using the search terms "gallbladder" AND "parastomal hernia." Additionally, a reference check of the results was conducted to identify further case reports. Eighteen case reports were included in the review. The mean age of the reported cases was 77.2 years, with a female predominance of 88.9% (n = 16). Seventy-seven percent (n = 14) of patients had an original ileal stoma or conduit. The average duration from stoma placement to clinical presentation was 5.8 years and abdominal pain was the most common presenting complaint. CT imaging was the most frequently utilised modality for successful diagnosis, with only two herniations identified during surgical exploration. Notably, 66.6% (n = 12) of patients experienced associated gallbladder complications, including cholecystitis, torsion, incarceration, and even perforation, all of which necessitated cholecystectomy. Cholecystic parastomal herniation is a rare phenomenon that should be considered in differential diagnoses for similar presentations. Currently, no standardized classification or management approach exists. Based on our findings, we propose classifying gallbladder herniations into two categories: simple (without inflammatory sequelae) and complicated (with cholecystitis, gallbladder torsion, incarceration, or perforation). Simple herniations may be managed electively with intraoperative reduction of the gallbladder. In contrast, complicated herniations presenting during acute admissions require emergency surgical intervention, involving a combined cholecystectomy and PSH repair.

Spontaneous Resolution of Parastomal Gallbladder Herniation After Attempted Surgical Intervention: A Case Report and Review of the Literature

Cholecystic parastomal herniation is a rare condition that has only been documented 16 times in the literature. We present a case report and literature review of cholecystic parastomal herniation managed with diagnostic laparoscopy without cholecystectomy or hernia repair. Furthermore, we assess the demographics, presentation, stoma types, and management of cholecystic parastomal hernias across all documented cases.

A Case of Perforated Cholecystitis into a Parastomal Hernia

INTRODUCTION

Parastomal hernia is a common complication following an enterostomy. Gallbladder herniation into parastomal hernia is rare and may become symptomatic and inflamed and very rarely can lead to gallbladder perforation. We present the first case of gallbladder perforation inside a parastomal hernia with a unique skin change. Case Description. In this report, an 87-year-old female with a history of previous open cystectomy and ileal conduit formation, presented with right upper quadrant pain and worsening parastomal swelling. A computed tomography scan showed a parastomal herniation of the gallbladder, cholelithiasis, and possible early acute cholecystitis. Within 12 hours of admission, bile staining skin changes developed around her urostomy site which raised our suspicion of a perforated gallbladder. Biliary peritonitis was confirmed on laparoscopy the same day. We proceeded with an open midline cholecystectomy without hernia repair. The patient was well at her last follow-up. Discussion. A literature review found 14 published cases of incarcerated gallbladder hernia. This uncommon condition mainly affects elderly females. Ten cases were managed operatively, and four cases were managed nonoperatively, with good outcomes. Currently, no consensus on treatment guidelines exists. In a frail elderly patient, a nonoperative approach may be suitable. Operative management was indicated in this case due to clinical concerns of perforation due to developing skin changes. This cutaneous sign has not been previously documented in the literature.

CONCLUSION

While rare, the gallbladder can herniate and become incarcerated inside a parastomal hernia. Bile staining of the skin should raise clinical suspicion of perforation. Management options depend on patient and pathology factors and can be nonoperative or operative, with or without hernia repair.

Parastomal Gallbladder Herniation as an Incidental Preoperative Computed Tomography Finding

A 65-year-old woman with a long surgical history was referred to our hospital's Colorectal Unit for ileostomy management. The patient retained an ileostomy for almost a decade after a series of complicated operations she had undergone, which had several side effects such as electrolyte imbalances, high output, weight loss, and a parastomal hernia. Our hospital's colorectal surgeon proposed to replace the ileostomy with a permanent sigmoidostomy and asked for an imaging evaluation of the parastomal hernia content before the surgery. A computed tomography of the abdomen was performed using our Computed Tomography Department's 64-detector row CT scanner after oral administration of contrast media, without intravenous contrast media injection due to allergy. Concerning the parastomal ileostomal hernia, besides small bowel loops with intraluminal gastrografin, inside the parastomal hernial sac, there also was an almost rounded cystic lesion. Absence of the gallbladder at its typical position and no record of cholecystectomy raised suspicion for gallbladder projection inside the sac. Our suspicion was confirmed during the surgery. Nonexisting acute cholecystitis allowed easy reduction of the gallbladder along with the small bowel loops inside the peritoneal cavity, without proceeding to cholecystectomy at the same time. Finally, ileostomy was annulated and an end colostomy was established. Four days after the surgery, the patient was discharged from the hospital and was happy to live an almost normal life thereafter.

The Other Double Bubble Sign: Gastric Parastomal Hernia

Introduction: A parastomal hernia (PSH) is an abnormal herniation of an intra-abdominal organ or other tissue through an intentionally created fascial defect at an ostomy site. PSHs commonly involve reducible mobile segments of omentum, intra-abdominal fat, and bowel. However, PSHs may rarely involve fixed intra-abdominal organs such as the stomach. Case Description: A 68-year-old female underwent emergent Hartmann procedure for Hinchey III diverticulitis and subsequently developed a large reducible parastomal hernia. She was scheduled for an elective laparoscopic colostomy reversal. Prior to her scheduled reversal, the patient presented to the ED with anorexia, lack of colostomy output, emesis, and pain localized to her left lower quadrant. She was found to have gastric outlet obstruction secondary to herniation of the stomach through the left lower quadrant colostomy site. The patient was admitted and treated conservatively with resolution of her symptoms, but due to the high likelihood of recurrence, the decision was made to proceed with laparoscopic Hartmann colostomy reversal with coloproctostomy and primary closure of the fascia without mesh. Conclusion: The contents of a PSH can become incarcerated causing obstruction, strangulation, necrosis and even perforation over time. Fortunately, in this case, herniation of the stomach was recognized early. The patient underwent repair of the hernia defect in order to prevent recurrence of gastric herniation and its potential detrimental complications. The decision regarding the technical aspects of ostomy reversal in terms of mesh selection require further study. In our case, mesh was not used due to patient-specific factors and comorbidities.

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.

Parastomal gallbladder herniation: A case report and review of the literature

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Gallbladder herniation is a rare complication of a parastomal hernia, affecting primarily elderly females.

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For patients with parastomal swelling and pain gallbladder herniation should be included in the differential diagnosis.

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Elderly patients with multiple comorbidities may benefit from a conservative approach instead of surgery.

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The use of prophylactic mesh when creating a permanent end colostomy reduces the rate of parastomal hernias.

Introduction

Parastomal hernia is a common complication of patients living with an enterostomy. However, a parastomal hernia involving the gallbladder is a rare condition with only eight cases documented in the literature.

Presentation of case

We report the case of a 69-year old female who underwent an open right hemicolectomy with creation of a colostomy and terminal ileostomy. She presented with parastomal swelling and pain 16 months later. A computed tomography scan revealed a parastomal herniation of the gallbladder. We elected to proceed with a cholecystectomy and hernia repair, the patient was asymptomatic at her last follow-up.

Discussion

A systematic search of the literature found eight previously published cases. This condition primarily affects elderly females. Five patients were treated surgically and three conservatively, all with a favorable outcome. In frail patients without complicating factors, a conservative treatment approach with surveillance may be safe. We chose a surgical approach due to the symptomatic nature of the presentation and the gallstone containing hernia. This is the first case of a parastomal gallbladder herniation containing a large gallstone.

Conclusion

This report should help broadening the physician’s differential diagnosis in dealing with patients with symptomatic parastomal hernias and provide an example for diagnosis and management of this complication.

Gallbladder complicating a parastomal hernia

The presence of the gallbladder in a parastomal hernia is exceeding rare. We present the case of a 75-year-old female with a parastomal hernia complicated by presence of the gallbladder. The patient was managed with surgical intervention to repair the hernia and reduce the gallbladder to its correct abdominal position without cholecystectomy. She recovered well from her surgical repair, and was recurrence free at her 6-month outpatient visit. This is the one of seven reported cases of parastomal gallbladder herniation and fits with known pre determinants of advanced age and being female. We present this case due its interesting and novel nature.

Acute cholecystitis in a parastomal hernia causing a small bowel obstruction

A parastomal hernia is the abnormal protrusion of intra-abdominal tissue and organs through a defect in the abdominal wall around an ostomy. Commonly, they involve intra-abdominal fat, omentum or bowel. However, there are rare cases that involve other organs. We present the case of an 89-year-old gentleman with a gallbladder in his parastomal hernia. Due to his acute cholecystitis, the distended gallbladder compressed adjacent bowel loops in the parastomal hernia, resulting in a mechanical bowel obstruction. The patient was treated with antibiotics and a nasogastric tube. As his cholecystitis resolved his ostomy function returned.