Ultrasound-guided reduction of a Spigelian hernia in a difficult case: an unusual use of bedside emergency ultrasonography

An Indirect Inguinal Hernia in a Neonate Containing the Uterus, Ovary, and Fallopian Tube: A Report of a Rare Case and a Literature Review

An indirect inguinal hernia is a commonly seen congenital condition that can impact infants within their first year of life. An inguinal hernia arises when a portion of the intestines, omentum, or reproductive structures herniate into the scrotal sac or labia through the patent processus vaginalis. These hernias occur more frequently in preterm newborns. The contents of a hernia often consist of the small bowel, colon, omentum, and either the ovary or testicle. The occurrence of a uterus in a herniated sac is uncommon. The presence of a uterus, ovary, and fallopian tube is exceptionally rare, with only a few cases reported in the literature. We present a unique case of a 10-day-old female neonate who was delivered at 37 weeks of gestation and brought to the Paediatric Outpatient Department with swelling in the left inguinal region that had been present for the past five days. During the clinical examination, an irreducible mass was found in the left inguinal region. The ultrasound scan showed the uterus, ovary, fallopian tube, and minimal free fluid in the herniated sac. Colour Doppler evaluation of the uterus and ovaries revealed good vascularity. A diagnosis of a left inguinal hernia containing the uterus, left ovary, and fallopian tube, with no signs of ovarian torsion, was established. We performed a surgical procedure in which the likelihood of adhesions was taken into consideration, and the organs were removed from the hernial sac. We conducted the reintegration of the organs back into the pelvis, ligation of the high sac, and further repair of the internal inguinal ring to prevent the recurrence of the hernia. The surgical procedure was successful, and the postoperative period was without any complications. After the surgery, the patient was advised to have clinical and radiological follow-up for a period of one year. We recommend that a high-resolution ultrasound (HRUS) scan be routinely performed in neonates with an asymptomatic or symptomatic palpable mass in the inguinal region for early diagnosis and characterization of the herniated structures, as well as to assess their viability.

Trocar site hernia after laparoscopy: Early recognition prevents catastrophic sequelae

BACKGROUND

Trocar site hernia is a rare but potentially serious complication of laparoscopic surgery that may lead to bowel incarceration and strangulation. Prompt diagnosis by emergency physicians facilitates timely intervention that prevents bowel necrosis. We report a case of trocar site hernia presenting to the emergency department (ED) with abdominal pain that was correctly diagnosed and promptly managed.

CASE REPORT

A 25-year-old woman, gravida 2, abortion 2, underwent outpatient surgery and laparoscopic removal of a ruptured right-sided tubal pregnancy without any intraoperative difficulties. However, 48 h later, she presented to the ED complaining of acute abdominal pain and nausea. Computed tomography revealed a loop of small bowel herniating through a 12-mm right lower quadrant trocar site defect in the fascia. She was taken back to the operating room, where the computed tomography findings were confirmed and the entrapped bowel was successfully reduced and the fascial defect repaired. The patient was discharged home feeling much improved. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Trocar site hernia is a rare but potentially dangerous complication that can present with acute symptoms or be asymptomatic if late in onset. Intestinal necrosis begins as soon as 6 h after constriction of blood flow to entrapped bowel, so timely intervention is critically important. Therefore, trocar site hernias should be considered in patients presenting with abdominal complaints after laparoscopic surgery and included in the differential diagnosis of bowel obstruction.

Point-of Care Ultrasound in Stratifying Clinically Evolving Inguinal and Femoral Hernias

BACKGROUND

Point-of-care ultrasound (POCUS) is an optimal imaging modality for the risk stratification of patients presenting to the emergency department (ED) with inguinal and femoral hernias, allowing for better evaluation of clinical presentations and guiding appropriate treatment. The lack of ultrasound classification for inguinal and femoral hernias has led to inconsistent use and often underuse of POCUS in this patient population. Several groin hernia classifications are available, but most are complex and often targeted toward surgical management.

OBJECTIVES

The objective of this study is to review the use of POCUS in the diagnosis of inguinal and femoral hernias, providing a synopsis of critical ultrasound findings in determining signs of incarceration, strangulation, and small bowel obstruction, and suggesting a simple and educative sonographic classification for inguinal or femoral hernias.

DISCUSSION

POCUS can reliably confirm the presence of groin hernias and can uniquely identify specific ultrasound findings predictive of complications, such as aperistaltic nonreducible bowel loops, free fluid in the hernia sac, and lack of color doppler in the entrapped mesentery and bowel walls. POCUS can also aid in determining the presence of small bowel obstruction by detecting dilated loops of bowel >25 mm adjacent and proximal to the hernia site.

CONCLUSIONS

In the ED, POCUS can confirm the presence of a hernia sac and identify and predict surgical emergencies, such as bowel incarceration or strangulation, which are the most important elements in the management of patients presenting with possible inguinal or femoral hernias.

Ultrasound-guided reduction of an incarcerated obturator hernia in an elderly patient

Obturator hernia is a rare but clinically relevant cause of intestinal obstruction, usually found in elderly, thin, multiparous women. It is difficult to diagnose, leading to diagnostic delay with a high incidence of strangulation and a high mortality rate. Surgery is the only reported treatment. We report the case of an 86-year-old woman, in whom an early diagnosis of incarcerated obturator hernia was made with subsequent reduction by compression with an ultrasound transducer. When the risk of strangulation is presumed to be low, ultrasound-guided reduction of an obturator hernia is achievable and worth considering.

Left Lower Quadrant Abdominal Mass: A Case of Spigelian Hernia Diagnosed by Emergency Ultrasound

Spigelian hernia is rare. The diagnosis of Spigelian hernia is often challenging. We report a case of Spigelian hernia in which emergency ultrasonography diagnosed correctly a Spigelian hernia, which was later confirmed by computed tomography and at surgery. In our opinion, ultrasonography can be an important tool for emergency physicians in cases of abdominal pain or abdominal mass.

Point-of-Care Ultrasound Identification of an Abdominal Hernia

Pediatric emergency medicine physicians may be able to use point-of-care ultrasound (POCUS) as a tool to evaluate abdominal wall masses. We present a case of a 2-month-old infant with a lower abdominal mass identified as a hernia sac by POCUS. It was initially thought to represent a Spigelian-type abdominal wall hernia but subsequently determined to be an unusual presentation of an inguinal hernia with testicular entrapment. We review each of these diagnoses in addition to relevant POCUS findings.

Inguinoscrotal hernia in infants: Three case reports in ultrasound diagnosis

An inguinal hernia occurs when an intestinal loop or part of the omentum or genital organs passes into the scrotal cavity or labia through an incompletely obliterated processus vaginalis. Inguinal hernias are most common in preterm neonates, especially at 32-weeks gestation. Content of hernia is mostly bowel and ovary/testicles. Presence of uterus in herniated sac is rare, and only few cases are reported in literature. Hernia is more frequently located on the right side because the right processus vaginalis closes later than the left. Physical examination is sufficient to enable diagnosis in most cases. Ultrasound examination is indicated in patients with inconclusive physical findings, in patients with acute scrotum, and to investigate contralateral involvement in patients in whom only a unilateral hernia is clinically evident. Routinely, color or power Doppler imaging is used in inguinal-scrotal hernia to investigate intestinal and testicular/ovarian perfusion. Urgent surgery is indicated in patients with an akinetic dilated bowel loop (a sign of strangulation) or impaired testicular/ovarian perfusion.

Diagnosis of a Strangulated Laparoscopic Incisional Hernia with Point-of-Care Ultrasonography

The use of point-of-care ultrasound for the diagnosis of bowel obstructions and hernias is becoming increasingly common in the emergency department (ED). Using a relatively rare case of an incisional port hernia, we demonstrate the ultrasound findings of a strangulated hernia causing a partial small bowel obstruction. A 46-year-old female presented four days following a laparoscopic surgery complaining of abdominal pain, nausea and lack of bowel movements. There was a palpable mass in the left lower quadrant under the 12mm trocar port incision. ED point-of-care ultrasound revealed herniated akinetic loops of bowel through her laparoscopy incision. This is the first case report to describe the use of point-of-care ultrasound for the diagnosis of a strangulated incisional port hernia at the bedside.

Emergency and elective laparoscopic repair of spigelian hernias: two case reports and a review of the literature

Diagnosing spigelian hernias through physical examination can be particularly challenging. Increasingly, laparoscopy is being used to both confirm the diagnosis and carry out therapeutic repair. Here, we describe 2 cases of successful laparoscopic repair of spigelian hernias using an Endocatch assisted sutured technique. A review of the literature describing the role of laparoscopy in the management of spigelian hernia is also provided.

Mesh-Free Laparoscopic Spigelian Hernia Repair

Varied Spigelian hernia mesh repair techniques have been described, although evidence suggests laparoscopy results in less morbidity and shorter hospitalization compared with open procedures. Laparoscopic suture repair of Spigelian hernias is rarely reported. Two patients with small Spigelian hernias (≤2 cm) were diagnosed and repaired laparoscopically using a transabdominal suture technique. Under laparoscopic guidance, a suture-passer was used to place two or three transfacial, interrupted 0 polypropylene sutures along the horizontal plane of the defect. Sutures were tied extracorporeally and closure was confirmed laparoscopically. These cases spurred a review of world literature (2001–2007) including clinical characteristics, operative techniques, and urgency of operations in Spigelian hernia patients. Data were compared using Fisher's exact test. One year postoperatively, the patients are without sequelae or recurrence. Literature review demonstrated most patients were females ( P < 0.001), ranged in age from 60 to 80 years ( P = 0.042), and presented with left-sided hernias ( P = 0.026). Open mesh repair (182/392 cases; 47%) was the most common technique; however, increasingly articles describe laparoscopic mesh repair. Mesh-free laparoscopic suture repair is feasible and safe. This novel uncomplicated approach to small Spigelian hernias combines the benefits of laparoscopic localization, reduction, and closure without the morbidity and cost associated with foreign material.

Ultrasound may decrease the emergency surgery rate of incarcerated inguinal hernia

OBJECTIVE

Manual reduction is the standard procedure for incarcerated inguinal hernia reduction. The role of ultrasound in incarcerated inguinal hernia reduction has not been defined. The aim of this study was to determine whether ultrasound can improve the ability to reduce incarcerated inguinal hernia safely when manual reduction fails and thereby decrease the emergency surgery rate.

MATERIAL AND METHODS

Between January 1994 and December 2003, 112 adult patients with incarcerated inguinal hernias were admitted to a university medical center and classified into two groups. Group I consisted of 61 patients who received emergency surgical reduction after the failure of two attempts at manual reduction. In Group II, comprising 51 patients, ultrasound-guided reduction was performed when two attempts at manual reduction failed. Emergency surgical reduction was scheduled if both ultrasound-guided reduction and two attempts at manual reduction failed. The difference in emergency surgery rates between groups I and II was compared.

RESULTS

In group I, manual reduction was successful in 55 cases (90.2%) and 6 patients underwent emergency surgery. In group II, manual reduction was successful in 45 cases, ultrasound-guided reduction in 4 cases, 1 reduction was avoided after ultrasonic examination, and 1 patient underwent emergency surgery. The emergency surgery rates in groups I and II were 9.8% and 2.0%, respectively.

CONCLUSIONS

Ultrasound can improve the ability to reduce incarcerated inguinal hernia safely when manual reduction fails and may decrease the rate of emergency surgery.

Extraperitoneal Laparoscopic Approach to Spigelian Hernia Combined With Groin Hernias

Spigelian hernia is a rare form of abdominal wall hernia. It occurs when peritoneum with or without organs or preperitoneal fat exists through a defect in the Spigelian fascia. A 63 year old male patient complaint of inguinal hernias and Spigelian hernia treated with laparoscopic approach that has been not previously reported in the literature. The use of the laparoscope has simplified the diagnosis, clarified its localization, and facilitated the subsequent repair of these hernias.

Partial preoperative reduction of inguinal hernia through compression with an ultrasound transducer

Sonography and CT are effective tools in early diagnosis of asymptomatic inguinal hernia. Sonography can be used not only for the diagnosis of hernia but also for its treatment. Real-time sonographically guided hernia reduction may avoid tissue damage that can arise from misguided compression. We report a unique case in which an incarcerated omental hernia in a 50-year-old woman was diagnosed and subsequently reduced via compression with an ultrasound transducer.