An unusual internal hernia

An Unusual

Internal

THOMAS CRAIG, M.D., JAMES ALLEN,

M.D. AND

From Obio State University School oj Medicine and the Department of Surgery, Ohio State University Hospital, Columbus, Ohio.

I

NTERNAL

hernias

quently

many

pathoIogic

and diagnosis difficult. unusual treated

cases

of

other

defect

a distal

portion

resuItant

infarcted symptoms

was

case,

one

omentum of the

Iocation the which

of the

signs

CRAWFORD,

M.D.,

Columbus,

O&o

L

An which

had herniated

The for

pre-

choIecystitis

appendicitis.

produced disease

been

the

in both through

of the omentum infarction.

is two

have

case

acute

acute

was found

months

hernia In

mimic

intervention

twelve

interna

hospita1.

diagnosis

in the

past

infre-

They

conditions,

to operative

the

in this

omental with

encountered surgery.

intra-abdomina1

prior

Within

operative and

are

in abdomina1

PATRICK

Hernia

and

operation

was performed.

FIG I. Note defect in the omentum with herniation of the distat free edge of the omentum and resultant infarction.

CASE REPORTS CASE I. J. P., a twenty-six year oId student, was in good health until one month prior to admission. At that time, he first noticed an intermittent, mild, aching pain in the upper abdomen which was unrelated to position or time. This pain did not radiate and was unaffected by oral intake. It occurred three times within twenty-four hours, and then the patient was free of symptoms unti1 four days prior to admission. Then a dull, aching pain again spread across the entire upper abdomen. After severa hours the pain was reIieved spontaneously. At 3 A.M. on the day of admission the patient was awakened by severe pain in the right upper abdominal quadrant. This remained IocaIized and continuous and was aggravated by deep inspiration and body motion. No gastrointestinal or urinary symptoms were present. Initial examination showed the patient to be in marked distress because of pain. He was afebriIe and his puIse was 90. Respirations were shallow, but examination of the chest and Iungs showed no abnormaIities. The abdomen had a norma contour. There was voluntary rigidity and rebound tenderness of the abdomina1 wall in the right upper quadrant. BoweI sounds were hyperactive. The Ieukocyte count was 13,000 per cu. mm. with

63 per cent poIymorphonucIear Ieukocytes. Urinalysis and roentgenograms of the chest and abdomen were not remarkabIe. The serum amyIase was normaI. Shortly after admission, the pain subsided spontaneously. TweIve hours Iater the leukocyte count was 7,000 per cu. mm. A gastroduodena1 examination was within normal limits. ChoIecystography showed non-visuaIization of the gallbladder. A few hours later, the knife-like pain returned with increased severity. There was increased abdominat rigidity and tenderness. AbdominaI laparotomy was performed, and the preoperative diagnosis was progressing acute cholecystitis. At operation an infarcted portion of the greater omentum was found attached by membranous adhesions to the anterior abdomina1 wall in the right upper quadrant. Herniation of the dista1 free edge of the omentum through a central omental defect had caused the infarction. (Fig. I.) The gaIIbIadder was normaI. The damaged omenturn was resected, and the patient had an uneventful recovery.

CASEII. R. S., a twenty year oId coIIege student was we11 unti1 five days prior to admission when he 505

American

Journal

of Surgery,

Volume

IOI. April

rp6r

Craig,

AIIen

and

experienced the insidious onset of aching, midabdominal pain. This pain did not radiate. Soon afterward the patient had two loose stools of normal color. The patient had no fever, chiIIs, gastrointestinal or urinary symptoms. Two days before admission the pain shifted to the right lower quadrant of the abdomen and persisted with varying intensity. Diarrhea did not occur again. The patient was able to continue a11 activities in spite of his discomfort. PhysicaI examination reveaIed a moderately ill man with a temperature of 100.2’~. and a puIse of 92. Positive physica findings were Iimited to the abdomen where there was IocaIized and rebound tenderness in the right Iower quadrant. Bowel sounds wery: normal. Rectal examination reveaIed tenderness on the right side but no paIpabIe mass. Leukocyte count on admission was 13,400 per cu. mm. with a norma differentiat. UrinaIysis showed 9 to 15 white bIood ceIIs per high powered field. A diagnosis of acute appendicitis was made. At operation the appendix was found to be normal. A mass of dusky infarcted omentum was found firmIy attached to the edge of the bIadder and the anterior abdomina1 waI1in the right Iower quadrant. This mass was found to be periphera1 omentum that had herniated through an omental defect with resultant infarction. The segment of omentum was excised and the defect closed. The patient’s postoperative course was uneventful.

Crawford

The most common site is the opening in the transverse mesocoIon foIIowing posterior gastroenterostomy. The two cases reported here are cIassified as hernias since a defect was present aIthough no hernia sac was produced. The cause for the omenta1 defects is not known. It has been postulated that abdomina1 trauma may produce these defects or that previous inffammatory disorders of the omentum may produce weak areas that subsequentIy tear. It aIso has been suggested that congenita1 omenta1 defects so far may occur. In the Iight of evidence presented, none of these approaches has been convincingly substantiated. InternaI hernias are diagnostic probIems. In most instances symptoms are those of smaI1 bowe1 obstruction. Often a short cIosed loop obstruction may be produced. This diagnosis shouId be suspected in those patients who manifest intermittent obstruction of the smaI1 bowe1 when there has been no previous surgery. In the cases iIIustrated symptoms were mereIy those of Iocalized inflammatory disease at the site of the infarcted omentum. Atypical patterns of pain and symptomatoIogy were evident in both cases aIthough these were signs of IocaIized inflammatory disease. The atypica1 signs and symptoms may delay surgica1 treatment. If intestine is invoIved in the process, deIay may Iead to vascuIar compromise with subsequent necrosis and peritonitis. The signs of progression of the disease may be masked until this occurs. If this process earIy surgica1 intervention is is suspected, indicated.

COMMENTS

Internal herniation is the precipitating factor in fewer than I per cent of cases of acute intestina1 obstruction. These cases represent herniation of the smaI1 intestine through defects or weakened areas of parieta1 peritonea1 attachment. Weak areas of attachment most commonly occur at the point of reflection of the peritoneum over the abdomina1 parietes. The

SUMMARY

most common site is the paraduodena1 reffections where herniation can occur either to the right or Ieft [J]. These hernias are often most diff%xIt to treat because of the essentia1 vascular structures that form part of the neck of the hernia. Second in frequency are hernias through the iIeocoIic peritonea1 refIections. Hernias aIso may occur through weak areas of the mesentery of the ascending and descending colon and through the peIvic floor, either anterior or posterior to the bIadder. The broad ligament in the femaIe, the foramen of WinsIow into the Iesser peritonea1 sac, and defects in the greater omenturn are other sites for internal hernia. Herniation may aIso occur through peritonea defects created by previous surgery.

Two unusual cases of transepipIoic omenta1 hernia are presented. UnIike most internal hernias, smaI1 bowe1 was not invoIved. Symptoms in both cases were atypica1, and preoperative diagnosis was that of other intra-abdomina1 disease. The pathogenesis of internal hernias and some probIems of treatment are discussed. REFERENCES NATHEN, H. and MOSELY, J. E. Intern4 hernia. Rev. Gastroenterol., 20: 787, 1943. JOHNSON, J. R. InternaI hernia. Arch. Surg., 60: I 171, ‘950. HAUSMAN, G. H. and MORTON, S. D. Intra-abdominal

hernia. Arch. Swg., 39: 973, 1939. SNOW, G. Idiopathic segmenta infarction of the greater omentum. Am. J. Digest. Dis., 20: 43, 1953.

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