LAPAROSCOPIC MANAGMENT OF COMPLICATED PARACAECAL HERNIA

Trigui Aymen |

La tunisie chirurgicale - 2021 ; Vol 2021

Resumé

Internal hernias (IH) are rare and account for 0.5 to 5.8% of cases of intestinal obstruction. Pericecal hernias are exceedingly rare and represent approximately 6 to 13% of internal hernias. Pre operative diagnosis is difficult and might causes intestinal necrosis increasing the morbidity and mortality. We report a case of a 64-year-old woman, who present a small bowel obstruction due to a paracecal hernia and which the diagnosis and treatment has been successfully achieved under laparoscopic approach. We propose to focus on the diagnostic and therapeutic modalities of this rare entity.

Mots Clés

Paracecal hernia; Internal hernia; Laparoscopic surgery; Small bowel obstruction; Computerized tomography (CT).

Introduction :

Internal hernias (IH) are rare and account for 0.5 to 5.8% of cases of intestinal obstruction. Pericecal hernias are exceedingly rare and represent approximately 6 to 13% of internal hernias [1]. Pre operative diagnosis is difficult and might causes intestinal necrosis increasing the morbidity and mortality.

Article

Case Report:

A 64-year-old woman, with previous history of open appendicectomy trough Mc Burney’s incision in childhood, had consulted to emergency department for diffuse abdominal pain with vomiting, anorexia and diarrehea, evolving since 3 days. Physical examination revealed diffuse abdominal tenderness, which was distended. There is no evidence of organomegaly or abdominal wall hernia. Abdominal radiograph showed an intestinal air-fluid levels. Computed tomography (CT) has revealed a jejuno-ileal distension upstream of a volvulus of an ileal loop on flange at the level of the right iliac fossa. So that pre operative diagnosis of obstruction of the distal ileum on flange was retained. The patient was operated on emergency by laparoscopic approach. A 10 mm port was initially placed under the umbilicus by minimum laparotomy. Two 5 mm ports were then added in the right lateral and right lower abdominal regions. The abdomen was insufflated to a pressure of 12 mm Hg. Exploration per operatively revealed a protrusion of 30 cm of viable small bowel intestine trough an abnormal orifice located behind the cecum. The incarcerated small bowel was reduced and the hernia orifice was sutured. Review of the abdominal CT performed post operatively had concluded on the presence of dilated bowel loops located behind the cecum and the ascending colon with displaced, engorged and stretched mesenteric vascular pedicle (Fig 1). The post operative course was uneventful and no recurrence was noted with 18 months of follow-up.       

Discussion:

An internal hernia is defined as a protrusion of the abdominal viscera into the fossae, foramina, recessus, or congenital defect within the abdominal or pelvic cavity [2] . They account for 0.5 to 5.8% of cases of intestinal obstruction. The most common type is paraduodenal hernia (55%). Paracecal hernia is rare and account for 6 to 13% of IH [1]. A literature search on Medline using the key words “paracecal hernia” was performed, and found only 17 cases of paracecal henia [1, 2].

 Two mechanisms for the development of paracecal hernia have been advanced: the first one is that the hernia orifice is a congenital anatomic structure resulting from imperfect fusion or resorption occuring in the paracecal area secondary to abnormal end- result of ileocecal migration occurring during midgut rotation in the fifth month of gestation [2], so that four types of peritoneal recesses are distinguished : superior ileocecal recess, inferior ileocecal recess, retrocecal recess, and paracolic sulci, all of which may become hernial orifices.[2]. The second possibility is tissue fragility due to aging, pressure elevation of the inner abdomen, and retroperitoneal adhesion [2]. In most of the cases of pericecal hernia, the ileal loops herniated through the peritoneal defect and occupy the right paracolic gutter.

Pre operative diagnosis of paracecal hernia is often difficult because of non specific clinical presentation and which may be intermittent [1, 2]. The condition is often asymptomatic, if there is no complication. However, these hernias may induce intermittent pain in the right iliac fossa or develop into a palpable mass in this area and may leads to small bowel obstruction with rapid progression to strangulation such as our case which present as a strangulated paracecal hernia. The differential diagnosis is posed with undiagnosed Crohn’s disease obstructing the small bowel, an incarcerated femoral or obturator hernia, an obstructing phytobezoar, gallstone ileus , obstructing neoplasms and others  cases of  internal hernias. CT appears to offer the highest potential for use in the diagnosis of IH. The CT appearance of a pericecal hernia is specific, which reveals fluid-filled small bowel loops located lateral to the cecum and posterior to the ascending colon. In addition, displaced mesenteric vascular pedicle can be identified within the hernial sac; a beaking appearance at the aperture of the peritoneal recess and the dilation of small bowel loops with a transition zone can also be found in the CT examination [1]. In patients with milder clinical presentation in whom barium enema is possible, a cluster of ileal loops may be seen posterior and lateral to the cecum and ascending colon.    

Surgery is an important procedure in regard to treatment as well as diagnosis. Moreover, minimally invasive surgeries are considered to be diagnostic procedures [3]. In a review of the literature only 2 cases of paracecal internal hernia were diagnosed laparoscopiccaly [4, 5]. Only one of these two cases was successfully treated by laparoscopic surgery and achieved a good postoperative course [4]. The other case was converted to open surgery in order to avoid injury to the small intestine [5]. Our case is the second one of laparoscopic diagnosis and successful treatment of paracecal hernia. Most authors recommend to enlarge the opening orifice pouch in order to reduce incarcerated small bowel and to close the hernia orifice in order to prevent the recurrence of the hernia [2]. In case of suffering intestinal loop, they recommend segmentary resection and primary anastomosis [2].

Conclusion:

Small bowel obstruction due to paracecal hernia is exceedingly rare, our case describe a laparoscopic diagnosis and treatment of this rare entity which should be kept in mind of both surgeons and radiologists even in present of previous history of abdominal surgery.

Conflicts of interest: none.

 

Références

[1] Choh N.A, Rasheed M, Jehangir M. The computed tomography diagnosis of paracecal hernia. Hernia 2010; 14:527–529.

[2].  KABASHIMA A, UEDA N,  YONEMURA Y, MASHINO K, FUJII K, IKEDA T, TASHIRO H, and SAKATA H. Laparoscopic Surgery for the Diagnosis and Treatment of a Paracecal Hernia Repair: Report of a Case. Surg Today 2010; 40:373–375.

 [3]. Laparoscopic treatment for small bowel obstruction: report of a case. Surg Today 2008;38:661–3.

[4]. Hirokawa T, Hayakawa T, Tanaka M, Sawai H, Okada Y, Takeyama H, et al. Laparoscopic surgery for diagnosis and treatment of bowel obstruction: case report of paracecal hernia. Med Sci Monit 2007; 13:79–82.

[5]. Omori H, Asahi H, Inoue Y, Irinoda T, Saito K. Laparoscopic paracecal hernia repair. J Laparoendosc Adv Surg Tech A 2003; 13: 55–7.

 

Fig n°1: Incarcerated small bowel loops behind the cecum and ascending colon at the level of the right iliac fossa.