Hepatic Herniation Research Articles

Hepatic herniation: A rare presentation of abdominal incisional hernia

Hepatic herniation: A rare presentation of abdominal incisional hernia

Herniation of the Left Hepatic Lobe, Unusual Presentation of an Incisional Hernia

Hepatic herniation through an abdominal incisional hernia is an extremely rare phenomenon that has been reported in the medical literature in few case reports. It is associated with complications such as hepatic encephalopathy and Budd-Chiari syndrome. Most cases can be managed conservatively through observation, but many cases require surgical intervention to preserve liver function. Our case is a 61-year-old female who presented with herniation of the left hepatic lobe through an abdominal incisional hernia which was managed surgically.

P-050 A CASE OF EPIGASTRIC HERNIA WITH INCARCERATION OF THE LEFT HEPATIC LOBE AND REVIEW OF THE LITERATURE

Abstract Abstract An epigastrishe hernias with hepatic herniation are extremely rare. This is the first case of epigastric hernie with leber left lobe incaceration in the literatur. The other seven cases are cases with incisional hernia which have been reported so far in the literature. . We report a case of an epigastrishe hernia with incacerated hepatic left lobe along with a review of the literature. A 71-year-old female patient was admitted to our hospital with acute pain and complain of epigastric swelling. On examination, she had a tender 5 cm×5 cm epigastric lump and was diagnosed as incacerated epigastric hernia. Contrast-enhanced CT of the abdomen revealed a ventral hernia with herniation of omentum and left hepatic lobe. The patient underwent open IPOM mesh repair and is asymptomatic at 1-month follow-up. Background Ventral hernias with hepatic herniation are extremely rare. Hepatic herniation through congenital defects such as diaphragmatic hernia or omphaloceles are known to occur, but subcutaneous hepatic herniation through a ventral hernia is rarely encountered. We report a case of epigastric hernia with hepatic herniation, and its clinical and radiological findings, along with a review of the literature.

Post-traumatic giant thrombosis of inferior vena cava induced right-sided blunt traumatic diaphragmatic injury: a case report

BackgroundInferior vena cava thrombosis is a severe disease as it carries a higher risk of developing pulmonary embolism associated with a high mortality rate. The incidence of inferior vena cava thrombosis is extremely low and is commonly associated with outflow obstruction of the inferior vena cava. The frequency of traumatic diaphragmatic injuries is less than 1% of all traumatic injuries. In addition, it was not a typical cause of inferior vena cava obstruction. We report the case of the patient who presented with giant thrombosis of the inferior vena cava, which required surgical treatment-induced right-sided blunt traumatic diaphragmatic injury.Case presentationA 60-year-old male presented to the emergency department with pelvic and lower leg pain. He was working on a dump truck with the bed raised position. Suddenly, the bed came down, and his body was crushed and injured. Primary CT showed a right lung contusion and elevation of the right diaphragm but no apparent liver injury. The right pleural effusion gradually worsened after admission, as the traumatic diaphragmatic injury was highly suspected. Repeat CT showed aggravation of elevation of the right-sided diaphragm, narrowing of the inferior hepatic vena cava due to left cephalic deviation of the liver, and formation of a giant thrombus in the inferior vena cava. No adverse hemodynamic effects were observed due to thrombus formation, and we performed thrombolytic therapy. The day after starting thrombolytic therapy, the patient developed pulmonary embolism due to a dropped in SpO2 needed oxygen, and dyspnea triggered by coughing. Thrombolytic therapy was continued after the diagnosis of pulmonary embolism. However, thrombolytic therapy was ineffective, so we decided on surgical thrombectomy and inferior vena cava filter placement. The postoperative course was not eventful, and an anticoagulant was started. The patient was transferred to the hospital on the 62nd day for rehabilitation.ConclusionsWhen a diaphragmatic hernia is suspected of causing hepatic hernia and narrowing of the inferior vena cava, it may be necessary to consider emergency surgical treatment to prevent secondary inferior vena cava thrombosis and fatal pulmonary embolism.

Anterolateral defect of left congenital diaphragmatic hernia with hepatic herniation

Anterolateral defect of the diaphragm is an extremely rare type of congenital diaphragmatic hernia (CDH). We report our experience with a rare anterolateral type of CDH. His birth weight was estimated as 2700 g. A CDH was suspected on fetal ultrasound at 20 weeks' gestation. Fetal MRI performed at 34 weeks and 1 day of gestation showed elevation of the intestinal tract, stomach, and outer left lobe of the liver. A boy was delivered by caesarian section at 37 weeks and 0 days of gestation. Surgery was performed on the fourth day after delivery. The dorsal muscle bundle was well developed, but the ventral diaphragm was deficient, and a diagnosis of anterolateral type CDH was made. The size of the diaphragmatic defect was 5 × 3 cm. On the 15th day after surgery, the tracheal tube was extubated, and the patient was discharged 51 days after delivery. The patient is still being followed up, but no signs of recurrence have been observed. We experienced a case of an unusual form of left anterolateral CDH. The postnatal course was relatively stable, although a severe form was predicted due to the presence of hepatic elevation.

A case of Bochdalek hernia with anomalous hepatic lobe heterotopia-case report

BackgroundBochdalek hernia is the most common type of congenital diaphragmatic hernia (CDH) resulting from postero-lateral diaphragmatic defect. Hepatic heterotopia is very rarely associated with CDH, and hepatic herniation favors the worst prognosis.Case presentationWe present a case of a neonate diagnosed with right Bochdalek hernia (BH) with anomalous hepatic lobe heterotopia. Intra operatively, mal-rotated loops were also found to be herniating in the right hemithorax. The mal-rotated loops were reduced back into abdomen after performing Ladd’s procedure and diaphragmatic defect was repaired over the anomalous liver lobe. Baby was discharged on 7th postoperative day and follow-ups showed good recovery.ConclusionThis case report discusses the presentation, classification, and significance of this association. Our case report is noteworthy as Bochdalek hernia is very rarely associated with anomalous hepatic lobe.

Laparoscopic repair of hepatic herniation through a ventral incisional hernia: a case report

BackgroundVentral incisional hernia is a common problem after abdominal surgery. Most patients with these hernias present with greater omentum and gastrointestinal prolapse. However, hepatic herniation through a ventral incisional hernia is a rare phenomenon that has been seldom reported in the literature. We report the case of a ventral incisional hernia with hepatic herniation treated with laparoscopic repair.Case presentationA 68-year-old Japanese women with a history of myocardial resection for hypertrophic cardiomyopathy 1 year earlier was admitted to our hospital with symptoms of vomiting and epigastric pain. Physical examination showed a 4-cm epigastric mass. Abdominal computed tomography revealed left hepatic lobe herniation through the lower edge of a mid-sternal incision. We diagnosed the patient with a ventral incisional hernia with hepatic herniation. The patient underwent laparoscopic hernia repair. During an 18-month follow-up, no recurrence or symptoms have been observed.ConclusionsTo the best of our knowledge, this is the first case report of laparoscopic repair of ventral incisional hernias with hepatic herniation. Laparoscopic repair was useful and suitable for this rare herniation due to its minimally invasive nature and ability to achieve sufficient visibility of the surgical field. Laparoscopic repair could be a potential treatment option for elective surgery for this disease, which is often treated conservatively.

Postoperative Diaphragmatic Liver Herniation Diagnosed by Point-of-Care Ultrasound.

Point-of-care ultrasound (PoCUS) is a sensitive and specific tool in early identification of malignant pathologies in unstable patients leading to improved outcomes. Postoperative diaphragmatic rupture is rare, can be life-threatening, and is difficult to diagnose. This report describes a 62-year-old women undergoing thoracoscopic right hemidiaphragm plication with acute postoperative hemodynamic instability. Bedside PoCUS identified hepatic herniation into the thorax causing cardiac compression and lateral displacement, which lead to expedited imaging and surgical reexploration.

Розміри легень при різних анатомічних варіантах вродженої діафрагмальної грижі у плода

The objective: to compare lung indices in fetuses with different anatomical variants of left-sided congenital diaphragmatic hernia, determined by two-dimensional ultrasound examination. Materials and methods. Data from 157 ultrasound examinations in 136 fetuses as patients with the most typical anatomical variants of left-sided diaphragmatic hernia were analyzed. The area of the lungs and the herniated liver were measured in the standard cross section of fetal thorax, at the level of a four-chamber view, with following calculation of prognostic indices. Comparison of indices’ means in groups depending on the abdominal organs herniated into fetal chest was performed using Student’s t-test. Results. The most numerous group in our study was one with herniation of the liver, stomach and intestines (62.5%). Significantly lower values of all lung indices were found in this group (p≤0.0001). In particular, observed-to-expected area ratio equaled to 35.59±8.8 and 31.73±10.51 in these fetuses in II and III trimesters respectively. In fetuses with intestines herniation, this index was 60.67±10.93 and 57.37±7.98, in fetuses with stomach and intestines herniation – 53.20±7.02 and 51.77±9.57 in II and III trimesters, respectively. Differential analysis of lung indices depending on the degree of liver herniation showed the presence of statistically highly significant difference in both second and third trimesters. In the group with mild liver herniation, the largest lung sizes and indices were determined, which were similar to values registered in groups without hepatic herniation. The lowest values of all lung indices were registered in the group with severe liver herniation. Conclusions. The anatomical variant of left diaphragmatic hernia with herniation of liver, stomach and intestines into thorax was the most common among our study population; in this group the lowest values of term-independent lung indices were observed. However, this group turned out to be heterogeneous: with different degrees of liver herniation, different degrees of pulmonary hypoplasia were found. Significant differences in lung indices found in II trimester can become a basis for early assessment of the severity of pathology and prediction of postnatal outcome. Keywords: congenital diaphragmatic hernia, liver herniation, pulmonary hypoplasia, lung size, prenatal diagnosis.

A Rare Case of Partial Diaphragmatic Eventration with Hepatic Herniation

A 43 year old Female with past history of hypertension, diabetes mellitus presented to the Emergency room with a chief complaint of left flank pain. Her physical examination was notable for left sided flank tenderness with no abdominal rigidity or guarding. Routine blood work showed normal complete blood count, with normal comprehensive metabolic profile. A chest xray showed a soft tissue mass at the right lung base. Further contrast Computed Tomography(CT) of the chest and abdomen showed an incidental soft tissue mass at right lung base that measured 4.4 cm in diameter representing a focal eventration of the right hemi-diaphragm with liver tissue extending through the eventration.(Fig 1,2).2343_A Figure 1. Arrow depicting hepatic herniation2343_B Figure 2. Coronal CT showing hepatic mass extending through diaphragamDiaphragmatic eventration was first recognized by Jean Louis Petit in 1774 and the term was coined by Beclard in 1916. It is defined anatomically by thinning of the diaphragmatic tissue, characterized by the cephalic displacement of all or a part of an intact diaphragm. While complete eventration in more common on left, partial eventration is seen majorly on the right side. Congenital diaphragmatic eventration has been frequently cited as common in infancy, requiring urgent care and observation but it is rarely seen in adults. Typically this entity is frequently asymptomatic but can rarely manifest as progressive dyspnea, chest pain, abdominal discomfort, nausea, vomiting, heartburn and recurrent pneumonia. Partial eventration are usually detected incidentally on chest x-ray as a smooth homogeneous mass in continuation with the diaphragm.Ultrasound may reveal more anatomical detail about the diaphragmatic integrity, specifically eventration content or other diaphragmatic pathologies.If a contrast CT scan is performed, hepatic or omental vascular enhancements are seen as hyper-dense areas. Other modalities such as fluoroscopy with sniff testing and Magnetic resonance imaging are done if the diagnosis is still in doubt. Once diagnosed asymptomatic patients are usually managed conservatively and diaphragmatic plication is done in symptomatic patient. Our patient's left sided pain was musculoskeletal and not related to the diaphragmatic eventration. Her pain resolved with analgesics and she has remained asymptomatic on follow up visits. In summary we present a rare case of partial diaphragmatic eventration with hepatic herniation. Our case highlights conservative management in asymptomatic patients with diaphragmatic eventration.

A rare case report of right hepatic lobe herniation through an incisional anterolateral abdominal wall hernia following an open choledochotomy with a concise literature review

Hepatic herniation through an incisional anterolateral abdominal wall hernia is an extremely rare condition. Here, we are reporting a case of hepatic herniation through the anterolateral abdominal wall which had been managed conservatively in a 75-year-old female patient. In addition, we are presenting a brief summary of all previously indexed reported cases to help other surgeons in managing similar rare cases the optimal way.

副肝葉,異所性肝を含めた臍帯内残存肝ヘルニアの発生機序 : 臍帯内に腫瘤状肝組織を認めた1例の検索から

副肝葉,異所性肝を含めた臍帯内残存肝ヘルニアの発生機序 : 臍帯内に腫瘤状肝組織を認めた1例の検索から

Hepatic Herniation After Sternotomy

The patient is a 90-year-old woman with a history of hypertension, AFib and sternotomy for a valve substitution in 2008. She reported a subxiphoid mass ever since the sternotomy, which it was decided not to treat because of the age of the patient. She consulted due to vomiting and epigastric pain, and upon examination a subxiphoid incisional hernia was detected (Fig. 1), which was irreducible and contained what appeared to be the liver. Lab work showed GPT 234 U/L and GOT 141 U/L. Abdominal CT (Fig. 2) showed partial herniation of the left liver lobe with compromised vascular function. The patient underwent emergency surgery, which entailed laparotomy, reduction of the herniated liver and repair of the defect with intraperitoneal dual-layer mesh. The patient was discharged on the 4th day post-op. Diagnosis: hepatic herniation after sternotomy. c i r e s p . 2 0 1 4 ; 9 2 ( 9 ) : 6 2 5

Segment hepatic herniation through a diaphragm defect simulating basal lung nodes

Methods A 51 year old female non-smoker, who had high blood pressure, was diagnosed with left lobe liver abscess, was suspicioned as carcinoma of pancreatic head. Definitive diagnosis was liver abscess and basal right lung node. Additional thoracic tests included a CT without contrast showing a node in the right lung inferior lobe, measuring 4x3 cm in diameter anterio-posteriorly and 4x5 cm in diameter transversally. Respiratory function tests were optimal; thus it was decided to achieve a diagnostictherapeutical surgical procedure of the lung nodes in order to make a differential diagnosis of primary pulmonary tumor or metastatic lesions of another type of lesion in liver.

Left hepatic lobe herniation through an incisional anterior abdominal wall hernia and right adrenal myelolipoma: a case report and review of the literature

IntroductionHerniation of the liver through an anterior abdominal wall hernia defect is rare. To the best of our knowledge, only three cases have been described in the literature.Case presentationA 70-year-old Mexican woman presented with a one-week history of right upper quadrant abdominal pain, nausea, vomiting, and jaundice to our Department of General Surgery. Her medical history included an open cholecystectomy from 20 years earlier and excessive weight. She presented with jaundice, abdominal distension with a midline surgical scar, right upper quadrant tenderness, and a large midline abdominal wall defect with dullness upon percussion and protrusion of a large, tender, and firm mass. The results of laboratory tests were suggestive of cholestasis. Ultrasound revealed choledocholithiasis. A computed tomography scan showed a protrusion of the left hepatic lobe through the anterior abdominal wall defect and a well-defined, soft tissue density lesion in the right adrenal topography. An endoscopic common bile duct stone extraction was unsuccessful. During surgery, the right adrenal tumor was resected first. The hernia was approached through a median supraumbilical incision; the totality of the left lobe was protruding through the abdominal wall defect, and once the lobe was reduced to its normal position, a common bile duct surgical exploration with multiple stone extraction was performed. Finally, the abdominal wall was reconstructed. Histopathology revealed an adrenal myelolipoma. Six months after the operation, our patient remains in good health.ConclusionsThe case of liver herniation through an incisional anterior abdominal wall hernia in this report represents, to the best of our knowledge, the fourth such case reported in the literature. The rarity of this medical entity makes it almost impossible to specifically describe predisposing risk factors for liver herniation. Obesity, the right adrenal myelolipoma mass effect, and the previous abdominal surgery are likely to have contributed to incisional hernia formation.

Diaphragm rupture in a liver transplant patient receiving chronic immunosuppressive therapy with sirolimus

We read with great interest the article by Wagner et al.1 recently published in Liver Transplantation. The authors presented a patient with massive, asymptomatic diaphragmatic hepatic herniation after orthotopic liver transplantation. They discussed all the possible potential causes of the diaphragm rupture, such as a devitalized diaphragmatic muscle, extubation with an acute reduction of the intrathorax pressure, surgical techniques, blunt trauma, a preexisting Bochdalek hernia, an intraoperative diaphragmatic injury, and the presence of preoperative ascites in conjunction with increased intra-abdominal pressure. However, we have to add a few comments. In our opinion, the authors did not consider a possible role of the primary immunosuppressant. To support this hypothesis, we report a patient with a spontaneous, nontraumatic diaphragmatic rupture with gastric herniation into the thorax occurring 16 months after orthotopic liver transplantation with no clear etiology. Whole graft liver transplantation was uneventful; preexisting Bochdalek hernias, intraoperative diaphragm injuries, and massive ascites were not present in our patient. The only relevant connection was the chronic immunosuppressive regimen, which was maintained with mammalian target of rapamycin inhibitors in both cases. It has already been reported in the literature that the mammalian target of rapamycin class of immunosuppressive drugs (sirolimus and everolimus) is related to incisional hernias and impaired wound healing after transplantation because of the drugs' well-known antiproliferative effects.2-6 By blocking angiogenetic activity, sirolimus has shown a potent indirect mechanism in addition to its direct effects on tumor cells; this effect is linked to a decrease in the production of vascular endothelial growth factor and to a markedly inhibited response of vascular endothelial cells to stimulation by vascular endothelial growth factor.7, 8 A possible connection between mammalian target of rapamycin inhibitors and spontaneous diaphragmatic herniation might be related to these antiangiogenetic effects, which could weaken the diaphragm structure previously impaired during hepatectomy and thereby facilitate a spontaneous diaphragmatic rupture with intrathoracic visceral herniation. Gian Luigi Adani M.D.*, Anna Rossetto M.D.*, Vittorio Bresadola M.D.*, Umberto Baccarani M.D.*, * Department of Surgery and Transplantation Unit, Udine University Hospital, Udine, Italy.

Split-liver transplantation in the setting of hepatic herniation due to a congenital diaphragmatic hernia in a down syndrome patient

Split-liver transplantation in the setting of hepatic herniation due to a congenital diaphragmatic hernia in a down syndrome patient

Traumatic handlebar hernia associated with hepatic herniation: a case report and review of the literature

A traumatic abdominal wall hernia (TAWH) is a rare type of hernia that occurs after blunt trauma to the abdomen. TAWH caused by direct trauma from bicycle handlebars is even more rare with fewer than 30 cases having being reported. Recognition of these hernias is important, because they may be associated with significant intrabdominal injuries. Despite an overall increase in incidence of blunt abdominal trauma, cases of TAWH remain rare, probably because of elasticity of the abdominal wall resists the shear forces generated by a traumatic impact. A high level of clinical suspicion is required for diagnosis of TAWH in patients with handlebar injuries. We present the case of a 20-year-old man with a traumatic handlebar hernia associated with herniation of the liver and hepatic ductal injury, which was managed successfully by a delayed repair of the hernia.

PRENATAL DIAGNOSIS AND PERINATAL OUTCOME OF 38 CASES WITH CONGENITAL DIAPHRAGMATIC HERNIA: 8-YEAR EXPERIENCE OF A TERTIARY BRAZILIAN CENTER

To evaluate the perinatal results for neonates with congenital diaphragmatic hernia diagnosed prenatally. We reviewed data from 38 cases of congenital diaphragmatic hernia diagnosed prenatally from January 1995 to December 2003 in the Fetal Medicine Unit of the Department of Obstetrics and Gynecology, São Paulo University Medical School. The main data analyzed were gestational age at diagnosis, fetal karyotyping, side of diaphragmatic defect, presence of associated structural malformations, hepatic herniation, and severe mediastinal shift. Perinatal outcomes were obtained by reviewing hospital documents or by directly calling the patients' immediate relatives. Mean gestational age at diagnosis was 29 weeks (range, 16-37 weeks). Thirty (79%) cases had a left diaphragmatic defect and 8 (21%) had a right lesion. Associated structural malformations were observed in 21 (55%) cases, in which 12 fetuses had a normal karyotype and 9 had chromosomal abnormalities. Isolated congenital diaphragmatic hernia was confirmed in 17 (45%) cases. The overall perinatal mortality rate was 92%. Rates of fetal deaths, early neonatal deaths, late neonatal deaths, and survival were 42%, 50%, 0%, and 8%, respectively, in cases with associated structural malformations but normal karyotyping; 56%, 44%, 0%, and 0% for cases with chromosomal abnormalities; and, 0%, 76%, 12%, and 12% in cases with isolated congenital diaphragmatic hernia. The neonatal mortality rate was 89% in cases with isolated congenital diaphragmatic hernia. Perinatal mortality was very high in prenatally diagnosed cases of congenital diaphragmatic hernia. Earlier perinatal deaths are associated with the presence of other structural defects or chromosomal abnormalities. In cases of isolated congenital diaphragmatic hernia, mortality is related to the presence of herniated liver, right-sided lesion, and major mediastinal shift.

Different Sonographic Pictures of Traumatic Hepatic Herniation and Reasons for Their Differences

Sonographic features used in the diagnosis of diaphragmatic rupture with hepatic herni-ation have been reported in several previous studies. Most of those studies demonstrated the sonographic pictures, but did not discuss the reasons behind the formation of those particular pictures. We report three cases of traumatic hepatic herniation with different sonographic pictures and discuss the reasons for their differences. Case 1 represents a negative sonographic study even though the chest film showed the impression of the hepatic herniation. In case 2, sonography revealed a relatively small volume of herniated liver compared to the larger volume of hepatic herniation seen on chest film. In case 3, a complete illustration of the hepatic herniation in one fused sonographic image included disrupted diaphragm, herniated outline with waist-like configuration of the liver, separation of the liver and right kidney, and interposed bowel gas within the separated area. From these three cases, we can conclude that different locations, narrow or wide constriction of the herniated neck, and different degrees of severity of liver herniation would affect the specific sonographic picture.