Selected Articles from the
Journal Abdominal Surgery

This article originally appeared in the Winter 2009 / Spring 2010 issue of the Journal.

Internal Herniation in an Unusual Peritoneal Aperture

Matthijs P Somford MD
Resident General Surgery

David Reynders MD
General Surgeon

Arjen M Rijken MD PhD
General Surgeon

Amphia Hospital Breda, Holland

Corresponding author:
Matthijs P. Somford, MD
Amphia Hospital, department of Surgery
P.O. Box 90158
4800RK Breda
The Netherlands, Europe
T: +3176 595 3000
M: +316 2488 1380
Fax: +3176 595 3818
Email: mp_somford@hotmail.com

SUMMARY
Internal herniation is a rare cause of intestinal obstruction. Especially in patients with no prior abdominal surgery. We report an unusual case of internal herniation and intestinal obstruction in a patient with no prior abdominal surgery.

SHORT REPORT
A 65 year old male patient with abdominal complaints was seen at our emergency department. The complaints started approximately 8 hours before presentation. The pain started diffusely in the entire abdomen. As time evolved the pain localized in the lower abdomen. The pain was continuously present. There was no nausea or vomiting but his appetite was lessened. His defecation had been unremarkable.

On physical examination we found a temperature of 36.6 degrees Celsius. The abdomen showed ileus peristalsis and palpation was tender in the lower abdomen, specifically in the right lower abdomen.

On plain radiographs of the abdomen and ultrasound there was a small intestine ileus without free air. A computertomograph scan showed the ileus of the small intestine and also a change of caliber 15-20 centimeters from the cecum but no tumor to explain this change.

The patient was admitted and observed for twenty-four hours.When the complaints did not change we decided to operate the patient. At laparotomy inspection revealed an unusual internal herniation. It became clear that the top of the appendix had an adhesion with the small intestine, thus forming a ring through which a large part of the small intestine had herniated (figure 1). The small intestine could be quite easily released (figure 2) and appendectomy was performed. The patient made a slow recovery and was discharged home 12 days after the operation. Pathologic examination of the appendix showed inflammation and no malignancy.

Figure 1 Showing the appendix with no signs of inflammation around a part of the small intestine.

Figure 2 The aperture formed by the appendix shown by the tweezers after removing the herniated intestine.

DISCUSSION
Internal herniation in patients with no earlier abdominal surgery is uncommon. In case of an internal herniation, most of the time the small bowel goes through a normal or abnormal aperture in the peritoneal cavitiy.³ Well known hernias in these cases are paraduodenal, mesocolic, supra- and/or perivesical, intersigmoid and, although rarely, omental hernias.^{1- 4} These hernia’s lead to obstruction in only a small amount of the cases. An incidence of 0.2-0.9% has been reported.^{3, 5} Not any form of radiological investigation is sensitive to find internal herniation, a high index of suspicion and a timely surgical intervention may be the only way of reducing the morbidity and mortality in these patients. In a case of herniation in a mesenterial aperture the treatment consist of closing the opening after reducing the hernia. In the case described above appendectomy will suffice.

To our knowledge an internal herniation because of an adhesion of the top of the appendix to the small bowel has never been reported before.We speculate the mild inflammation in the appendix is the reason for the adhesion. The possibility of a congenital adhesion seems very unlikely.

REFERENCES

1. Kulacoglu H, Tumer H, Aktimur R et al. Internal herniation with fatal outcome: herniation through an unusual apertura between epiploic appendices and greater omentum Acta chirurgica Belgica 2006 106:109-11.

2. Yokota T, Yamada Y, Murakami Y, et al. Emergency abdominal surgery for sigmoid mesocolic hernia. The American journal of emergency medicine 2002 20:137-8.

3. Tauro L, Vijaya G, D'Souza C, et al. Mesocolichemia. An unusual internal hernia. Saudi Journal of Gastroenterolology 2007 13:141-3.

4. Kirschner M. Die Eingriffe bei den Bauchbrüchen. 2 ed. Berlin: Springer-Verlag. 1957

5. Munir A, Saleem SM, Hussain S. Paraduodenal hernia—a case report. Journal of Pakistan Medical Association 2004 54:162-3.