A Rare Case of Small Bowel Obstruction in a 15-Year-Old Girl: Internal Hernia Associated with Meckel's Diverticulum

BACKGROUND Meckel's diverticulum is a congenital remnant of the omphalomesenteric duct and is the most common congenital gastrointestinal malformation. Most patients are asymptomatic, but a rare presentation is with subacute small bowel obstruction (SBO) due to herniation of bowel loops through an internal hernia formed by the Meckel's diverticulum and adjacent mesentery that forms an internal hernia. This report is of a 15-year-old girl presenting as an emergency with vomiting and small bowel obstruction due to an internal hernia associated with Meckel's diverticulum. CASE REPORT We present a case of a 15-year-old girl who presented to the Children's Emergency (CE) department with persistent vomiting and abdominal distension and tenderness. X-rays demonstrated dilated small bowel loops, prompting admission under Pediatric Surgery (PAS). A subsequent computed tomography (CT) scan was performed, which demonstrated multiple dilated small bowel loops, confirming SBO, and a blind-ending "C-shaped" bowel loop at the region of the terminal ileum. A diagnostic laparotomy was performed, which confirmed the presence of a Meckel's diverticulum. The tip of the Meckel's diverticulum was adherent to part of the small bowel mesentery, forming an internal hernia defect through which a loop of proximal ileum had herniated, resulting in SBO. She then underwent a laparoscopy-assisted transumbilical Meckel's diverticulectomy (LATUM). The patient recovered uneventfully and was discharged on the 4th postoperative day. CONCLUSIONS In children presenting with SBO, the possibility of Meckel's diverticulum as an etiology should be considered as a differential diagnosis. Early diagnosis and prompt intervention will improve clinical outcomes and avoid complications.

The significance of initial lactate levels in emergency department presentations of abdominal wall hernia

INTRODUCTION

Abdominal wall hernias are a frequent cause of abdominal pain-related emergency department visits. Our study aimed to establish the connection between lactate levels and patient outcomes in those with abdominal pain due to abdominal wall hernias.

MATERIALS AND METHODS

Our research followed a retrospective, observational, and descriptive approach and two center. We included patients who visited the emergency department for abdominal pain and were confirmed to have abdominal wall hernias through ultrasound.

RESULTS

We enrolled 493 patients meeting the criteria. Median age was 65 years, with 54% (n = 266) being male. Regarding outcomes, 40.5% (n = 200) were hospitalized, 27.7% (n = 137) underwent surgery, and 7.9% (n = 39) underwent bowel resection. Mortality rate during hernia-related hospital admission was 0.6% (n = 3). For hospitalized patients, there were significant differences in white blood cell count, neutrophil count and percentage, platelet count, lymphocyte count, and percentage (p < 0.05). Patients undergoing resection showed significant differences in neutrophil count, neutrophil percentage, lymphocyte count, and lymphocyte percentage (p < 0.05). Lactate levels were statistically significant in all patient groups requiring hospitalization, surgery, and resection (p < 0.05). Sensitivity and specificity of lactate test results indicated in patients undergoing bowel resection, lactate values ≥1.96 mmol/L had a specificity of 64%, sensitivity of 71%, and a negative predictive value of 96% (p < 0.05).

CONCLUSION

Low lactate levels in patients presenting to the emergency department with abdominal pain caused by abdominal wall hernias have a high negative predictive value for excluding strangulation and the need for bowel resection. Therefore, we recommend the use of lactate as an additional diagnostic tool in emergency department presentations related to abdominal wall hernias.

[A case of abdominal internal hernia through the foramen of Winslow in a pediatric emergency department]

Abdominal internal hernia is a rare cause of intestinal obstruction in pediatric emergency departments, being the herniation through the foramen of Winslow an exceptional entity (less than 0.5% of the herniae). We report the case of a 15-year-old adolescent male without previous surgical interventions who presented with abdominal pain and vomiting; computed tomography scans showed intestinal obstruction due to an internal hernia through the foramen of Winslow. To reduce the herniated ileum, the patient required surgical intervention with diagnostic laparoscopy, which, due to bad visualization, was changed to supraumbilical midline laparotomy. There was no need to resect the affected ileum as it appeared healthy. We did not perform a preventive technique to reduce the risk of recurrence. Postoperative pelvic collection was conservatively managed with antibiotics. The patient undergoes regular follow-up in the pediatric surgery department.

Right paraduodenal hernia, classification, and selection of surgical methods: a case report and review of the literature

BACKGROUND

Considering that right paraduodenal hernia is a rare internal hernia with abnormal anatomy and is often encountered during an emergency, surgeons may lack knowledge about it and choose incorrect treatment. Thus, this case report is a helpful complement to the few previously reported cases of right paraduodenal hernia. Additionally, we reviewed all the reported right paraduodenal hernia cases and proposed appropriate surgical strategies according to different anatomical features.

CASE PRESENTATION

The case involved a 33-year-old Chinese male patient who was admitted to the hospital due to abdominal pain. The patient was initially diagnosed with small bowel obstruction, and conservative treatment failed. An emergency operation was arranged, during which a diagnosis of right paraduodenal hernia was made instead. After surgery, the patient recovered well without abdominal pain for 2 years.

CONCLUSION

Although right paraduodenal hernia accounts only for a small proportion of paraduodenal hernia, its anatomical characteristics can vary considerably. We divided right paraduodenal hernia into three types, with each type requiring a different surgical strategy.

Internal hernia through the foramen of Winslow: a rare cause of intestinal obstruction with imminent ischaemia of the caecum

An internal hernia through the foramen of Winslow represents a rare surgical pathology. This report describes a case with incipient caecal ischaemia and discusses current diagnostic and therapeutic approaches. A patient in his early 60s presented at the emergency department with abdominal pain and last bowel movement three days prior. A CT scan of the abdomen suggested an internal hernia into the lesser sac. Intraoperatively, the suspected diagnosis could be confirmed laparoscopically with a twisted mobile caecum herniating through the foramen of Winslow. Due to a suspected ischaemia and laparoscopic frustrated reduction, a right open hemicolectomy was performed. The hernia gap was closed. The postoperative course was uneventful. Despite the rarity of internal hernias in patients without prior abdominal surgery, surgeons should be aware of this entity. The diagnosis can be difficult and sometimes only established intraoperatively. Open surgery is usually required. If the gap is clearly identified, the recommendations tend towards its closure.

Internal hernia with volvulus after major abdominal reconstructions in pediatric urology - An infrequently reported and potentially devastating complication

INTRODUCTION

Enterocystoplasty (EC), appendico- or ileovesicostomy (APV), and appendicocecostomy (APC) can facilitate continence and prevent renal damage for patients with congenital urologic or bowel disease. Bowel obstruction is a well-documented complication of these procedures, and the etiology of obstruction is variable. The aim of this study is to determine the incidence and describe the presentation, surgical findings, and outcomes of bowel obstruction from internal herniation due to these reconstructions.

METHODS

In this single institution retrospective cohort study patients who underwent EC, APV, and/or an APC between 1/2011 and 4/2022 were identified via CPT codes within the institutional billing database. Records for any subsequent exploratory laparotomy during this same timeframe were reviewed. The primary outcome was an internal hernia of bowel into the potential space between the reconstruction and the posterior or anterior abdominal wall.

RESULTS

Two hundred fifty seven index procedures were performed in 139 patients. These patients were followed for a median of 60 months (IQR 35-104 months). Nineteen patients underwent a subsequent exploratory laparotomy. The primary outcome occurred in 4 patients (including one patient who received their index procedure elsewhere) for a complication rate of 1% (3/257). The complications occurred between 19 months and 9 years after their index procedure (median 5 years). Patients presented with bowel obstruction; two patients also had sudden pain following an ACE flush. One complication was caused by small bowel and cecum passing around the APC and subsequently volvulizing. A second was caused by bowel herniating behind the EC's mesentery and the posterior abdominal wall. A third was caused by bowel herniating behind the APV mesentery and subsequently volvulizing. The exact etiology of fourth internal herniation is unknown. Of the three surviving patients, all required resection of ischemic bowel and 2 required resection of the involved reconstruction. One patient died intraoperatively from cardiac arrest. Only 1 patient required a subsequent procedure to regain lost function.

CONCLUSION

Internal herniation caused by small or large bowel passing through a defect between the mesentery and abdominal wall or twisting around a channel occurred in 1% of 257 reconstructions performed over 11 years. This complication can arise many years after abdominal reconstruction, resulting in bowel resection and possibly takedown of the reconstruction. When anatomically possible and technically feasible, the surgeon should close any potential spaces created during the initial abdominal reconstruction.

Uncommon presentation of Meckel's diverticulum in a child with decompensated hypovolemic shock

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract and may cause serious complications such as intestinal obstruction, gastrointestinal hemorrhage, or inflammation with/without perforation, which can present with non-spe-cific symptoms and signs. We report on the case of a 2.5-year-old boy admitted to our emergency department in poor condition, with compatible signs of decompensated hypovolemic shock. This case finally resulted in intestinal volvulus and internal hernia, a very rare combination of two complications of MD, as determined in the operating room.

Manual Closed Reduction of Incarcerated Hernia: Is It Safe in the Emergency Department?

BACKGROUND

Emergency surgical repair is the standard approach to the management of an incarcerated abdominal wall hernia (IAWH). In cases of very high-risk patients, manual closed reduction (MCR) of IAWH may prevent the need for emergency surgery.

OBJECTIVES

To evaluate the safety, success rate, and complications of MCR in the management of IAWH conducted in an emergency department.

METHODS

The data of all patients who underwent MCR between 2012 and 2018 were retrospectively collected. Patient demographics, presenting symptoms, clinical parameters, and management during the hospitalization were retrieved from the medical charts.

RESULTS

Overall, 548 patients underwent MCR during the study period. The success rate was 25.4% (139 patients). One patient had a complication that required a laparotomy 2 days after his discharge. A recurrent incarceration occurred in 23%, 60% of them underwent successful repeated MCR and the others underwent emergency surgery. Six patients (1.4%) had a bowel perforation after a failed MCR.

CONCLUSIONS

MCR can be performed safely in the emergency department and should be consider as an option to treat IAWH, especially in high operative risk patients.

Chylous ascites in the setting of internal hernia: a reassuring sign

BACKGROUND

Chylous ascites is often reported in cases with lymphatic obstruction or after lymphatic injuries such as intraabdominal malignancies or lymphadenectomies. However, chylous ascites is also frequently encountered in operations for internal hernias. We sought to characterize the frequency and conditions when chylous ascites is encountered in general surgery patients.

METHODS

Data from patients who underwent operations for CPT codes related to open and laparoscopic abdominal and gastrointestinal surgery in our tertiary hospital from 2010 to 2019 were reviewed. Patients with the postoperative diagnosis of internal hernia were identified and categorized into three groups: Internal Hernia with chylous ascites, non-chylous ascites, and no ascites. Demographics, prior surgical history, CT findings, source of internal hernia, open or laparoscopic surgery, and preoperative labs were recorded and compared.

RESULTS

Fifty-six patients were found to have internal hernias and were included in our study. 80.3% were female and 86% had a previous Roux-en-Y gastric bypass procedure (RYGBP). Laparoscopy was the main approach for all groups. Ascites was present in 46% of the cases. Specifically, chylous ascites was observed in 27% of the total operations and was exclusively (100%) found in patients with gastric-bypass history. Furthermore, it was more commonly associated with Petersen's defect (p < 0.001), while the non-chylous fluid group was associated with herniation through the mesenteric defect (p < 0.001).

CONCLUSIONS

Chylous ascites is a common finding during internal hernia operations. Unlike other more morbid conditions, identification of chylous ascites during an internal hernia operation appears innocuous. However, in the context of a patient with a history of RYGBP, the presence of chylous fluid signifies the associated small bowel obstruction is likely related to an internal hernia through a patent Petersen's defect.

Outcomes of obstructed abdominal wall hernia: results from the UK national small bowel obstruction audit

Background

Abdominal wall hernia is a common surgical condition. Patients may present in an emergency with bowel obstruction, incarceration or strangulation. Small bowel obstruction (SBO) is a serious surgical condition associated with significant morbidity. The aim of this study was to describe current management and outcomes of patients with obstructed hernia in the UK as identified in the National Audit of Small Bowel Obstruction (NASBO).

Methods

NASBO collated data on adults treated for SBO at 131 UK hospitals between January and March 2017. Those with obstruction due to abdominal wall hernia were included in this study. Demographics, co‐morbidity, imaging, operative treatment, and in‐hospital outcomes were recorded. Modelling for factors associated with mortality and complications was undertaken using Cox proportional hazards and multivariable regression modelling.

Results

NASBO included 2341 patients, of whom 415 (17·7 per cent) had SBO due to hernia. Surgery was performed in 312 (75·2 per cent) of the 415 patients; small bowel resection was required in 198 (63·5 per cent) of these operations. Non‐operative management was reported in 35 (54 per cent) of 65 patients with a parastomal hernia and in 34 (32·1 per cent) of 106 patients with an incisional hernia. The in‐hospital mortality rate was 9·4 per cent (39 of 415), and was highest in patients with a groin hernia (11·1 per cent, 17 of 153). Complications were common, including lower respiratory tract infection in 16·3 per cent of patients with a groin hernia. Increased age was associated with an increased risk of death (hazard ratio 1·05, 95 per cent c.i. 1·01 to 1·10; P = 0·009) and complications (odds ratio 1·05, 95 per cent c.i. 1·02 to 1·09; P = 0·001).

Conclusion

NASBO has highlighted poor outcomes for patients with SBO due to hernia, highlighting the need for quality improvement initiatives in this group.

Case report of laparoscopic reduction of retro-ureter incarcerated small bowel obstruction

RATIONALE

Various types of internal hernias have been reported including paraduodenal, intersigmoidal, pericecal, foramen of Winslow, as well as transmesenteric and retroanastomotic hernias. However, small bowel obstruction secondary to an internal hernia caused by the ureter is rare, and only a few cases have been reported worldwide. We report a case of small bowel herniation caused by the ureter in a woman who underwent radical hysterectomy for cervical cancer.

PATIENT CONCERNS

A 53-year-old woman presented with acute abdominal pain and vomiting and reported a history of radical hysterectomy for cervical cancer 6 years prior to presentation.

DIAGNOSES

Computed tomography revealed segmental luminal dilatation of pelvic ileal loops, 2 transition zones with the beak sign in the left-sided pelvic cavity, and reduced enhancement of bowel loops. Hydronephrosis with abrupt luminal narrowing of the left distal ureter was also observed.

INTERVENTIONS

Exploratory laparoscopy revealed incarcerated bowel segments beneath an adhesive band. We did not immediately cut the adhesive band and continued to trace the course of the small bowel and attempted reduction of the hernia. Reduction of the hernia was not difficult; therefore, the entire small bowel could be disentangled from the pelvic adhesions without any small bowel injury. After reduction of the herniated small bowel, we could confirm that the adhesive band was the left ureter (ureteral peristalsis was observed). The reduced segments of the small bowel appeared viable, and resection was not required.

OUTCOMES

The patient was discharged 2 days postoperatively without any complication.

LESSONS

Cutting band during adhesiolysis enables release of bowel obstruction. However, owing to the different types of internal hernias that are known to occur, it is essential to confirm the patient's history and preoperative CT findings to avoid complications.

The reality of general surgery training and increased complexity of abdominal wall hernia surgery

INTRODUCTION

The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature.

METHODS

A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated.

RESULTS

All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures.

CONCLUSION

A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.

Intestinal obstruction due to congenital bands in adults who have never had abdominal surgery Two case reports and a review of the literature

Congenital abdominal bands are a very rare entity and are often silent for a person's entire life. In a very few circumstances, however, they can manifest with clinical symptoms. Diagnosis of these bands is very challenging as the patient has never submitted for abdominal surgery and imaging, laboratory tests and clinical examination can be silent or unspecific. Two patients were admitted to and operated on in our hospital between June 2017 and July 2018. All patients had a bowel obstruction at the time of presentation, presenting no emission of faeces or gas. Conservative therapy was tried in one case, and surgical intervention was required. At surgery, both patients were found to have congenital bands causing the occlusion. The postoperative courses were uneventful. Small bowel obstruction (SBO) by congenital bands remains a challenging disease for surgeons. Diagnosis of SBO has to be suspected even if radiology does not indicate any relevant features. Laparoscopy should be the preferred approach, but if not feasible, then open surgery can resolve the case. KEY WORDS: Adhesions, Congenital bands, Intestinal occlusion, Laparoscopy.

Socioeconomic disparities in the complexity of hernias evaluated at Emergency Departments across the United States

BACKGROUND

Hernias represent one of the most common surgical conditions with a high-burden on health expenditures. We examined the impact of socioeconomic-status and complexity of presentation among patients in the Emergency Department (ED).

METHODS

Retrospective analysis of 2006-2014 data from the Nationwide Emergency Department Sample, identified adult discharges with a diagnosis of inguinal, femoral, and umbilical hernia. Cases were dichotomized: complicated and uncomplicated. Unadjusted and adjusted analyses were used to determine factors that influence ED presentation.

RESULTS

Among 264,484 patients included, 73% presented as uncomplicated hernias and were evaluated at urban hospitals (86%). Uncomplicated presentation was more likely in Medicaid (OR 1.56 95%CI1.50-1.61) and uninsured (OR 1.73 95%CI 1.67-1.78), but less likely for patients within the third and fourth MHI quartile (OR 0.82 95%CI 0.80-0.84 and OR 0.77 95%CI 0.75-0.79), respectively.

CONCLUSION

Uninsured, publicly-insured, and low-MHI patients were more likely to present to ED with uncomplicated hernias. This finding might reflect a lack of access to primary surgical care for non-urgent surgical diseases.

Mechanical Stress as a Cause of Hidradenitis Suppurativa: A Lesson from a Patient with a Monster Hernia

We have read with great interest the case report recently published in Acta Dermatovenerologica Croatica by Boer and Mihajlovic (1), which describes a 33-year-old woman with an 18-year history of classic hidradenitis suppurativa (HS) who developed HS-like lesions at the position of the bra strap. We agree with Boer and Mihajlovic: according to our clinical experience, we are convinced that mechanical stress may contribute or, in some cases, result in the development of HS. In this regard, we will describe the case of a patient with a monster hernia who presented HS-like lesions on his abdomen corresponding to the perihernial skin area, suggesting that mechanical stress was an important pathogenic factor for HS development. A 54-year-old man without any previous history of HS developed chronic, recurrent, inflammatory nodules, cysts, and depressed scars at the location of a giant abdominal hernia (Figure 1). The lesions occurred four years ago, six months after the hernia had reached its current size. Cultures from skin swabs showed commensal skin flora and moderate mixed anaerobic bacteria, as would be expected in HS lesions. No lesions occurred in other inverse areas generally affected by HS, such as the axillary and anogenito-crural regions. It is likely that the mechanical stress in the abdominal region was greater than the one occurring at the other folds due to the pressure of the trousers and belt. In fact, there are many kinds of mechanical stress: friction, pressure, pulling, tension, and pinching. Friction can be defined as the resistance to motion in the direction of the common boundary of the two surfaces. The body areas which are at greater risk for such frictional forces are mainly the skin folds, such as axillae, groins, and buttocks. There is a substantial difference between frictional and pressor stress: pressure is defined as the force per unit exerted parallel to the plane of interest. Pressure on the skin can be caused by tight dressings (2). Frictional and pressor forces can act concurrently and synergistically, starting the series of events that lead to clinical onset of HS, as most likely happened in our patient at the abdomen right below the hernia, where the trousers and belt are tightened. It is believed today that the primary event in HS is follicular inflammation: in predisposed subjects, folliculitis can develop into HS. Follicular enlargement has been observed in HS skin. It has been hypothesized that constant mechanical forces, such as pressure and friction, may lead to follicular occlusion, dilatation, microtears, and ruptures with ensuing abscesses (1-6). This case report corroborates observations from the last three decades: HS is a disease of the follicular epithelium rather than the apocrine glands (7,8), and mechanical stress, friction, and pressure may have an important role in its pathogenesis.

A strangled hernia through the Winslow's hiatus: about a rare situation

Winslow's hiatus hernia is the rarest of the internal hernias. Its diagnosis is difficult and requires an urgent laparotomy to avoid necrosis of the incarcerated loop or even the death of the patient. We report the case of a patient operated urgently for acute intestinal obstruction caused by a strangled hernia through the Winslow's hiatus. A reduction by traction of the hernia was undertaken. Rapid management of this pathology is important using clinical and radiographical elements.

A case report of spontaneous umbilical enterocutaneous fistula resulting from an incarcerated Richter's hernia, with a brief literature review

BACKGROUND

Richter's hernia is a high-risk ischaemic gastrointestinal disorder that is typically diagnosed in a delayed manner due to a lack of obvious symptoms. Spontaneous umbilical enterocutaneous fistula (ECF) resulting from an incarcerated Richter's hernia is extremely rare.

CASE PRESENTATION

A 62-year-old female presented with a chief complaint of recurrent umbilical region infection for the preceding 20 months with no symptoms of ileus. Preoperative CT and fistulography revealed an incarcerated Richter's hernia complicated by an ECF. Exploratory laparotomy revealed a loop of the distal ileum adherent to the umbilical region that was retrieved back into the abdominal cavity. Side-to-side ileo-ileal anastomosis was performed using a 75 mm linear stapler to remove the affected ileum segment. The internal hernia ring was closed using plication sutures instead of via mesh repair due to the patient's small defect and infection risk.

CONCLUSION

Richter's hernia can be observed at any age but is particularly common in frail, elderly patients. This nonspecific clinical and laboratory findings of this condition are associated with a high misdiagnosis rate, resulting inrelatively high mortality. Abdominal CT and gastrointestinal imaging are recommended if Richter's hernia is suspected. Timely surgical intervention is crucial for reducing mortality and improving prognosis.

[Etiology and prognosis of acute mechanical intestinal obstructions at the National Hospital of Zinder: Cross-sectional study of 171 patients]

Acute mechanical intestinal obstruction (AIO) is one of the most frequent pathologies in emergency digestive surgery. The objective of this study was to describe the etiologic and prognostic features of acute mechanical intestinal obstruction at the National Hospital of Zinder (HNZ), Niger. We conducted a cross-sectional study including all the patients operated for AIO over a period of 24 months (January 2013 - December 2014) Mechanical intestinal obstructions represent 24.50% (n=171) of digestive surgical emergencies (n=622). The median age was 25 years (range: 1 day-95 years). The sex ratio was 3.5 in favour of men. Children accounted for 38.60% (n=66). The seat of the obstacle was at the level of the small bowel in 60.82% (n=104), colonic in 21.63% (n=37) and mixed in 17.54% (n=30). The mechanism of strangulation accounted for 88,89% (n=152), among these strangulated hernias were detected in 49,70% (n=85) of patients and acute intestinal invaginations in 19,88% (n=34) of patients. Anorectal malformations and tumors were the main cause of obstruction in 7.02% (n=12) and 3.51% (n=6) of cases respectively. Intestinal resection was performed in 52 cases (30.41%). Septic complications prevailed (n=39/53); among these parietal suppuration (n=23). The average length of stay in hospital was 7.82 days. The overall mortality rate was 11.70% (n=20). This was statistically correlated to intestinal necrosis (p=0.01) and to delayed hospital admission (p=0.04). There are many causes of AIO which are dominated by strangulated hernia. The high morbidity and mortality rate from AIO might be prevented by early treatment performed before intestinal necrosis occurs.

Timing of Abdominal CT Evaluation Impacts the Diagnosis of Paraduodenal Hernia

Internal hernias are the causes of 0.5 to 5.8 per cent of all cases of small bowel obstruction. Left paraduodenal hernia (PDH) is the most common congenital internal hernia encountered in adults. The symptoms and physical findings associated with PDH are vague and nonspecific before the onset of complicated intestinal obstruction. Diagnoses are most commonly established by CT. This case presentation and review is intended to promote clinicians' awareness of this unusual but potentially highly morbid condition, discuss CT findings associated with PDH, and illustrate the importance of timing in the acquisition of diagnostic abdominal CT scans.

[MORPHOLOGICAL PECULIARITIES OF MUSCULO-APONEUROTIC TISSUES OF ANTERIOR ABDOMINAL WALL IN PATIENTS, SUFFERING MORBID OBESITY]

Results of morphological investigation of musculo-aponeurotic structures of anterior abdominal wall were presented in the morbid obesity patients. The role of obesity as a primary cause for morphofunctional insufficience of musculo-aponeurotic structures was established.

Image of acute bowel ischemia secondary to internal pelvic hernia

Internal hernias are visceral protrusions through the peritoneum or mesentery into an abdominal cavity compartment. Hernial orifices are either pre-extant anatomical structures or abnormal defects secondary to surgery, trauma, inflammation, and circulation disorders. Their diagnosis is challenging since clinical and imaging findings are usually unclear. We report a case of this rare condition in order to assess its diagnostic approach and need for early management.

[CHOICE OF THE TREATMENT TACTICS IN PATIENTS, SUFFERING POSTOPERATIVE HERNIA OF ANTERIOR ABDOMINAL WALL WITH CONCOMITANT MORBID OBESITY]

Experience of treatment of 73 patients, suffering postoperative hernia of anterior abdominal wall with concomitant obesity, was presented. In 31 (42.5%) of them in a period of reduction and stabilization of a body mass the allohernioplasty as a second stage after bariatric operation was done, and in 9 (42.5%)--simultant bariatric operations with hernioplasty and dermatolipectomy. During a follow-up period after bariatric operation and hernioplasty the hernia recurrence have occurred in 3 (9.1%) patients, after hernioplasty--in 11 (33.3%), witnessing high efficacy of staged treatment in such patients.

Internal Hernias in Acute Abdomen: Review of Literature and Report of four Cases

Internal hernias are very rare in clinical practice. Because of a wide range of symptoms that can sometimes be non-specific, surgeons often disregard internal hernias in the spectrum of differential diagnosis in acute abdomen. Finding the diagnosis before an internal hernia causes an acute abdomen is sometimes difficult despite modern diagnostic tools. Reason for diagnosis delay is mostly because of wide range of symptoms and variable time period of abdominal pain before patients visit the physician. Furthermore, the delayed diagnosis can put patients in dangerous life threatening condition because internal hernias can cause acute bowel or intestinal obstruction. In such cases high mortality has been recorded so internal hernias presenting as acute abdomen may need operations as soon as possible. Performance of image studies could easily lead to a specific diagnosis and the best surgical strategy. Occasionally, an urgent laparotomy is the only diagnostic procedure and treatment. Here we present four patients with developed acute abdomen due to internal hernia and a course of treatment along with a review of the literature.

Left-sided transmesocolic herniation of small bowel in an otherwise unaffected abdomen

Transmesocolic hernia is an uncommon type of internal hernia with incidence ranging from approximately 5-10%. To the best of our knowledge, this is the first reported case of a transmesocolic hernia through a gap within the descending mesocolon presenting clinically as an intestinal obstruction. A 75-year-old man was admitted with clinical features of intestinal obstruction. An abdominal X-ray showed multiple small bowel loops with air fluid levels. Contrast-enhanced CT of the abdomen revealed small bowel obstruction not only on the right, but also on the left side of the collapsed descending colon. Emergency surgery was performed. Strangulated bowel loops with gangrenous changes were resected and double-barrel ileostomy was carried out. The postoperative period was uneventful. Restoration of bowel was performed after 6 weeks. Preoperative diagnosis of bowel obstruction caused by a transmesocolic hernia remains difficult despite the currently available imaging techniques. Prompt surgery can prevent serious complications such as peritonitis and sepsis.

INTESTINAL OBSTRUCTION DUE TO RARE INTERNAL SUPRAVESICAL HERNIA

Supravesical hernias are very rarely seen and reported as a possible cause of small bowel obstruction. The proper diagnosis of which is usually made intra-operatively as the preliminary diagnosis despite the availability of advanced radiological investigations which are not very helpful. There are two anatomical variants of supravesical hernias, of which internal one usually presents as small bowel obstruction. We present a case of 62 year old man, presented to us in emergency with three day history of absolute constipation, abdominal distention, and vomiting. On exploratory laparotomy, the terminal ileum loops were retrieved from the supravesical hernial defect by gentle traction and the defect was closed. Post-operative period remained uneventful. Supravesical hernias though very rare still can be a possible cause of small bowel obstruction. The diagnosis is usually made per operatively where the bowel loops are seen to be strangulated in the hernia defect.

Recurrent incisional hernia, enterocutaneous fistula and loss of the substance of the abdominal wall: plastic with organic prosthesis, skin graft and VAC therapy. Clinical case

Surgical wounds dehiscence is a serious post-operatory complication, with an incidence between 0.4% and 3.5%. Mortality is more than 45%. Complex wounds treatment may require a multidisciplinary management. VAC Therapy could be an alternative treatment regarding complex wound. VAC therapy has been recently introduced on skin's graft tissue management reducing skin graft rejection. The use of biological prosthesis has been tested in a contaminated field, better than synthetic meshes, which often need to be removed. The Permacol is more resistant to degradation by proteases due to its cross-links. Surgery is still considered the best treatment for digestive fistula. A 58 years old obese woman come to our attention, she was operated for an abdominal hernia. She had a post-operatory entero-cutaneous fistula. She was submitted to bowel resection, the anastomosis has been tailored and the hernia of the abdominal wall has been repaired with biological mesh for managing such condition. She had a wound dehiscence with loss of substance and the exposure of the biological prosthesis, nearly 20 cm diameter. She was treated first with antibiotic therapy and simple medications. In addiction, antibiotic therapy was necessary late associated to 7 months with advanced medications allowed a small reduction's defect. Because of its, treatment went on for two more months using VAC therapy. Antibiotic's therapy was finally suspended. The VAC therapy allowed the reduction of the gap, between skin and subcutaneous tissue, and the defect's size preparing a suitable ground for the skin graft. The graft, managed with the vac therapy, was necessary to complete the healing process.

Pulmonary complications of abdominal wall defects

The abdominal wall is an integral component of the chest wall. Defects in the ventral abdominal wall alter respiratory mechanics and can impair diaphragm function. Congenital abdominal wall defects also are associated with abnormalities in lung growth and development that lead to pulmonary hypoplasia, pulmonary hypertension, and alterations in thoracic cage formation. Although infants with ventral abdominal wall defects can experience life-threatening pulmonary complications, older children typically experience a more benign respiratory course. Studies of lung and chest wall function in older children and adolescents with congenital abdominal wall defects are few; such investigations could provide strategies for improved respiratory performance, avoidance of respiratory morbidity, and enhanced exercise ability for these children.

[Congenital trans-mesenteric hernia with incarceration in a five-year-old boy]

This is a case report of a five-year-old boy, presenting with abdominal pain and signs of gastrointestinal emergency imitating appendicitis. Diagnostic laparoscopy revealed an incarcerated internal hernia involving 50 cm of ischaemic small bowel. Bowel resection and primary anastomosis was performed. The post-operative outcome was uneventful. We wish to shed light on a seldom but important differential diagnosis to appendicitis in children, and raise attention to internal hernias in patients presenting with acute abdomen, whether it is due to congenital defects or a post-operative complication.

Internal herniation through the falciform ligament: an unusual cause of intestinal obstruction

The most common cause of intestinal obstruction in children is postsurgical adhesions. Internal herniation through the falciform ligament is very rare, but frequently causes small bowel obstruction when it occurs. To the best of our knowledge, this is the first case report regarding large bowel obstruction associated with midgut malrotation through the falciform ligament in a child.

[Foetal brain damage may follow gastric bypass surgery]

Bariatric surgery is performed on an increasing number of women of childbearing age. During pregnancy they have reduced risk of obesity-related complications but increased risk of bariatric surgery-related complications, including internal hernias. We present a case in which a pregnant woman required acute surgery for internal herniation and later gave birth to a child with cerebral palsy. Before performing bariatric surgery in women of childbearing age, thorough information about risks and benefits related to pregnancy should be given. Special medical attention during pregnancy is required.

Abdominal wall reconstruction in the obese: an assessment of complications from the National Surgical Quality Improvement Program datasets

BACKGROUND

This study utilizes the American College of Surgeons National Surgical Quality Improvement Program database to better understand the impact of obesity on perioperative surgical morbidity in abdominal wall reconstruction (AWR).

METHODS

We reviewed the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program databases, identifying cases of AWR and examining early complications in the context of obesity (body mass index > 30, World Health Organization classes 1 to 3).

RESULTS

Of 1,695 patients undergoing AWR, 1,078 (63.2%) patients were obese (mean body mass index = 37.6 kg/m(2)). Major surgical complications (15.3% vs 10.1%, P = .003), wound complications (12.5% vs 8.1%, P = .006), medical complications (16.2% vs 11.2%, P = .005) and return to the operating room (9.1% vs 5.4%, P = .006) were significantly increased, while renal complications (1.9% vs .8%, P = .09) neared significance. On logistic regression, obesity only directly led to a significantly increased odds of having a renal complication (odds ratio = 4.4, P = .04). Complications were still noted to increase with World Health Organization classification, including a concerning incidence of venous thromboembolism.

CONCLUSIONS

Although the incidence of complications increased with obesity, obesity itself does not appear to increase the odds of perioperative morbidity. Specific care should be given to VTE prophylaxis and to preventing renal complications.

When it is not a Spigelian hernia: abdominal cutaneous nerve entrapment syndrome

Abdominal wall pain at the linea semilunaris is classically the result of a Spigelian hernia. If no hernia is detected, these patients may be left with chronic pain without a diagnosis or treatment. A retrospective review was performed of patients presenting with abdominal wall pain at the linea semilunaris between 2009 and 2012. Of the 14 patients, three (21%) were diagnosed with a Spigelian hernia confirmed by imaging. The remaining patients were eventually diagnosed with abdominal cutaneous nerve entrapment syndrome (ACNES). The average delay in diagnosis was 4 years with patients with ACNES suffering twice as long with chronic pain. Patients with a Spigelian hernia and ACNES had different demographics and presenting complaints. Physical examination findings were nondiagnostic. Of the patients with ACNES, five (50%) had resolution of pain with serial nerve blocks alone; another five proceeded to surgical neurectomy with resolution of their pain. Thus, to prevent delay in diagnosis and treatment, patients with chronic abdominal wall pain at the linea semilunaris should first be ruled out for Spigelian hernia. Then, they should be evaluated and treated for ACNES.

Small bowel obstruction secondary to internal hernia through a defect of the broad ligament: preoperative multi-detector CT diagnosis

We report a case of small bowel obstruction secondary to internal hernia through a defect in the broad ligament diagnosed by MDCT and confirmed at surgery. The CT findings that allow the diagnosis of this very rare cause of SBO are presented here.

[Simultant laparoscopic operations for biliary calculi disease and hernia of the anterior abdominal wall]

The results of treatment of patients, in whom biliocalculous disease and hernia of anterior abdominal wall were diagnosed, were analyzed. The main aspects of diagnosis and prognosis of simultant operations in such patients, some technical procedures of operative interventions were depicted. Indications for performance of simultant completely laparoscopic and simultant laparoscopic combined operations in these patients were determined.

[Sciatic hernia as a cause of chronic pelvic pain]

Sciatic hernia constitutes the scarcest group of hernias of pelvic floor; however, they should be considered in the origin of chronic pelvic pain. The proper diagnosis of sciatic hernias has allowed to surgeons treating successfully patients with acute or chronic pelvic pain, with intestinal or ureteral obstruction and with urinary or gluteus sepsis. It has to be considered as differential diagnosis before the finding of a congenital or acquired gluteus mass. Laparoscopist gynecologist should know the existence of this defect, to be familiar with its aspect in laparoscopic view and to know the laparoscopic treatment of this disease.

[Assessment of the predisposing risk factors of the complicated postoperative course after combined operations]

Results of 335 combined operations were analyzed. Men were 89 (27%), women - 246 (73%), the majority of patients were of middle age. 285 (85%) operations included cholecystectomy. 195 (58%) patients had hernioplasty. The third place belonged to vascular operations - 76 (23%). Certain predisposing factors, correlating with the risk of the complicated postoperative course, were marked out. Indications and contraindications to the combined operation were assigned, based on the number of predisposing factors in a patient. Considering the increased risk of intraoperative complications during the combined operation (increased duration, blood loss), participation of highly experienced surgeons and use of modern high-tech equipment seem to be reasonable. The general results of the analysis prove that combined operations are effective, safe and economically beneficial.

[Rare internal hernia in the falciform ligament as a rare course of abdominal emergency and infrequent cause of ileus]

Intestinal obstruction caused by an internal hernia is considered to be a rare cause of ileus. The rarest of these is herniation through the falciform ligament. In our article we present the case of a 45-year old female patient operated on for small bowel herniation through a defect in the falciform ligament. The loops were laparoscopically repositioned into the free abdominal cavity and the defect was removed by electrocautery. After the operation the patient was stabilised and discharged into outpatient care. Our article also analyses relevant literature and the diagnostic methods because the abovementioned diagnosis is rare and often established as late as postoperatively. Key words: internal hernia - the falciform ligament - iatrogenous defect in the falciform ligament.

Obesity increases the odds of acquiring and incarcerating noninguinal abdominal wall hernias

The current data available describing the relationship of obesity and abdominal wall hernias is sparse. The objective of this study was to investigate the current prevalence of noninguinal abdominal wall hernias and their correlation with body mass index (BMI) and other demographic risk factors. Patients with umbilical, incisional, ventral, epigastric, or Spigelian hernias with or without incarceration were identified using the regional database for 14 hospitals over a 3-year period. Patients were stratified based on their BMI. Univariate and multivariate analyses were performed to distinguish other significant risk factors associated with the hernias. Of 2,807,414 patients, 26,268 (0.9%) had one of the specified diagnoses. Average age of the patients was 52 years and 61 per cent were male. The majority of patients had nonincarcerated umbilical hernias (74%). Average BMI was 32 kg/m2. Compared with patients with a normal BMI, the odds of having a hernia increased with BMI: BMI of 25 to 29.9 kg/m2 odds ratio (OR) 1.63, BMI of 30 to 39.9 kg/m2 OR 2.62, BMI 40 to 49.9 kg/m2 OR 3.91, BMI 50 to 59.9 kg/m2 OR 4.85, and BMI greater than 60 kg/m2 OR 5.17 (P<0.0001). Age older than 50 years was associated with a higher risk for having a hernia (OR, 2.12; 95% [CI], 2.07 to 2.17), whereas female gender was associated with a lower risk (OR, 0.53; 95% CI, 0.52 to 0.55). Those with incarcerated hernias had a higher average BMI (32 kg/m2 vs 35 kg/m2; P<0.0001). Overall, BMI greater than 40 kg/m2 showed an increased chance of incarceration, and a BMI greater than 60 kg/m2 had the highest chance of incarceration, OR 12.7 (P<0.0001). Age older than 50 years and female gender were also associated with a higher risk of incarceration (OR, 1.28; 95% CI, 1.02 to 1.59 and OR, 1.80; CI, 1.45 to 2.24). Increasing BMI and increasing age are associated with a higher prevalence and an increased risk of incarceration of noninguinal abdominal wall hernias.

Intestinal occlusion through extrinsec stenosis of transverse colon associated with internal right mesocolic hernia

RATIONALE

The incidence of malrotation has been estimated at 1 in 600 live births. An increased incidence of 0,2% has been found in barium swallow studies, whereas autopsy studies estimate that the true incidence may be high as 1% of the total population. The clinical manifestations are elusive; therefore, the diagnosis must be based on the presence or absence of the acute obstruction. Radiologic investigations, especially those using contrast substances, are the ones used most often in the diagnosis of malrotation. Laparoscopy may give the clinician a valuable tool that will help him diagnose the rotational anomalies and correct the potentially obstructing lesions with minimal surgical trauma to the patient. The role of the surgical treatment is to prevent volvulus and to treat any kind of obstruction. Ladd's procedure provides all the elements for reaching this goal.

OBJECTIVE

The following report describes a particular case of one female patient, 8 years old, admitted in our clinic with signs of intestinal obstruction. She had similar episodes in the last three months, but the symptoms had resolved spontaneously.

METHODS AND RESULTS

Upper gastrointestinal series showed an anomaly of rotation and barium enema discovered a tight stenosis on the transverse colon. Emergency surgery using laparotomy enabled diagnosis. Intraoperatively, a right mesocolic hernia and a transverse colon extrinsic stenosis due to abnormal peritoneal attachments were noted.

DISCUSSION

Colon obstruction due to peritoneal bands is extremely rare. The clinical manifestations are not specific and we need radiologic procedures to help diagnose the disease. The cause of the obstruction is not always evident despite the availability of modern imaging techniques. Since preoperative diagnosis is difficult, morbidity and mortality can be decreased by an early surgical intervention.

[Morphological diagnosis of connective tissue dysplasia in patients, suffering postoperative abdominal hernia]

The results of treatment of 122 patients, to whom alloplasty for postoperative abdominal hernia (POAH) was performed, were analyzed. In 76 patients a connective tissue dysplasia (CTD) was diagnosed.Determination of a various types of collagen content in connective tissue of patients, suffering CTD, may confirm or exclude this diagnosis. Diagnostic significance has the enhancement of a collagen type III content in comparison with such of a type I by three times and more. The method of lectinohistochemical investigation of connective tissue was applied as a precision-enhancing method of a CTD diagnosis. Mosaic or diffuse loss of SNA, LABA, ConA receptors of lectins by collagen fascicles, which reflect carbohydrate determinants of dense and strong collagen fascicles, made of collagen type I, witness the CTD presence. Along with this, there was observed a lectin WGA receptors expression increase, which constitutes a marker of fascicular structures, made of collagen, predominantly type III and a lectin PNA receptors, which are revealed around vessels.

[Internal herniation during pregnancy following gastric bypass surgery]

In Denmark, the number of bariatric operations, including gastric bypass surgery, has increased dramatically in recent years. Internal herniation as a possible cause of acute abdominal pain, is a well-known complication after gastric bypass operation. We report two cases of internal herniation during pregnancy following gastric bypass operation. The diagnosis of internal herniation can be difficult as radiologic investigations may be inconclusive. Clinical suspicion alone should lead to surgical exploration due to the risks of morbidity and mortality if patients are not diagnosed properly.