Usefulness of Oblique Multiplanar Images on Multi-Detector Computed Tomography for Diagnosing Intersigmoid Hernia

A case report of intersigmoid hernia treated using laparoscopic surgery

INTRODUCTION AND IMPORTANCE

Intersigmoid hernia (ISH) is a rare disease that is difficult to diagnose preoperatively and sometimes causes intestinal necrosis that requires emergency surgery.

CASE PRESENTATION

The patient was an 87-year-old male with no history of abdominal surgery who visited our emergency outpatient service due to left lower quadrant pain and vomiting as chief complaints. Abdominal findings showed tenderness with the severest point in the left lower quadrant of the abdomen. Contrast-enhanced CT showed poor imaging of the dorsal sigmoid colon and an expanded proximal small intestine, with regional ascites around the small intestines. The patient was diagnosed with small bowel obstruction associated with ISH incarceration and underwent emergency surgery. Invagination of the small intestine into the intersigmoid fossa was found by laparoscopy. The incarcerated part was removed and the hernia orifice was sutured and closed. Mild congestion was seen in the incarcerated small intestine, but with no findings of ischemia. Thus, intestinal resection was determined to be unnecessary. The postoperative course was good and the patient was discharged on postoperative day 6.

CLINICAL DISCUSSION

ISH is often diagnosed as simple ileus at the initial visit, which can result in delayed surgery. There are no case reports of complete remission of ISH with conservative therapy, and treatment with surgery is generally required. Our patient underwent early surgery because of CT findings that were characteristic of ISH and allowed diagnosis before surgery.

CONCLUSION

Early diagnosis of ISH and performance of laparoscopic surgery can avoid the need for intestinal resection.

Laparoscopy-Assisted Repair for Intersigmoid Hernia

Intersigmoid hernia is a rare clinical entity. Only 6 cases of laparoscopic repair for intersigmoid hernia have been reported since 1977. We herein report such a case, which was successfully diagnosed preoperatively and treated with laparoscopic repair. A 50-year-old man with a chief complaint of abdominal pain and vomiting was admitted for the treatment of small bowel obstruction. The patient had no history of abdominal surgery. Computed tomography showed a dilated small bowel and a closed loop of small bowel dorsal to the sigmoid colon and the sigmoid mesocolon. With a diagnosis of an incarcerated internal hernia, the patient underwent emergency laparoscopy-assisted surgery. Laparoscopy showed that the ileum had herniated into the intersigmoid fossa, and therefore the patient was diagnosed with an intersigmoid hernia. Because bowel ischemia was not observed, we reduced the incarcerated small bowel, and the hernial defect was widely opened. After operation, the patient developed ileus and was treated with transnasal ileus tube. Thereafter, the patient made a satisfactory recovery and was discharged on postoperative day 21. The patient is in good general condition without ileus 42 months postoperatively.

Intersigmoid Hernia: A Forgotten Diagnosis-A Systematic Review of the Literature over Anatomical, Diagnostic, Surgical, and Medicolegal Aspects

Introduction

Intersigmoid hernia is a hernia of the small bowel into the intersigmoid fossa. It is well known to be a rare condition. Recent reports reveal that the preoperative differentiation of intersigmoid hernias is difficult and the diagnosis is often confirmed during the laparotomic exploration. Due to the vague clinical manifestation in most cases, the surgical treatment is frequently delayed.

Materials and Methods

In this study, we systematically reviewed the literature up to 2019 covering 114 studies and 124 patients with an intersigmoid hernia. The purpose of this work is to improve the understanding of the anatomical aspects, clinical presentation, diagnosis, and treatment of intersigmoid hernia so as to assist the preoperative differentiation of these hernias when presented as acute abdomen in the emergency department.

Results

The diameter of the intersigmoid recess was reported with mean 2.65 cm (range 1-10 cm, SD 1.15 cm) and the length of the incarcerated small intestine was between 3 cm (min) and 150 cm (max): mean 25.25 cm, SD 35.04 cm. The diameter of the sigmoid recess was greater in patients who underwent resection due to strangulation (mean 3.31 cm, SD 1.53 cm) compared to those who underwent only reduction of the hernia (mean 2.35 cm, SD 0.74 cm). The time from onset to operation was less in patients undergoing resection surgery due to throttling (mean 3.03 days, SD 3.01 days) compared to those who underwent only a reduction of hernia incarceration (mean 8.49 days, SD 6.83 days).

Conclusion

Intersigmoid hernia is often a forgotten diagnosis and a clinical challange due to its anatomical characteristics.

Emergency laparoscopic approach without sufficient preoperative decompression for intersigmoid hernia: A case report

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Emergency laparoscopy can be performed without sufficient small bowel decompression.

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MDCT is advantageous for preoperatively recognizing anatomical relationships.

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Careful preoperative diagnosis and emergency laparoscopy can lead to good outcomes.

Introduction

In acute care surgery, an increasing number of patients operatively treated for small bowel obstruction undergo laparoscopic procedures. However, intersigmoid hernia is a rare condition. In some reports, surgeons have successfully operated on patients with an intersigmoid hernia via a laparoscopic approach. The laparoscopic approach has the advantage of facilitating simultaneous diagnosis and surgical intervention for intersigmoid hernias. In the laparoscopic approach, sufficient decompression of the small bowel is preoperatively performed in most cases.

Presentation of case

We encountered a patient with an intersigmoid hernia who underwent an emergency laparoscopic approach without sufficient decompression. Because sufficient decompression of the small bowel was not preoperatively performed, it was difficult to establish a working space and visualize the site of obstruction; however, we performed the laparoscopic approach safely, and diagnosis and surgical intervention were possible. Moreover, the postoperative course was uneventful.

Discussion

We successfully performed an emergency surgery using a laparoscopic approach for an intersigmoid hernia without sufficient decompression. The success of the procedure is attributable to the disease-specific surgical strategy, surgical technique, and the recent technological advances in multidetector-row computed tomography.

Conclusion

We believe that careful preoperative diagnosis and strategy can lead to a good outcome and that the significance of emergency laparoscopic approach without sufficient decompression will keep increasing.

Diagnosis of incarcerated intramesosigmoid hernia aided by multiplanar reconstruction images of multidetector computed tomography: a case report

Background

Internal hernia is a rare cause of intestinal obstruction, and sigmoid mesocolon hernia is an extremely rare form of this condition.

Among sigmoid mesocolon hernias, intramesosigmoid hernia is the least frequent subtype.

We described a case of intramesosigmoid hernia through the orifice on the right leaf of the mesosigmoid with an incarcerated ileum of 6 cm in length without strangulation. This case was diagnosed by multidetector computed tomography with multiplanar reconstruction images and treated without resection of the small intestine in a 52-year-old man with characteristic diagnostic images.

Case presentation

A 52-year-old man suffering periumbilical cramping pain with sudden onset that had persisted for 1 week without recovery was referred to Fukui Katsuyama General Hospital. Multidetector computed tomography revealed small bowel obstruction, and an incarcerated short intestinal loop was revealed by sagittal slices of the multiplanar reconstruction images of the routine study of the left side of the pelvic space. Sagittal multiplanar reconstruction images also showed narrow belt-shaped fluid retention contacting the tip of the incarcerated short loop toward the cranial direction localized in the mesosigmoid. These findings indicated that the fluid and the herniated small bowel were wrapped together in the mesosigmoid, which was characteristic of intramesosigmoid hernia.

The patient underwent laparotomy operation 2 days after admission. The ileum, which was approximately 75 cm proximal to the ileocecal junction and herniated into the mesosigmoid through the right leaf, was released without resection. The orifice located in the central part of the right leaf was oval shaped and measured less than 2 cm in diameter. The left leaf of the mesosigmoid was intact. The orifice of the right lobe was closed by suture. The patient showed an uneventful recovery.

Conclusion

We report an extremely rare case of incarcerated intramesosigmoid hernia that was diagnosed by multidetector computed tomography with multiplanar reconstruction images. The finding of narrow belt-shaped fluid retention contacting the tip of the incarcerated short intestinal loop is characteristic of intramesosigmoid hernia and will be useful for conclusively differentiating this disease from transmesosigmoid hernia. Although intramesosigmoid hernia is a rare cause of internal hernia, multidetector computed tomography and multiplanar reconstruction images can provide the characteristic findings and proved useful for the precise preoperative diagnosis and treatment of intramesosigmoid hernia.