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Hernia–Masquerader of Surgical Disorders
Symposium on Surgery of Hernia
Hernia - Masquerader of Surgical Disorders Bernard J. Ficarra, MD., SeD., Ph.D. *
A simple hernia that is looked at unsuspectingly from day to daywhat does it hide beneath its surface? Often residing behind the hernial mask is concealed organic disease which has lain dormant for months or years. Symptoms will develop and a patient will incriminate a hernia which has been present chronically as the causative agent for sudden acute symptoms. It is well to remember that serious pathologic processes may be concealed by a hernia without resulting in any distress. Suddenly there occurs a complaint of pain or discomfort at the hernial site. In the absence of an incarceration or strangulation of the hernia, thought should be given to the possibility of an underlying pathologic entity unrelated to the obviously apparent hernia. Too often the obvious is indicted for what is not apparent. This present communication is the result of a purposeful observation on this subject over the past 20 years.
UMBILICAL HERNIA The readily apparent umbilicus is the least suspect of having a hernia with associated or underlying disease. However, umbilical hernias are among the easiest of all hernias to become incarcerated or strangulated. In addition aggravation of the hernial state is characterized by a rounding of the umbilical area and then cupola formation. In obese persons the umbilicus disappears from view and the patient sees only a circle of skin as the umbilicus fades away between dermal creases. In one instance a papilloma of the umbilicus was sheltered beneath a cupolous umbilicus. The patient noticed spots of blood on her undergarments but attributed the staining to irritation because the dome of the umbilical hernia was red and slightly excoriated. Since the hernia was of long duration it was accepted as commonplace and not too alarming. "Professorial Research Associate, Postgraduate School, Long Island University; Director of Surgical Research, The Ficarra Foundation, Inc., Oyster Bay, Long Island, New York
Surgical Clinics of North America- Vol, 51, No.6, December 1971
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Case 1 The patient was 45 years of age, rather obese, and had had an umbilical hernia for many years. She dated the hernia with the pregnancy of 15 years ago or more. Although the hernia increased in size it was accepted as a situation of little concern. When blood stains appeared on her undergarments she believed the bleeding was the result of skin irritation from tight underclothing. She sought professional advice only when the bleeding became grossly disturbing. The bleeding was intermittent in type, occasionally associated with a malodorous discharge. At the time of her initial examination she was found to be in a satisfactory physical state with no unusual findings excepting for the umbilical lesion. Within the depth of an umbilical crevice was a raspberry-like red mass which was somewhat warty in texture with a broad base. The appearance of the lesion was that of a multifaceted papilloma which was removed, and the hernia was repaired. The pathologist's report was that of a benign papilloma. Figures 1 and 2 recall two other instances of umbilical hernia veiling serious diseases.
EPIGASTRIC HERNIA A characteristic of epigastric hernia is pain because of the compression of a nerve by a cluster of lipomatous tissue, which is the universal content of epigastric hernia. A hernia, present in the epigastric area for
Figure 1. Post mortem specimen of omentum showing pearl-like neoplastic infiltration in a 56 year old woman with an umbilical hernia of many years' duration. When new symptoms developed about the umbilical hernia the patient attributed them to the hernia. The patient succumbed to adenocarcinomatosis, primary site undetermined. From Ficarra, B. J.: J.A.M.A., 150:478, 1952, reproduced by permission.
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Figure 2. Scout film of the abdomen demonstrating an acute small bowel obstruction in a pregnant woman (arrows mark fetal head). Patient had an umbilical hernia. When it commenced to enlarge with some pain she attributed the hernial enlargement to the natural course of even1:s associated with pregnancy. In reality the patient had a small bowel obstruction due to postoperative adhesions.
many years without major complaints, which suddenly becomes troublesome, may augur an underlying disease. Too frequently new symptoms are attributed to an old hernia. Beneath an epigastric hernia may lurk such disease processes as: gastric and duodenal ulcers, gastric or duodenal diverticula, gastrojejunocolic fistula, pancreatitis, pancreatic calculi, metastatic disease, or hiatus hernia. Inflammatory and ulcerative diseases of the stomach and duodenum are frequently encountered in patients with epigastric hernias. The examining physician or surgeon should become highly suspicious of the non symptomatic epigastric hernia that suddenly or gradually becomes associated with chest pain. It is strange to relate that chest pain has been a complaint in four patients (Table 1) with epigastric hernia who were found to have a gastric ulcer. In a previous survey of gastric procedures, an analytical study was made of postgastrectomy complications.5 This series included only 10 patients with gastric ulcer, 4 of which had an epigastric hernia with the development of newer symptoms attributed to the hernia. The major complaint in these 4 patients was pain in the chest. From Table 1 it can be seen that chest pain was an outstanding complaint. Since the chest complaints were assumed to result from the epigastric hernia, initially no thought was given to gastric disease. When the symptoms continued, electrocardiograms were taken at repeated intervals with chest x-rays. It was serendipity that brought about a request for upper gastrointestinal barium studies. These x-rays demon-
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Four Patients with Epigastric Hernia and Gastric Ulcer DURATION OF
CASE NO.
EPIGASTRIC AGE
SEX
HERNIA
64
M
10 yr.
Discomfort posterior chest and pain in lower right side of chest for 6 to 8 months
2
48
M
8 yr.
Pain in upper abdomen and lower chest for 2 years
3
40
F
5 yr.
Pain across upper abdomen and chest with nausea and epigastric pain for 1 year
4
67
F
10 yr. or more
SUBSEQUENT COMPLAINT
Pain in right lower chest and diaphragmatic area for 5 years
strated a gastric ulcer located along the lesser curvature in each of the four individuals. Physiologic investigations concerning the location of pain and its relation to lesions of various organs have demonstrated that two types of pain (local and referred) are to be considered. Intensive study by the English physiologist Henry Head brought to light that the cutaneous pain felt in visceral disease was located in the areas whose sensory nerves enter the spinal cord at the same segment which supplied nerves to the corresponding viscera. In disease of an organ, impulses pass from its nerves to a segment of the cord and are felt as pain in the skin areas whose sensory nerves enter the same cord segment. 2 • 6 In the 4 cases of gastric ulcer the inflammatory ulcerating process apparently irritated the diaphragm, resulting in pain referred to the chest area. Pain resulting from diaphragmatic irritation has a double distribution, a large local area of pain on the affected side of the lower portion of the thorax and upper part of the abdomen plus a second small area on the neck or shoulder on the same side. It has been shown that the diaphragm has a twofold sensory supply. The peripheral rim of the diaphragmatic pleura is innervated by sensory branches from the intercostal nerves while the central portion is innervated by the phrenic nerve.2 Inflammatory irritation of the outer margin of the diaphragm irritates the branches of the intercostal nerves and the pain is felt in the corresponding spinal segment in the lower portion of the thorax as these 4 cases of gastric ulcer demonstrate. Over the past many years 3 instances of gastric diverticula in patients with long-standing epigastric hernias were encountered. All were male patients, aged 40, 45 and 52. All had had hernias for many years and then developed gastric symptoms which were erroneously referred to the hernias. Upon closer examination and x-ray study, diverticula were found. The presence of diverticula in the gastrointestinal tract does not elicit much enthusiasm from a surgical viewpoint. However, when a gastric diverticulum is demonstrated, the rarity of this lesion captivates
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the interest of all. Gastric diverticula are sac-like evaginations of the stomach wall. The cavity is continuous with the stomach by an orifice or neck-like formation. Associated gastric disease may occur in proven cases of diverticula. The combination of diverticulum and ulcer has been stressed. More commonly the diverticulum is the site of inflammation resulting in localized gastritis. This gastritic process is both intradiverticular and peridiverticular in location. When the gastritis is of sufficient severity to cause symptoms, then attention is drawn to the epigastric hernia. Erroneously the hernia is indicted for the patient's complaints. Failure to employ barium x-ray studies of the upper gastrointestinal tract will prevent detection of the underlying diverticulum. Correction of the epigastric hernia will not eliminate the patient's complaints when the true source of the symptoms is due to the diverticulum.
MESENTERIC ARTERY SYNDROME When thoughts are centered about upper abdominal hernias, either ventral or epigastric, consideration must be given to the possible existence of a mesenteric artery syndrome lurking beneath the innocuous appearing integument. Many authors have written about the syndrome of duodenal obstruction, which may result from any abnormal obstruction to the third portion of the duodenum as it ascends and crosses the vertebral column. Some investigators have called this state duodenal ileus.3 Among the causes for this form of duodenal dysfunction are: inflammatory paralytic ileus, post-vagotomy state or other neuromuscular disorders, aganglionosis of Auerbach's plexus, collagenous diseases, occlusion secondary to extrinsic pressure as vascular compression, adhesive bands, edema of the mesenteric root, pressure from adjacent masses, narrowing of the duodenum from congenital stenosis, tumor anomalies, and so forth. This mesenteric artery syndrome presents bizarre symptoms in the earlier stages, since alteration in position will accentuate or alleviate distress. When the patient is in the supine position the syndrome will reappear and the existing symptom will become accentuated. As the obstruction increases, the symptoms become more pronounced and more frequent, with multiple episodes of nausea and vomiting. When surgery is performed for this syndrome it has been noted that there is frequently a complicating disease such as peptic ulcer or pancreatitis. In order to assist in arriving at a proper diagnosis of underlying disease, adequate barium x-ray studies are essential.
VENTRAL OR INCISIONAL HERNIAS Incisional and ventral hernias are major offenders in concealing underlying disease processes. Incisions in the right upper quadrant of the abdomen are notorious for camouflaging surgical diseases within the abdomen. Special reference is made to gall bladder disease. Often the patient has been uninformed or misinformed concerning the surgery
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performed. Cholecystostomy may be confused with cholecystectomy. Thus a recurrence of painful symptoms in the right upper quadrant in a patient who had a cholecystostomy may be due to recurrent gall bladder disease with or without cholelithiasis. If the patient gives a history of having had a cholecystectomy, then the trap is set for the examiner to indict the incisional hernia for the presenting complaints or label the disturbing process as a postcholecystectomy syndrome. A propos of incisional hernia and underlying disease, a situation presented itself in 1969 which was the subject of a malpractice action. * The legal action centered about the recurrence of symptoms following a cholecystectomy. The lawsuit became a battle of medical experts, wherein the symptom complex was attributed to postoperative adhesions beneath an incisional hernia versus a postcholecystectomy syndrome due to a long cystic duct remnant. The point of fact finally resolved about medical negligence and professional culpability for leaving a remnant of a long cystic duct. Another instance of an incisional hernia concealing organic disease centers about a gastrojejunocolic fistula which occurred in an adult man.
Case 2 A. R., a 45 year old office clerk, had a posterior gastroenterostomy for a duodenal ulcer 5 years prior to his hospital admission. Following this operation, a ventral hernia developed. He had recurrent symptoms which were attributed to the hernia. The major symptom was pain over the operative site. Physical examination confirmed the presence of the ventral hernia. There was no tenderness, and no masses were present. After much delay and hesitancy the patient finally consented to x-ray studies when diarrhea weakened him. Barium studies demonstrated the presence of a gastrojejunocolic fistula. After an adequate preoperative regimen, which included antibiotics and sulfasuxidine, the patient was subjected to a one-stage operation for the correction of a gastrojejunocolic fistula which developed following a gastroenterostomy for peptic ulcer. Diseases of the pancreas may be present beneath an incisional hernia with variable symptoms that are falsely attributed to the hernia. This is especially true when there is a low grade pancreatitis present or a subacute exacerbation of chronic pancreatitis in a patient concerning whom the diagnosis of pancreatitis was not confirmed.
Case 3 A 48 year old housewife entered the hospital with a chief complaint of generalized abdominal pain. The pain began 4 days before admission, at which time it was sudden in onset, diffusely distributed over the abdomen, and radiated laterally and downward. The patient had an incisional ventral hernia following gall bladder surgery. She attributed her painful symptoms to the hernia. Physical examination on admission demonstrated a well developed, ':'Winfrey vs. Farbat, 170 N.W. 2d 34, Michigan, Sept. 24, 1969.
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Figure 3. Flat plate X-ray of the abdomen showing two large pancreatitic calculi in a 35 year old seaman with an epigastric hernia who attributed his gastrointestinal symptoms to the epigastric henia. When the hernia was repaired the symptoms continued. It was only after the recurrence of symptoms after herniorrhaphy that a flat plate x-ray of the abdomen was taken. The x-ray demonstrated two calculi in the tail of the pancreas. These calculi were removed surgically, which completely freed the patient of gastrointestinal complaints.
well nourished obese female in acute distress and shock. Blood pressure was 90 mm. Hg systolic, 60 diastolic; pulse 120 of fair quality and tension; temperature 102.2 F.; respirations 38 rapid and shallow; slight dyspnea was present. The patient was transferred from the medical to the surgical service at this time, with the tentative diagnosis of acute gall bladder disease with perforation. Up to this time the patient continued to believe that all her symptoms were due to the incisional hernia. Surgery was performed upon this patient. The findings of significance concerned the pancreas. This organ was slightly enlarged, soft in consistency, hemorrhagic in appearance, and reddish brown in color. The gall bladder was distended and contained numerous multifaceted calculi. Operative diagnosis was acute hemorrhagic pancreatitis and subacute cholecystitis with cholelithiasis. Herein is an example of underlying pancreatitis in a patient with a long-standing incisional hernia. In other instances of ventral or incisional hernia it is well to remember that subclinical duodenal disease may lie surreptitiously beneath these hernias. For example, the incidence of Crohn's disease of the duodenum is being reported more frequently in the current literature. This entity should be remembered in patients who present bizarre symptoms. Sometimes the proffered complaints are loss of weight, diarrhea, and fever. Here again is a potent argument for the urgent necessity of having x-ray studies of the gastrointestinal tract in all
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patients with ventral or incisional hernia in an effort to identify dormant diseases. One must be mindful that an incisional hernia in the lower abdominal quadrants, either right or left, may harbor a disease process. It is not unusual for diverticulitis, sigmoiditis, or carcinoma to be beneath a left incisional hernia. A history of an appendectomy with a resultant incisional hernia in a patient who presents complaints does not mean that symptoms are caused by the incisional hernia. Beneath this hernia may be found segmental ileitis or neoplasm. In 1964 there was presented before the Superior Court of the Commonwealth of Massachusetts an often quoted legal case'" involving the vermiform appendix. The records stated that the patient had an operation for perforated appendicitis. Subsequently an incisional weakness developed. Years later symptoms occurred in the area of the healed operative scar. The symptoms were attributed to postoperative adhesions in an incisional hernia. Finally a second operation was performed upon the complaining patient and an acute gangrenous appendix was found and removed. In the battle of the medical experts, it was determined that the initial procedure was supposedly an appendectomy but in reality was a partial appendectomy with an evacuation of an appendiceal abscess. The patient was not informed as to the true nature of the initial operative findings.
HIATUS HERNIA Occluded from the examiner's eyes is herniation through the diaphragm. Often a small hernia produces nondescript symptoms which are discounted as insignificant. Nevertheless a sliding type of hiatal hernia may exist and deceive the alert clinician or the perusing roentgenologist. Hiatal hernia undetected and untreated over a period of years produces a fibrous stricture that can be corrected only by surgical treatment. Esophagocardiomyotomy is necessary, followed by a hernia repair. When a sliding hiatal hernia becomes incarcerated, the tough fibrous stricture is conducive to early and serious circulatory occlusion as edema progresses. Hence it is that resection of the distal esophagus and proximal half of the stomach may be necessary. Therefore thought must be given to sliding hiatal hernia in those patients who present bizarre upper gastrointestinal complaints. When thought is given to diaphragmatic hernias and strangulation, one must be mindful that the growing violence in the world should be a warning of the rising hazard of hiatal hernia strangulation in victims of all forms of trauma. Even though disruption of the diaphragm as the result of direct or indirect trauma has become increasingly more frequent, the identification of hernial strangulation is missed. The result is delay in surgical intervention and subsequent high mortality. This is *Haggerty V. McCarthy 181, N.E. 2d 562 Massachusetts, April 1964.
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especially true when minimal symptoms suggest the presence of peptic ulceration, gall bladder disease, or coronary artery insufficiency. When none of these is diagnosed, the patient is denied further evaluating studies that could affirm the presence of diaphragm herniation.
INGUINAL HERNIA The most frequent of all hernias are those in the inguinal and femoral regions. Inguinal and scrotal hernias are more apt to conceal hidden disease processes than any other hernias, in my experience. As an associate visiting surgeon for many years on the emergency service of a large municipal hospital, the presence of appendicitis, acute or otherwise, in a patient with hernia is sufficiently common not to require citation of specific cases. However, on one occasion during the repair of a right scrotal hernia a plastic exudate was cleared away and a hidden Meckel's diverticulum was found in the hernial sac (Fig. 4). Neoplastic lesions of the cecum and rectosigmoid have been found in scrotal hernias. In one instance the signs of intestinal obstruction were attributed to hernial incarceration, when in reality the true cause was an obstructing annular rectosigmoidal carcinoma.
Case 4 In keeping with the carcinoma theme, a case in point concerns a patient past 50 years of age who was admitted to the hospital because of a left inguinal hernia. He had this hernia for many years, but entered the hospital because of acute pain at the hernial site. He was operated upon and a satisfactory herniorrhaphy was performed. His pain disappeared. As he was leaving the hospital on the day of discharge, he tripped in the corridor of the hospital, sustaining a fracture of the left femur. X-ray studies demonstrated a pathologic fracture of the femur with a
Figure 4.
Meckel's diverticulum found in the right scrotal hernia of a young man.
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metastasis in the pubic bone. One area of metastasis was in close proximity to the original area of pain which was attributed to the inguinal hernia. Rectal examination indicated the presence of a large, hard irregular prostate compatible with a neoplastic process.
Case 5 A 22 year old man was admitted to the hospital because of pain over the left inguinal region, where a hernia had existed for many years. At the time of admission to the hospital his temperature was 102 F. Examination of the inguinal area was unsatisfactory because of excruciating pain. Attempts at inserting an examining finger into the inguinal ring resulted in such severe pain that the patient objected strenuously. After further questioning and gentle examination a diagnosis of inflammation of the vas deferens was made. Smear and culture from a urethral specimen confirmed the diagnosis when intracellular diplococci were found. With the rapid rise in gonorrheal infection in young adults inflammation of the vas deferens should be remembered in young patients with sudden pain in a long-standing hernia.
Case 6 An elderly man was admitted to the surgical service for an incarcerated scrotal hernia. Examination confirmed the presence of the large scrotal hernia, but it was not incarcerated. Elevation of the scrotum and examination of the perineum brought into view a large bulging mass. Further questioning of the pcttient elicited a history of urethral stricture and an antecedent venereal infection. The patient was transferred to the genitourinary service for treatment of urinary extravasation.
Case 7 A 32 year old man was seen in surgical consultation. He presented the history of pain in the right groin following the exertion of attempting to open a window. The next day he had difficulty in walking and noticed an inguinal mass. He was examined by his family physician, who reduced an incarcerated hernia (according to the patient's history). Two days later the pain increased in severity and began to radiate down the thigh. It was at this stage that the patient was seen in consultation. There was no visible hernia, but marked tenderness was elicited over the pubic bone. The external ring could not be examined because of pain. The temperature was recorded at 103.6 F. Abdominal examination did not reveal any intra-abdominal disease process. It was believed that the patient had some infection in or near the pubic bone. (X-ray studies failed to demonstrate any bone injury or disease.) The patient was treated empirically with antibiotics. Subsequently a deep inguinal abscess developed and required' incision and drainage. Following this surgical procedure his recovery was rapid. Examination then disclosed the presence of a classical indirect inguinal hernia. It is believed that the abscess formed as an acute exacerbation of a chronic infection which was secondary to a previous injury. The patient had an antecedent history of a fractured pelvis associated with a perforated urinary bladder plus a pelvic infection. The acute
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hidden infection was obscured by the inguinal hernia to which the patient was oriented as to the cause for his pain.
Case 8 In a previous publication a report was made of an instance of mesenteric thrombosis associated with an inguinal hernia. 4 The patient was a 59 year old man who entered the hospital because of pain in the left inguinal region. He had had a hernia for the past 2 or 3 years. Since the day before admission the pain had increased in severity and frequency. Physical examination unfolded a left scrotal hernia which was reduced via taxis by the hospital resident. Twelve hours later signs of an acute abdominal condition became manifest. At operation an ulcerating rectosigmoidal neoplasm was found, associated with a thrombosis of the inferior mesenteric artery and vein with gangrene of the descending colon and sigmoid. The patient expired 16 hours after surgery. The major cause for the poor salvage rate in patients with intestinal ischemic syndromes is delayed or incorrect diagnosis. Sudden occlusion of the blood supply to the intestine results in acute gangrene within 6 hours. The mortality rate in the presence of gangrene is extremely high, approaching 90 per cent even with surgical intervention. Early recognition of the occlusive syndrome and confirmation by superior mesenteric and celiac arteriography is effective in arriving at a proper diagnosis with subsequent adequate surgical treatment. If surgical therapy is to be beneficial, it must be accomplished within 6 hours of the onset of this symptom complex.
Case 9 A elderly man entered the hospital because of the major complaint of pain in the left inguinal region. The history was one of a "swelling" in the left inguinal region and testicle for 3 years (a hernia). For the past 3 or 4 months he had had occasional pains in this area. Since the day before admission the pain had become more severe and constant. No vomiting occurred at any time. On the morning of admission he passed some small, hard feces. He ate his usual breakfast. There was no history of weight loss, melena, or gastrointestinal disturbances. The only past history worthy of recount was an operation 2 years previously for hernia. Twelve hours after admission signs of an acute surgical state within the abdomen developed. Rectal examination at that time demonstrated external hemorrhoids and an enlarged prostate, and fresh blood was present on the examining finger. Laboratory data (after actue signs developed) were as follows: white blood count 21,000 with 88 per cent polymorphonuclear leukocytes; red blood count 3,100,000; hemoglobin 60 per cent; urinalysis was normal; a scout film of the abdomen demonstrated dilated intestinal patterns (Fig. 5). Thirty-six hours after the onset of his pain the panent was subjected to an exploratory laparotomy. At the time of operation 1,500 ml. of blood-tinged peritoneal fluid was found. An ulcerating rectosigmoidal neoplasm was present, associated with a thrombosis of the inferior mesenteric vein, plus gangrene of the descending colon and sigmoid. The gangrenous area was resected. The splenic flexure was employed
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Figure 5. Scout film of abdomen (flat plate x-ray) showing dilated large and small intestine (arrows) suggesting intestinal obstruction. This pattern is seen in mesenteric vascular occlusion. A barium enema in this patient revealed no obstruction. This type of roentgen study is valuable in arriving at a diagnosis of mesenteric thrombosis.
as a colostomy; the viable distal rectosigmoid was placed in the lower pole of the incision. The patient was in irreversible shock. Fourteen hours after the operation the patient expired. Venous thrombosis of the mesenteric vessels is usually associated with infection in organs or viscera that are tributaries to the portal vein. The pathologic conditions commonly antedating the thrombosis are appendicitis, inflammatory pelvic disease or ulcerating colonic carcinoma. Primary venous thrombosis is quite rare. When it occurs it is due to endophlebitis or phlebosclerosis.! In secondary thrombosis when inflammatory lesions are not in evidence, injury to the vessel wall (as in constrictions from an incarcerated and/or strangulated hernia) should be remembered as an etiologic factor. Case 9 illustrates quite vividly how easily organic disease may be concealed beneath a hernia. Past experience has taught that a patient may have an inguinal hernia for many years and then suddenly develop pain in the inguinal region. Too frequently the hernia is indicted for this newly felt distress. This was the situation that prevailed in Case 9. The patient attributed his difficulty to the hernia which, unknown to himself, masked a hidden ulcerating neoplasm. This new growth nurtured an autochthonous thrombosis which caused the concatenation of events resulting in an inferior mesenteric venous occlusion with gangrene of the descending and sigmoid colons (Fig. 6). Case 10 A 40 year old housewife went on a crash reducing diet. She succeeded in losing a great deal of weight and noted a swelling in the femoral area which was diagnosed as a simple femoral hernia. When she was assured that it was not a neoplasm she did not pursue any other
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Figure 6. Microphotograph (x 125) of an ulcerating anaplastic adenocarcinoma of the rectosigmoid (left side of photograph) with secondary inflammatory changes (right side of photograph). Center portion shows cellular infiltration into muscular layers of intestinal wall with edema secondary to mesenteric thrombosis.
palliative or definitive treatment for the femoral hernia. The patient was cancer-conscious because of a past history of postoperative radiation therapy for ovarian carcinoma. As time passed the patient experienced vague symptoms at the femoral hernia site. She sought hospitalization when her lower abdomen became softly distended with a slight rise in temperature, to 100 F., with chills. During her hospitalization complete diagnostic procedures were performed which included barium studies of the gastrointestinal tract. The ingested barium passed through the intestinal tract with a small trickle of barium emanating into the vagina as pictured in Figure 7. When laparotomy was performed a loop of ileum was found adherent in the pelvis and at the femoral hernia site. In addition there was a fistulous tract between an ulcerating ileal segment and the anterior vaginal vault. The necrotic process involved the urinary bladder, allowing the escaping barium to exit through the urethra into the vagina. The patient had a satisfactory postoperative course but developed a postradiation anemia, and finally she succumbed. Tracing the clinical picture backward, one realizes that the radiation therapy was the cause for the intestinal ulceration perhaps originating from vascular embarrassment causing ischemic tissue necrosis. The slowly spreading infection, although limited to the pelvis, eventually presented itself as an external fistula but prior to doing so caused a referral of pain to the femoral hernia which was erroneously blamed for the regional distress. 0
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Figure 7. Barium x-ray studies of a 40 year old housewife showing a collection of barium in the pelvis. The barium is saucershaped. indicating its presence in the urinary bladder. Arrows mark the barium exiting through the urethra and trickling into the vagina.
CONCLUSIONS AND SUMMARY Herewith is presented a study of various forms of hernias which hide beneath themselves occult surgical diseases. Too often the obvious hernia is accepted as the major culprit for the patient's symptomatology. Experience teaches that herniorrhaphy should not be performed until a complete evaluation of the patient has been made with special reference to x-ray studies to affirm or deny the presence of any veiled intra-abdominal disease.
REFERENCES 1. Boyd, W.: Surgical Pathology. Philadelphia, W. B. Saunders Co., 1953. 2. Capps, J. A., and Coleman, G. H.: Experimental and Clinical Study of Pain in the Pleura, Pericardium and Peritoneum. New York, Macmillan Co., 1932. 3. Collins, H. L.: Mesenteric artery syndrome. Abdomin. Surg., 13:32,1971. 4. Ficarra, B. J.: Mesenteric vascular occlusion. Amer. J. Surg., 66:168-177,1944. 5. Ficarra, B. J.: Postgastrectomy complications. Amer. J. Gastroenterol., 30:222-224,1958. 6. Major, R.': Physical Diagnosis. Philadelphia, W. B. Saunders Co" 1937.
The Ficarra Foundation, Inc. Oyster Bay, Long Island New York 11771
Hernia - Masquerader of Surgical Disorders Bernard J. Ficarra, MD., SeD., Ph.D. *
A simple hernia that is looked at unsuspectingly from day to daywhat does it hide beneath its surface? Often residing behind the hernial mask is concealed organic disease which has lain dormant for months or years. Symptoms will develop and a patient will incriminate a hernia which has been present chronically as the causative agent for sudden acute symptoms. It is well to remember that serious pathologic processes may be concealed by a hernia without resulting in any distress. Suddenly there occurs a complaint of pain or discomfort at the hernial site. In the absence of an incarceration or strangulation of the hernia, thought should be given to the possibility of an underlying pathologic entity unrelated to the obviously apparent hernia. Too often the obvious is indicted for what is not apparent. This present communication is the result of a purposeful observation on this subject over the past 20 years.
UMBILICAL HERNIA The readily apparent umbilicus is the least suspect of having a hernia with associated or underlying disease. However, umbilical hernias are among the easiest of all hernias to become incarcerated or strangulated. In addition aggravation of the hernial state is characterized by a rounding of the umbilical area and then cupola formation. In obese persons the umbilicus disappears from view and the patient sees only a circle of skin as the umbilicus fades away between dermal creases. In one instance a papilloma of the umbilicus was sheltered beneath a cupolous umbilicus. The patient noticed spots of blood on her undergarments but attributed the staining to irritation because the dome of the umbilical hernia was red and slightly excoriated. Since the hernia was of long duration it was accepted as commonplace and not too alarming. "Professorial Research Associate, Postgraduate School, Long Island University; Director of Surgical Research, The Ficarra Foundation, Inc., Oyster Bay, Long Island, New York
Surgical Clinics of North America- Vol, 51, No.6, December 1971
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Case 1 The patient was 45 years of age, rather obese, and had had an umbilical hernia for many years. She dated the hernia with the pregnancy of 15 years ago or more. Although the hernia increased in size it was accepted as a situation of little concern. When blood stains appeared on her undergarments she believed the bleeding was the result of skin irritation from tight underclothing. She sought professional advice only when the bleeding became grossly disturbing. The bleeding was intermittent in type, occasionally associated with a malodorous discharge. At the time of her initial examination she was found to be in a satisfactory physical state with no unusual findings excepting for the umbilical lesion. Within the depth of an umbilical crevice was a raspberry-like red mass which was somewhat warty in texture with a broad base. The appearance of the lesion was that of a multifaceted papilloma which was removed, and the hernia was repaired. The pathologist's report was that of a benign papilloma. Figures 1 and 2 recall two other instances of umbilical hernia veiling serious diseases.
EPIGASTRIC HERNIA A characteristic of epigastric hernia is pain because of the compression of a nerve by a cluster of lipomatous tissue, which is the universal content of epigastric hernia. A hernia, present in the epigastric area for
Figure 1. Post mortem specimen of omentum showing pearl-like neoplastic infiltration in a 56 year old woman with an umbilical hernia of many years' duration. When new symptoms developed about the umbilical hernia the patient attributed them to the hernia. The patient succumbed to adenocarcinomatosis, primary site undetermined. From Ficarra, B. J.: J.A.M.A., 150:478, 1952, reproduced by permission.
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Figure 2. Scout film of the abdomen demonstrating an acute small bowel obstruction in a pregnant woman (arrows mark fetal head). Patient had an umbilical hernia. When it commenced to enlarge with some pain she attributed the hernial enlargement to the natural course of even1:s associated with pregnancy. In reality the patient had a small bowel obstruction due to postoperative adhesions.
many years without major complaints, which suddenly becomes troublesome, may augur an underlying disease. Too frequently new symptoms are attributed to an old hernia. Beneath an epigastric hernia may lurk such disease processes as: gastric and duodenal ulcers, gastric or duodenal diverticula, gastrojejunocolic fistula, pancreatitis, pancreatic calculi, metastatic disease, or hiatus hernia. Inflammatory and ulcerative diseases of the stomach and duodenum are frequently encountered in patients with epigastric hernias. The examining physician or surgeon should become highly suspicious of the non symptomatic epigastric hernia that suddenly or gradually becomes associated with chest pain. It is strange to relate that chest pain has been a complaint in four patients (Table 1) with epigastric hernia who were found to have a gastric ulcer. In a previous survey of gastric procedures, an analytical study was made of postgastrectomy complications.5 This series included only 10 patients with gastric ulcer, 4 of which had an epigastric hernia with the development of newer symptoms attributed to the hernia. The major complaint in these 4 patients was pain in the chest. From Table 1 it can be seen that chest pain was an outstanding complaint. Since the chest complaints were assumed to result from the epigastric hernia, initially no thought was given to gastric disease. When the symptoms continued, electrocardiograms were taken at repeated intervals with chest x-rays. It was serendipity that brought about a request for upper gastrointestinal barium studies. These x-rays demon-
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Table 1.
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FICARRA
Four Patients with Epigastric Hernia and Gastric Ulcer DURATION OF
CASE NO.
EPIGASTRIC AGE
SEX
HERNIA
64
M
10 yr.
Discomfort posterior chest and pain in lower right side of chest for 6 to 8 months
2
48
M
8 yr.
Pain in upper abdomen and lower chest for 2 years
3
40
F
5 yr.
Pain across upper abdomen and chest with nausea and epigastric pain for 1 year
4
67
F
10 yr. or more
SUBSEQUENT COMPLAINT
Pain in right lower chest and diaphragmatic area for 5 years
strated a gastric ulcer located along the lesser curvature in each of the four individuals. Physiologic investigations concerning the location of pain and its relation to lesions of various organs have demonstrated that two types of pain (local and referred) are to be considered. Intensive study by the English physiologist Henry Head brought to light that the cutaneous pain felt in visceral disease was located in the areas whose sensory nerves enter the spinal cord at the same segment which supplied nerves to the corresponding viscera. In disease of an organ, impulses pass from its nerves to a segment of the cord and are felt as pain in the skin areas whose sensory nerves enter the same cord segment. 2 • 6 In the 4 cases of gastric ulcer the inflammatory ulcerating process apparently irritated the diaphragm, resulting in pain referred to the chest area. Pain resulting from diaphragmatic irritation has a double distribution, a large local area of pain on the affected side of the lower portion of the thorax and upper part of the abdomen plus a second small area on the neck or shoulder on the same side. It has been shown that the diaphragm has a twofold sensory supply. The peripheral rim of the diaphragmatic pleura is innervated by sensory branches from the intercostal nerves while the central portion is innervated by the phrenic nerve.2 Inflammatory irritation of the outer margin of the diaphragm irritates the branches of the intercostal nerves and the pain is felt in the corresponding spinal segment in the lower portion of the thorax as these 4 cases of gastric ulcer demonstrate. Over the past many years 3 instances of gastric diverticula in patients with long-standing epigastric hernias were encountered. All were male patients, aged 40, 45 and 52. All had had hernias for many years and then developed gastric symptoms which were erroneously referred to the hernias. Upon closer examination and x-ray study, diverticula were found. The presence of diverticula in the gastrointestinal tract does not elicit much enthusiasm from a surgical viewpoint. However, when a gastric diverticulum is demonstrated, the rarity of this lesion captivates
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the interest of all. Gastric diverticula are sac-like evaginations of the stomach wall. The cavity is continuous with the stomach by an orifice or neck-like formation. Associated gastric disease may occur in proven cases of diverticula. The combination of diverticulum and ulcer has been stressed. More commonly the diverticulum is the site of inflammation resulting in localized gastritis. This gastritic process is both intradiverticular and peridiverticular in location. When the gastritis is of sufficient severity to cause symptoms, then attention is drawn to the epigastric hernia. Erroneously the hernia is indicted for the patient's complaints. Failure to employ barium x-ray studies of the upper gastrointestinal tract will prevent detection of the underlying diverticulum. Correction of the epigastric hernia will not eliminate the patient's complaints when the true source of the symptoms is due to the diverticulum.
MESENTERIC ARTERY SYNDROME When thoughts are centered about upper abdominal hernias, either ventral or epigastric, consideration must be given to the possible existence of a mesenteric artery syndrome lurking beneath the innocuous appearing integument. Many authors have written about the syndrome of duodenal obstruction, which may result from any abnormal obstruction to the third portion of the duodenum as it ascends and crosses the vertebral column. Some investigators have called this state duodenal ileus.3 Among the causes for this form of duodenal dysfunction are: inflammatory paralytic ileus, post-vagotomy state or other neuromuscular disorders, aganglionosis of Auerbach's plexus, collagenous diseases, occlusion secondary to extrinsic pressure as vascular compression, adhesive bands, edema of the mesenteric root, pressure from adjacent masses, narrowing of the duodenum from congenital stenosis, tumor anomalies, and so forth. This mesenteric artery syndrome presents bizarre symptoms in the earlier stages, since alteration in position will accentuate or alleviate distress. When the patient is in the supine position the syndrome will reappear and the existing symptom will become accentuated. As the obstruction increases, the symptoms become more pronounced and more frequent, with multiple episodes of nausea and vomiting. When surgery is performed for this syndrome it has been noted that there is frequently a complicating disease such as peptic ulcer or pancreatitis. In order to assist in arriving at a proper diagnosis of underlying disease, adequate barium x-ray studies are essential.
VENTRAL OR INCISIONAL HERNIAS Incisional and ventral hernias are major offenders in concealing underlying disease processes. Incisions in the right upper quadrant of the abdomen are notorious for camouflaging surgical diseases within the abdomen. Special reference is made to gall bladder disease. Often the patient has been uninformed or misinformed concerning the surgery
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performed. Cholecystostomy may be confused with cholecystectomy. Thus a recurrence of painful symptoms in the right upper quadrant in a patient who had a cholecystostomy may be due to recurrent gall bladder disease with or without cholelithiasis. If the patient gives a history of having had a cholecystectomy, then the trap is set for the examiner to indict the incisional hernia for the presenting complaints or label the disturbing process as a postcholecystectomy syndrome. A propos of incisional hernia and underlying disease, a situation presented itself in 1969 which was the subject of a malpractice action. * The legal action centered about the recurrence of symptoms following a cholecystectomy. The lawsuit became a battle of medical experts, wherein the symptom complex was attributed to postoperative adhesions beneath an incisional hernia versus a postcholecystectomy syndrome due to a long cystic duct remnant. The point of fact finally resolved about medical negligence and professional culpability for leaving a remnant of a long cystic duct. Another instance of an incisional hernia concealing organic disease centers about a gastrojejunocolic fistula which occurred in an adult man.
Case 2 A. R., a 45 year old office clerk, had a posterior gastroenterostomy for a duodenal ulcer 5 years prior to his hospital admission. Following this operation, a ventral hernia developed. He had recurrent symptoms which were attributed to the hernia. The major symptom was pain over the operative site. Physical examination confirmed the presence of the ventral hernia. There was no tenderness, and no masses were present. After much delay and hesitancy the patient finally consented to x-ray studies when diarrhea weakened him. Barium studies demonstrated the presence of a gastrojejunocolic fistula. After an adequate preoperative regimen, which included antibiotics and sulfasuxidine, the patient was subjected to a one-stage operation for the correction of a gastrojejunocolic fistula which developed following a gastroenterostomy for peptic ulcer. Diseases of the pancreas may be present beneath an incisional hernia with variable symptoms that are falsely attributed to the hernia. This is especially true when there is a low grade pancreatitis present or a subacute exacerbation of chronic pancreatitis in a patient concerning whom the diagnosis of pancreatitis was not confirmed.
Case 3 A 48 year old housewife entered the hospital with a chief complaint of generalized abdominal pain. The pain began 4 days before admission, at which time it was sudden in onset, diffusely distributed over the abdomen, and radiated laterally and downward. The patient had an incisional ventral hernia following gall bladder surgery. She attributed her painful symptoms to the hernia. Physical examination on admission demonstrated a well developed, ':'Winfrey vs. Farbat, 170 N.W. 2d 34, Michigan, Sept. 24, 1969.
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Figure 3. Flat plate X-ray of the abdomen showing two large pancreatitic calculi in a 35 year old seaman with an epigastric hernia who attributed his gastrointestinal symptoms to the epigastric henia. When the hernia was repaired the symptoms continued. It was only after the recurrence of symptoms after herniorrhaphy that a flat plate x-ray of the abdomen was taken. The x-ray demonstrated two calculi in the tail of the pancreas. These calculi were removed surgically, which completely freed the patient of gastrointestinal complaints.
well nourished obese female in acute distress and shock. Blood pressure was 90 mm. Hg systolic, 60 diastolic; pulse 120 of fair quality and tension; temperature 102.2 F.; respirations 38 rapid and shallow; slight dyspnea was present. The patient was transferred from the medical to the surgical service at this time, with the tentative diagnosis of acute gall bladder disease with perforation. Up to this time the patient continued to believe that all her symptoms were due to the incisional hernia. Surgery was performed upon this patient. The findings of significance concerned the pancreas. This organ was slightly enlarged, soft in consistency, hemorrhagic in appearance, and reddish brown in color. The gall bladder was distended and contained numerous multifaceted calculi. Operative diagnosis was acute hemorrhagic pancreatitis and subacute cholecystitis with cholelithiasis. Herein is an example of underlying pancreatitis in a patient with a long-standing incisional hernia. In other instances of ventral or incisional hernia it is well to remember that subclinical duodenal disease may lie surreptitiously beneath these hernias. For example, the incidence of Crohn's disease of the duodenum is being reported more frequently in the current literature. This entity should be remembered in patients who present bizarre symptoms. Sometimes the proffered complaints are loss of weight, diarrhea, and fever. Here again is a potent argument for the urgent necessity of having x-ray studies of the gastrointestinal tract in all
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patients with ventral or incisional hernia in an effort to identify dormant diseases. One must be mindful that an incisional hernia in the lower abdominal quadrants, either right or left, may harbor a disease process. It is not unusual for diverticulitis, sigmoiditis, or carcinoma to be beneath a left incisional hernia. A history of an appendectomy with a resultant incisional hernia in a patient who presents complaints does not mean that symptoms are caused by the incisional hernia. Beneath this hernia may be found segmental ileitis or neoplasm. In 1964 there was presented before the Superior Court of the Commonwealth of Massachusetts an often quoted legal case'" involving the vermiform appendix. The records stated that the patient had an operation for perforated appendicitis. Subsequently an incisional weakness developed. Years later symptoms occurred in the area of the healed operative scar. The symptoms were attributed to postoperative adhesions in an incisional hernia. Finally a second operation was performed upon the complaining patient and an acute gangrenous appendix was found and removed. In the battle of the medical experts, it was determined that the initial procedure was supposedly an appendectomy but in reality was a partial appendectomy with an evacuation of an appendiceal abscess. The patient was not informed as to the true nature of the initial operative findings.
HIATUS HERNIA Occluded from the examiner's eyes is herniation through the diaphragm. Often a small hernia produces nondescript symptoms which are discounted as insignificant. Nevertheless a sliding type of hiatal hernia may exist and deceive the alert clinician or the perusing roentgenologist. Hiatal hernia undetected and untreated over a period of years produces a fibrous stricture that can be corrected only by surgical treatment. Esophagocardiomyotomy is necessary, followed by a hernia repair. When a sliding hiatal hernia becomes incarcerated, the tough fibrous stricture is conducive to early and serious circulatory occlusion as edema progresses. Hence it is that resection of the distal esophagus and proximal half of the stomach may be necessary. Therefore thought must be given to sliding hiatal hernia in those patients who present bizarre upper gastrointestinal complaints. When thought is given to diaphragmatic hernias and strangulation, one must be mindful that the growing violence in the world should be a warning of the rising hazard of hiatal hernia strangulation in victims of all forms of trauma. Even though disruption of the diaphragm as the result of direct or indirect trauma has become increasingly more frequent, the identification of hernial strangulation is missed. The result is delay in surgical intervention and subsequent high mortality. This is *Haggerty V. McCarthy 181, N.E. 2d 562 Massachusetts, April 1964.
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especially true when minimal symptoms suggest the presence of peptic ulceration, gall bladder disease, or coronary artery insufficiency. When none of these is diagnosed, the patient is denied further evaluating studies that could affirm the presence of diaphragm herniation.
INGUINAL HERNIA The most frequent of all hernias are those in the inguinal and femoral regions. Inguinal and scrotal hernias are more apt to conceal hidden disease processes than any other hernias, in my experience. As an associate visiting surgeon for many years on the emergency service of a large municipal hospital, the presence of appendicitis, acute or otherwise, in a patient with hernia is sufficiently common not to require citation of specific cases. However, on one occasion during the repair of a right scrotal hernia a plastic exudate was cleared away and a hidden Meckel's diverticulum was found in the hernial sac (Fig. 4). Neoplastic lesions of the cecum and rectosigmoid have been found in scrotal hernias. In one instance the signs of intestinal obstruction were attributed to hernial incarceration, when in reality the true cause was an obstructing annular rectosigmoidal carcinoma.
Case 4 In keeping with the carcinoma theme, a case in point concerns a patient past 50 years of age who was admitted to the hospital because of a left inguinal hernia. He had this hernia for many years, but entered the hospital because of acute pain at the hernial site. He was operated upon and a satisfactory herniorrhaphy was performed. His pain disappeared. As he was leaving the hospital on the day of discharge, he tripped in the corridor of the hospital, sustaining a fracture of the left femur. X-ray studies demonstrated a pathologic fracture of the femur with a
Figure 4.
Meckel's diverticulum found in the right scrotal hernia of a young man.
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metastasis in the pubic bone. One area of metastasis was in close proximity to the original area of pain which was attributed to the inguinal hernia. Rectal examination indicated the presence of a large, hard irregular prostate compatible with a neoplastic process.
Case 5 A 22 year old man was admitted to the hospital because of pain over the left inguinal region, where a hernia had existed for many years. At the time of admission to the hospital his temperature was 102 F. Examination of the inguinal area was unsatisfactory because of excruciating pain. Attempts at inserting an examining finger into the inguinal ring resulted in such severe pain that the patient objected strenuously. After further questioning and gentle examination a diagnosis of inflammation of the vas deferens was made. Smear and culture from a urethral specimen confirmed the diagnosis when intracellular diplococci were found. With the rapid rise in gonorrheal infection in young adults inflammation of the vas deferens should be remembered in young patients with sudden pain in a long-standing hernia.
Case 6 An elderly man was admitted to the surgical service for an incarcerated scrotal hernia. Examination confirmed the presence of the large scrotal hernia, but it was not incarcerated. Elevation of the scrotum and examination of the perineum brought into view a large bulging mass. Further questioning of the pcttient elicited a history of urethral stricture and an antecedent venereal infection. The patient was transferred to the genitourinary service for treatment of urinary extravasation.
Case 7 A 32 year old man was seen in surgical consultation. He presented the history of pain in the right groin following the exertion of attempting to open a window. The next day he had difficulty in walking and noticed an inguinal mass. He was examined by his family physician, who reduced an incarcerated hernia (according to the patient's history). Two days later the pain increased in severity and began to radiate down the thigh. It was at this stage that the patient was seen in consultation. There was no visible hernia, but marked tenderness was elicited over the pubic bone. The external ring could not be examined because of pain. The temperature was recorded at 103.6 F. Abdominal examination did not reveal any intra-abdominal disease process. It was believed that the patient had some infection in or near the pubic bone. (X-ray studies failed to demonstrate any bone injury or disease.) The patient was treated empirically with antibiotics. Subsequently a deep inguinal abscess developed and required' incision and drainage. Following this surgical procedure his recovery was rapid. Examination then disclosed the presence of a classical indirect inguinal hernia. It is believed that the abscess formed as an acute exacerbation of a chronic infection which was secondary to a previous injury. The patient had an antecedent history of a fractured pelvis associated with a perforated urinary bladder plus a pelvic infection. The acute
HERNIA-MASQUERADER OF SURGICAL DISORDERS
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hidden infection was obscured by the inguinal hernia to which the patient was oriented as to the cause for his pain.
Case 8 In a previous publication a report was made of an instance of mesenteric thrombosis associated with an inguinal hernia. 4 The patient was a 59 year old man who entered the hospital because of pain in the left inguinal region. He had had a hernia for the past 2 or 3 years. Since the day before admission the pain had increased in severity and frequency. Physical examination unfolded a left scrotal hernia which was reduced via taxis by the hospital resident. Twelve hours later signs of an acute abdominal condition became manifest. At operation an ulcerating rectosigmoidal neoplasm was found, associated with a thrombosis of the inferior mesenteric artery and vein with gangrene of the descending colon and sigmoid. The patient expired 16 hours after surgery. The major cause for the poor salvage rate in patients with intestinal ischemic syndromes is delayed or incorrect diagnosis. Sudden occlusion of the blood supply to the intestine results in acute gangrene within 6 hours. The mortality rate in the presence of gangrene is extremely high, approaching 90 per cent even with surgical intervention. Early recognition of the occlusive syndrome and confirmation by superior mesenteric and celiac arteriography is effective in arriving at a proper diagnosis with subsequent adequate surgical treatment. If surgical therapy is to be beneficial, it must be accomplished within 6 hours of the onset of this symptom complex.
Case 9 A elderly man entered the hospital because of the major complaint of pain in the left inguinal region. The history was one of a "swelling" in the left inguinal region and testicle for 3 years (a hernia). For the past 3 or 4 months he had had occasional pains in this area. Since the day before admission the pain had become more severe and constant. No vomiting occurred at any time. On the morning of admission he passed some small, hard feces. He ate his usual breakfast. There was no history of weight loss, melena, or gastrointestinal disturbances. The only past history worthy of recount was an operation 2 years previously for hernia. Twelve hours after admission signs of an acute surgical state within the abdomen developed. Rectal examination at that time demonstrated external hemorrhoids and an enlarged prostate, and fresh blood was present on the examining finger. Laboratory data (after actue signs developed) were as follows: white blood count 21,000 with 88 per cent polymorphonuclear leukocytes; red blood count 3,100,000; hemoglobin 60 per cent; urinalysis was normal; a scout film of the abdomen demonstrated dilated intestinal patterns (Fig. 5). Thirty-six hours after the onset of his pain the panent was subjected to an exploratory laparotomy. At the time of operation 1,500 ml. of blood-tinged peritoneal fluid was found. An ulcerating rectosigmoidal neoplasm was present, associated with a thrombosis of the inferior mesenteric vein, plus gangrene of the descending colon and sigmoid. The gangrenous area was resected. The splenic flexure was employed
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Figure 5. Scout film of abdomen (flat plate x-ray) showing dilated large and small intestine (arrows) suggesting intestinal obstruction. This pattern is seen in mesenteric vascular occlusion. A barium enema in this patient revealed no obstruction. This type of roentgen study is valuable in arriving at a diagnosis of mesenteric thrombosis.
as a colostomy; the viable distal rectosigmoid was placed in the lower pole of the incision. The patient was in irreversible shock. Fourteen hours after the operation the patient expired. Venous thrombosis of the mesenteric vessels is usually associated with infection in organs or viscera that are tributaries to the portal vein. The pathologic conditions commonly antedating the thrombosis are appendicitis, inflammatory pelvic disease or ulcerating colonic carcinoma. Primary venous thrombosis is quite rare. When it occurs it is due to endophlebitis or phlebosclerosis.! In secondary thrombosis when inflammatory lesions are not in evidence, injury to the vessel wall (as in constrictions from an incarcerated and/or strangulated hernia) should be remembered as an etiologic factor. Case 9 illustrates quite vividly how easily organic disease may be concealed beneath a hernia. Past experience has taught that a patient may have an inguinal hernia for many years and then suddenly develop pain in the inguinal region. Too frequently the hernia is indicted for this newly felt distress. This was the situation that prevailed in Case 9. The patient attributed his difficulty to the hernia which, unknown to himself, masked a hidden ulcerating neoplasm. This new growth nurtured an autochthonous thrombosis which caused the concatenation of events resulting in an inferior mesenteric venous occlusion with gangrene of the descending and sigmoid colons (Fig. 6). Case 10 A 40 year old housewife went on a crash reducing diet. She succeeded in losing a great deal of weight and noted a swelling in the femoral area which was diagnosed as a simple femoral hernia. When she was assured that it was not a neoplasm she did not pursue any other
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Figure 6. Microphotograph (x 125) of an ulcerating anaplastic adenocarcinoma of the rectosigmoid (left side of photograph) with secondary inflammatory changes (right side of photograph). Center portion shows cellular infiltration into muscular layers of intestinal wall with edema secondary to mesenteric thrombosis.
palliative or definitive treatment for the femoral hernia. The patient was cancer-conscious because of a past history of postoperative radiation therapy for ovarian carcinoma. As time passed the patient experienced vague symptoms at the femoral hernia site. She sought hospitalization when her lower abdomen became softly distended with a slight rise in temperature, to 100 F., with chills. During her hospitalization complete diagnostic procedures were performed which included barium studies of the gastrointestinal tract. The ingested barium passed through the intestinal tract with a small trickle of barium emanating into the vagina as pictured in Figure 7. When laparotomy was performed a loop of ileum was found adherent in the pelvis and at the femoral hernia site. In addition there was a fistulous tract between an ulcerating ileal segment and the anterior vaginal vault. The necrotic process involved the urinary bladder, allowing the escaping barium to exit through the urethra into the vagina. The patient had a satisfactory postoperative course but developed a postradiation anemia, and finally she succumbed. Tracing the clinical picture backward, one realizes that the radiation therapy was the cause for the intestinal ulceration perhaps originating from vascular embarrassment causing ischemic tissue necrosis. The slowly spreading infection, although limited to the pelvis, eventually presented itself as an external fistula but prior to doing so caused a referral of pain to the femoral hernia which was erroneously blamed for the regional distress. 0
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Figure 7. Barium x-ray studies of a 40 year old housewife showing a collection of barium in the pelvis. The barium is saucershaped. indicating its presence in the urinary bladder. Arrows mark the barium exiting through the urethra and trickling into the vagina.
CONCLUSIONS AND SUMMARY Herewith is presented a study of various forms of hernias which hide beneath themselves occult surgical diseases. Too often the obvious hernia is accepted as the major culprit for the patient's symptomatology. Experience teaches that herniorrhaphy should not be performed until a complete evaluation of the patient has been made with special reference to x-ray studies to affirm or deny the presence of any veiled intra-abdominal disease.
REFERENCES 1. Boyd, W.: Surgical Pathology. Philadelphia, W. B. Saunders Co., 1953. 2. Capps, J. A., and Coleman, G. H.: Experimental and Clinical Study of Pain in the Pleura, Pericardium and Peritoneum. New York, Macmillan Co., 1932. 3. Collins, H. L.: Mesenteric artery syndrome. Abdomin. Surg., 13:32,1971. 4. Ficarra, B. J.: Mesenteric vascular occlusion. Amer. J. Surg., 66:168-177,1944. 5. Ficarra, B. J.: Postgastrectomy complications. Amer. J. Gastroenterol., 30:222-224,1958. 6. Major, R.': Physical Diagnosis. Philadelphia, W. B. Saunders Co" 1937.
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