CASE REPORT & REVIEW OF LITERATURE
STRANGULATEDLITTRE’SHERNIA: CASEREPORT ANDREVIEWOFLITERATURE
S. M. Datey, Ajay Lunawat, Avinash Vishwani, Rishikant Vashistha, Akshay Sharma
- Professor. Department of General SurgerySri Aurobindo Medical College and Postgraduate Institute,Indore,Madhya Pradesh.
- Associate Professor. Department of General SurgerySri Aurobindo Medical College and Postgraduate Institute,Indore,Madhya Pradesh.
- Assistant Professor. Department of General SurgerySri Aurobindo Medical College and Postgraduate Institute,Madhya Pradesh.
- Assistant Professor. Department of General SurgerySri Aurobindo Medical College and Postgraduate Institute,Indore,Madhya Pradesh.
- Resident. Department of General SurgerySri Aurobindo Medical College and Postgraduate Institute,Indore,Madhya Pradesh.
CORRESPONDING AUTHOR:
Dr. Sanjay M. Datey,
Manushree, 43, ChikitsakNagar,
NearBombayHospital,
Indore (M.P.), India- 452010.
E-mail:
ABSTRACT: Littre'sherniaisuncommonclinicalentity. WearepresentingacaseofStrangulatedLittre'sHernia.A19yearsoldmale,camewithpainandswellinginrightinguinalregion,whichturnedouttobeanobstructedinguinalherniawithgangrenousMeckel'sdiverticulum.GangrenousMeckel'sdiverticulumwasresectedandanastomosisofileum wasdone. Hernialdefectwasrepaired.
DetailedreviewofliteraturerevealsthatalthoughMeckel'sdiverticulumisthemostprevalentcongenitalanomalyofthegastrointestinaltract,andherniasarealsocommon,butaStrangulatedLittre'sHernia(whereaMeckel'sdiverticulum isthecontentofahernialsac)isveryuncommon.
INTRODUCTION: WearereportingacaseofaStrangulatedLittre'sherniaina19yearoldmalefromSriAurobindoMedicalCollegeandPostgraduateInstituteofIndorewhichisaleadingtertiarycarecentreofCentralIndia.
DetailedreviewofliteraturedepictsthatstrangulationofaMeckel'sdiverticuluminanincarceratedherniaisuncommon.Caseshavebeenreportedsporadicallyintheliterature,wherea Meckel'sdiverticulumwasfoundinthesacsofparaumbilical,femoral,inguinal,andincisionalhernias. Wearepresentingthiscaseofclinicalinterest,asitisuncommon.
Meckel'sdiverticulumisfoundin2%ofpopulation,makingitthemostprevalentcongenitalabnormalityofthegastrointestinaltract (Ref.1). Herniasarecommon.ThereisararepossibilityofMeckel'sdiverticulumbecomingacontentofhernialsac. ThatiswhyLittre'sherniaissouncommonandveryfewcasesarereported. ALittre'sherniaisseenininguinalhernia(50%),umbilical hernia (20%),femoral hernia(20%) andother hernias (10%) (Ref. 2).
PresenceofMeckel'sdiverticulumanditsinvolvementinthepathologicalprocesscannotbediagnosedbyclinicalexamination.AlmostallcasesofMeckel'sdiverticulumarediagnosedonexplorationinoperation. ResectionofanincidentallydiagnosedMeckel'sdiverticulumisacontroversialsubject.ResectionofaMeckel'sdiverticulumshouldberecommendedifthereisnoperitonitisduetootherintraabdominalpathology. IthasbeendescribedthatMeckel'sdiverticulumhasa4% to 6%lifetimeriskofdevelopingacomplicationlikebleeding, intussusception,obstruction,orperforation. (Ref. 3).
CASEREPORT: ANineteenyearoldmalepresentedtotheemergencydepartmentofSriAurobindoMedicalCollegeandPostgraduateInstitute, withcomplaintsofaswellingandpain ofabruptonsetinrightgroin,oftwodaysduration. Healsohadmildfeverandfourloosemotionsonthepreviousday. Hedidnothaveanyhistoryofvomiting. Therewasaprevioushistoryofrightinguinalswellingwhichusedtoappearonexertionforlast3 to4years.Patientdidnothaveanytraumaorrecentinfectionofrightlowerlimborgenitaliawhichcouldhaveleadtoinguinallymphadenitis.
Onadmission,hewasstablehaemodynamicallyandnoabnormalitycouldbedetectedongeneralandsystemicexaminationofpatient. Onlocalexaminationofrightgroin,therewasatenderswellingof3x4 cm.intheregionofinguinalcanalwithraisedlocaltemperature. Therewasnocoughimpulseintheswelling. Clinicaldiagnosisofanincarceratedinguinalherniawithprobablestrangulationofitscontentswasmade.
Preoperativehematologicalandbiochemicalinvestigationsweredone. Exceptforapolymorphonuclearleucocytosis,allotherreportswerewithinnormallimits. Urgentoperationforexplorationofrightinguinalcanalwasplanned. Operationwasdoneundergeneralanesthesia. Onexploration aStrangulatedMeckel’sdiverticulumwasfoundinthesacofanobstructedindirectinguinalhernia. Deepinguinalringwascutlaterallyandtheobstructingringwasreleased. The ilealloopsweredeliveredinthewoundtoexcludeanyabnormality . AstheMeckel'sdiverticulumwasbroadbasedandgangrenousuptoitsjunctionwiththeileum,adecisiontoperformresectionofMeckel'sdiverticulumwithpartofileumwastaken. Resectionwasdoneandcontinuityofileumrestoredbyanendtoendanastomosis .Anastomosedloopofthebowelwasrepositedandperitoneumclosed. Repairoftheposteriorwallofinguinalcanalwasdonebyherniorrhaphy. Patienthadanuneventfulpostoperativerecovery .Hewasdischargedfromthehospitalafteraweekinasatisfactorycondition.
DISCUSSIONANDREVIEWOFLITERATURE: Littre'sherniaisdefinedastheprotrusionofMeckel'sdiverticulumthroughapotentialabdominalopening.(Ref.2) Littre'sherniaisuncommon, andadetailedreviewofliteraturerevealedthatveryfewcasesofaStrangulatedLittre'sHerniahavebeenreportedsofar.
Ourpatienthadatypicalpresentationasalthoughhepresentedwithusualsymptomsofpain, swellingandprevioushistoryofaswellingofgroinappearingonexertion,buthehadoneunusualsymptomofloosemotions. Thisincreaseinthefrequencyofbowelmovementscouldbeattributedtopartialocclusionofintestinallumen(asoccursinaRitcher'shernia) leadingtoirritationandinflammationofbowel. Thesymptomofloosemotioncouldbemisleadingandcancauseadangerousdelayinthediagnosisofanincarceratedhernia.
ContentsofahernialsaclikeMeckel'sdiverticulum (Littre'shernia), AppendixVermiformis (Amayand'shernia),partiallumenofintestine (Ritcher'shernia), ovary or a fallopiantubecannotbediagnosedbyclinicalexamination.Computerisedtomographycouldhavediagnoseditpreoperativelybutthisinvestigationisnotdoneroutinelyinallpatients.
Meckel'sdiverticulumwasdescribedbyGermanProfessorJohnFredricheMeckelin 1809asanilealdiverticulumpresentin2 %ofpopulation ontheantimesentericborder. Itisusuallylocated30to90cm. fromtheileocaecaljunction,measuring3 to6cminlengthand2cmindiameter. Meckel'sdiverticulum is atruediverticulumandrepresentsthepersistentpartoftheomphalomesentericductthroughwhichthemidgutcommunicateswithumbilicustillthefifthweekofintrauterinelife.
Meckel'sdiverticulumcancauselifethreateningcomplications. Diverticulitiscanleadtosevereperitonitisduetoperforation. Itcanbeasourceofgastrointestinalhemorrhage. Meckel'sdiverticulumcangetadheredtoparietalperitoneumorgointoahernialsacandactasafixedpointforavolvulus.
Park JJ et al (Ref 4)fromtheMayoclinichavepublishedtheresultsofaretrospectivestudyof1476patientsofMeckel'sdiverticulumbetween1950 and2002. ThisstudyisthemostcomprehensiveworkavailableonthesubjectofMeckel'sdiverticulum. Outof1476patients,onlytwohadincarcerationofMeckel'sdiverticuluminahernialsacoveraperiodof52years(1950-2002) inthecaseseriesofMayoClinic. ThestudywasdonebyPark JJet altofindoutwhichMeckel'sdiverticulumshouldberemovediffoundincidentallyinthecourseofanabdominaloperation .Theyobservedthatintoday'ssurgicalpracticeitissafetoremovealltheincidentallydetectedMeckel'sdiverticula, butitcannotbemadearule. MayoclinicstudybyPark JJ et alfurtherstatesthat"theyneithersupportnorrejecttherecommendationofexcisingalltheincidentalMeckel'sdiverticula". Sixteenpercentofthese1476patientshadsymptomaticMeckel'sdiverticulum. ThesepatientshadtheirabdominalproblemsduetoMeckel'sdiverticulumlikegastrointestinalhemorrhage, intestinalobstruction,intussusception,diverticulitisorperforation .Certainfeaturesinthese16%patientswerecommon, namely, themalesex,agewaslessthan50yearsandlengthofdiverticulumwasmorethan 2 cm. ThusitcanbesaidthatanincidentallydetectedMeckel'sdiverticulumofmorethan2 cminyoungmalesshouldalwaysberemoved.
Alexis de Littre (1700), A Frenchanatomist andphysicianwasthefirsttodescribeaprotrusionofilealdiverticuluminaninguinalhernia .Hepostulatedittobeatractiondiverticulumofileum. Zungiaet al (Ref 5) saidthatthetrueincidenceisdifficulttoestimatebecause Littre'sherniasareuncommon. Incarcerationandstrangulationof Meckel'sdiverticulumininguinalherniashavebeenreportedintwocasesbyCirillo etal (Ref 6)andMongardini et al (Ref 7).CasesofstrangulatedMeckel's diverticuluminahernialsachavebeenreportedbyAlbertTiuetal(Ref 8) in aParaumbilicalhernia, Perlman JA et al (Ref 9) inafemoralhernia ,Citgez b et al (Ref 9) inaVentralincisionalhernia andCastleden WM etal (Ref 10)inanUmbilicalhernia. PreoperativediagnosisofaMeckel'sdiverticulumwasnotpossibleinanyofthereportedcases. ThediagnosiswasestablishedonopeningthesacandresectionofMeckel's diverticulumwasdoneinallthecaseswithuneventfulrecovery .
Sinha et al (Ref 11) reportedacaseofLittre'sherniacausinganintestinalobstruction , whichwasdiagnosedbycomputerisedtomography. Withtheincreaseduseofcomputerisedtomographyinthediagnosisofacuteabdominalconditionsmorecaseswillbediagnosedpreoperatively.
Reviewofliterature andthiscasereportshowsthatMeckel'sdiverticulumcanbesafelyresectedwithrepairofhernias .Multiple pathologiesencounteredinthecourseofanabdominaloperationshouldbedealtwithonitsownmeritsandestablishedprinciplesofsurgicaltreatment.
ACKNOWLEDGMENT: WearethankfultoDr.VinodBhandari, Chairman, SriAurobindoMedicalCollegeandPostgraduateInstitute, DeanDr.S.D.JoshiandDr. P.K.Banerjee, ProfessorandHeadofDepartmentofSurgeryforthepermissiontopublish thiscasereport.
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OPERATIVEPHOTOGRAPH:ShowingexposureofrightinguinalcanalwithGangrenousMeckel’sDiverticulumwithloopofileum.
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