Perforated obturator Littr hernia in an elderly woman

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.

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.

Obturator hernia - a rare etiology of lateral thigh pain: A case report

BACKGROUND

Lateral thigh pain is a common complaint in patients visiting a pain clinic. Herein, we describe the case of a patient with lateral thigh pain caused by an obturator hernia.

CASE SUMMARY

An 83-year-old woman visited the emergency room with suddenly aggravated right lateral thigh pain. Magnetic resonance imaging of the thigh revealed no abnormal findings in the lateral thigh area. However, an obturator hernia between the pectineus and obturator externus muscles was observed by chance. Retroperitoneal computed tomography revealed a herniated small bowel with an incarceration point at the right obturator canal and a dilated loop of the small bowel upstream. Ultrasonography of the right inguinal region revealed a distended bowel loop in the right pectineus muscle.

CONCLUSION

Our report provides clinicians with information that an obturator hernia can cause lateral thigh pain.

Obturator hernias: a systematic review of the literature

PURPOSE

Obturator hernias (OH) are extremely rare hernias, accounting for 0.07-1% of all hernias. This is the first systematic review investigating their presentation, imaging, treatment outcomes, and recurrence rate.

METHODS

After a detailed search in electronic search engines, 74 studies matched our criteria. A review of these reports was conducted and the full texts were examined.

RESULTS

A total of 146 patients with a mean age of 78.8 years were included in our analysis, with 40.1%, 29.9%, and 25.2% of patients suffering from either a right, a left or bilateral OH, respectively. OH were associated with non-specific symptoms and signs; bowel obstruction being the most common. Howship-Romberg sign was present in 56.2% of patients. Computed tomography (CT) scan was the most frequently used diagnostic modality, inversely associated with perioperative mortality. Mesh repair demonstrated a significantly improved perioperative morbidity rate, compared with non-mesh repair. Approximately 30% of patients underwent a laparoscopic operation, which was associated with significantly decreased morbidity and mortality rate as well as length of hospital stay, compared with the open repair.

CONCLUSION

OHs are not associated with specific symptoms and signs; thus, they constitute a diagnostic challenge, requiring a high level of clinical suspicion. Undoubtedly, CT scan of the abdomen is the gold standard diagnostic tool. Their operative repair is mandatory, with the laparoscopic approach demonstrating significant advantages over the open repair.

Littre's hernia: a systematic review of the literature

PURPOSE

A hernia containing Meckel's diverticulum is called a Littre's Hernia. It's a rare entity and its diagnosis is often incidental during routine hernia repair surgery. The objective of this study is the evaluation of the current evidence on Littre's hernias regarding their clinical presentation and optimal treatment approach.

METHODS

PubMed and Cochrane bibliographical databases were searched from the beginning of time (last search: August 1st, 2018) for studies reporting on Littre's hernias in adult population.

RESULTS

Forty-five studies met our inclusion criteria and reported collectively on 53 patients (21 males and 32 females) presenting at health care units with a Littre's hernia. The most common sites of occurrence were femoral (39.6%) and inguinal (34%). The vast majority of cases (77.4%) concerned incarcerated hernias. All patients underwent surgical hernia repair accompanied by a diverticulectomy and 16.9% of them received mesh. Only 7.5% of patients experienced immediate postoperative complications.

CONCLUSIONS

A Littre hernia is a rare complication of Meckel's diverticulum. It requires surgical attention and all medical professionals should be encouraged to report such cases to expand our experience and optimize the therapeutic approach.