Ventral Bladder Hernia Following Tubal Ligation

Abstract

While involvement of the bladder in inguinal hernias is relatively common (1% to 10% incidence), reports of midline bladder hernias are rare.1–3 Such hernias are classified according to the relationship of the hernia to the peritoneum. The more common paraperitoneal bladder hernia involves the extraperitoneal part of the bladder that lies along the medial aspect of the hernial sac. In the intraperitoneal form the bladder is completely covered by peritoneum. The least common extraperitoneal form has no peritoneal covering.3 To our knowledge we report the first case of ventral bladder hernia following tubal ligation. CASE REPORT A 64-year-old female presented with a right lower quadrant mass 2 years in duration, and recent onset of dysuria and chills. Pressure on the mass caused suprapubic discomfort and an urge to urinate. History was significant for breast cancer, recurrent urinary tract infection and a tubal ligation 10 years previously. On physical examination the patient was obese and a 10 cm. mass was palpated in the right lower quadrant 2 cm. from the midline. The mass was believed to be protruding through the fascia of the abdominal wall and was nonreducible and tender on palpation. There was a well healed 2 cm. infraumbilical midline incision consistent with tubal ligation. There were no peritoneal signs, no inguinal or femoral hernias, and bowel sounds were present. Urinalysis revealed pyuria, bacteriuria and positive nitrites. Urine cultures yielded Escherichia coli. The patient was treated with ciprofloxacin for 5 days, which relieved the irritative voiding symptoms. Computerized tomography (CT) of the abdomen and pelvis showed a ventral abdominal wall hernia in the right lower quadrant that contained bladder (fig. 1). Cystography confirmed these findings (fig. 2). Ventral bladder hernia repair was performed through a Pfannenstiel incision. The abdominal wall fascial defect was identified and the bladder hernia was dissected off of the surrounding tissue. Attempts were made to reduce the bladder hernia without success and, thus, it was necessary to excise the segment of herniated bladder at the level of the fascial defect. The bladder was then mobilized from the abdominal wall fascial defect and closed, and the abdominal wall fascial defect was repaired. A layer of perivesical fat was left over the bladder suture line. A suprapubic tube was left indwelling for 10 days to drain the bladder. DISCUSSION