Peritoneal Sac Research Articles

A Rare Case of Complex Left Paraduodenal Hernia with Cocoon Abdomen

Paraduodenal hernias are rare congenital hernias that account for approximately 0.2-0.9% of all internal hernias. Among them, left paraduodenal hernias are even rarer, with an incidence of about 0.8%. Cocoon abdomen, also known as sclerosing encapsulating peritonitis, is a rare condition characterized by the encapsulation of the small bowel by a thick fibrous membrane, leading to intestinal obstruction. We present a rare case of a 45-year-old female patient who presented with complaints of left upper abdominal pain, intermittent vomiting, and abdominal distension for two months. Imaging studies revealed a complex left paraduodenal hernia with cocoon abdomen, leading to subacute intestinal obstruction. The patient underwent exploratory laparotomy, reduction of small bowel contents from the hernial sac, excision of the hernial sac, extensive adhesiolysis, and closure of the hernial defect. Intraoperatively, the entire small bowel from the duodenojejunal flexure to the ileocecal junction was encased in a thick peritoneal sac, with dense interbowel adhesions and a thick hernial sac. The postoperative course was complicated by paralytic ileus, which was managed conservatively. The patient recovered well and was discharged on a low-residue diet and appropriate medications. This case highlights the rare coexistence of a left paraduodenal hernia and cocoon abdomen, emphasizing the importance of early diagnosis and timely surgical intervention to prevent potential life-threatening complications

Caudal ventral midline herniation in a foal

SummaryThis report outlines the diagnosis, surgical treatment and successful outcome following the treatment of a foal presented with a congenital abdominal hernia. A focal ventral abdominal swelling, enlarging since birth, starting just caudal to the intact umbilicus and extending caudally over the prepuce was observed. Once in dorsal recumbency, the hernia was found to originate from a defect of the abdominal wall in the linea alba region. A simple closed herniorrhaphy with inversion of the large peritoneal sac into the abdomen was performed. Post‐operative complications included fever with the development of an abscess at the surgical site. This was diagnosed and drained with ultrasound guidance. Based on culture and sensitivity testing of the abscess exudate, antibiotic therapy was adapted and the foal made a full recovery. A clinical examination undertaken 1 year later revealed complete healing of the linea alba. Herniation due to a muscle wall default has not been previously reported in foals. This article reviews the commonly observed causes of herniation (umbilical and inguinal hernias). However, a third type of congenital ventral body wall hernia should be considered for the differential diagnosis of swelling of the preputial area in foals.

V-052 Laparoscopic Treatmenf of Spiegel Strangulated Hernia by TAPP Approach

Abstract Repair of hernia is a very common procedure performed by a general surgeon. Laparoscopic approach has demonstrated advantages over direct approach: less complications, faster recovery and less postoperative pain. In Spiegel hernias, if the ring is less than 2 cm, a simple laparoscopic suture can be performed; however, laparoscopic transabdominal preperitoneal (TAPP) hernioplasty has lower risk of recurrence. We report the case of a woman with and strangulated Spiegel hernia which was attempted by TAPP hernioplastly. 63 year old woman consulted in emergency for a swelling of the left flank an occlusive syndrome. Physical examination found a distended abdomen with presence of a painful mass in the left flank, irreducible. Radiological findings were inconclusive, so an ultrasound was performed which showed an abdominal wall defect of 15×15 mm with an ischemic small bowel loop herniation: strangulated Spiegel hernia. A exploratory laparoscopy was attempted emergently. It found a 2 cm hole at the abdominal wall with 15 cm of ischemic small bowel. Ischemia was confirmed with indocyanine green (ICG). Afterwards, TAPP herniopplasty was performed: peritoneal incision to create a peritoneal flap. The peritoneal sac was reduced and then, we closed the defect. After this, we placed a prosthesis covering the area of weakness in the pre-peritoneal space and fixed with biological glue. At least, we covered the mesh with the peritoneal closure. Finally, we performed a resection of ischemic bowel and isoperistaltic mechanical laterolateral extracorporeally anastomosis. She had an unremarkable post-operative course, and she was discharge on the 4th postoperative day.

Spiegel's hernia: A case report

Spiegel's hernia is a pathology of rare prevalence and represents less than 0.1% of abdominal wall hernias that corresponds to the protrusion of ́ a peritoneal sac through an acquired or congenital orifice of Spiegel's semi-lunar line. Diagnosis often proves difficult given its peculiar location that is unfamiliar to most primary care physicians in the emergency department. It is often diagnosed at the stage of complication thus making l ́strangulation a circumstance of discovery and then exposing to the sometimes serious consequences of diagnostic delay. We report the case of a 25-year-old man who had presented with the appearance of a painful swelling of the left iliac fossa. The morphological examination was in favor of a left spiegel hernia and the surgical exploration showed a hernia sac with epiploic content without any sign of pain.

Lateral inguinal hernia

Inguinal hernia has the most presentation of all hernia cases, which is about 75% of cases. Some risk factors that increase the incidence of inguinal hernia are old age, male, connective tissue abnormalities, and low body mass index. External risk factors consist of smoking, chronic coughing and carrying heavy loads. Inguinal hernias can be identified from the earlier clinical course and given treatment as early as possible. Surgery is the only therapy for an inguinal hernia aimed at removing the peritoneal sac and covering the defects on the fascia in the inguinal wall. Cases of hernia in rural areas may have delayed treatment because of limited facilities and public awareness of its complications. Cases of inguinal hernia that are treated too late can be life-threatening. Some complications can arise. A comprehensive specific approach in patients with an inguinal hernia in rural areas can increase the cure rate for inguinal hernia sufferers.

Incarcerated left-sided Amyand’s hernia and synchronous ipsilateral femoral hernia: first case report

BackgroundThe finding of a vermiform appendix within the peritoneal sac of an inguinal hernia is called Amyand’s hernia. The reported incidence of Amyand’s hernia and femoral hernia is 1% and 3.8%, respectively. To our knowledge, no cases have been reported in the literature that associate these two entities. We present the first case of incarcerated left-sided Amyand’s hernia and synchronous ipsilateral femoral hernia found during emergency surgery.Case presentationA 72-year-old woman was admitted to the Emergency Department for a complicated left inguinal hernia. An inguinotomy was performed that detected a large direct hernial sac and a synchronous femoral hernia. The opening of the inguinal hernia showed the presence of the cecum and the appendix, both without signs of inflammation. The femoral space was evaluated transinguinally, identifying the larger omentum that had slipped into the femoral canal. The primary closure of the posterior wall defect was performed with the McVay technique due to its large size, and then the hernioplasty was completed with a polypropylene mesh. No postoperative complications were reported.ConclusionsIn the context of an incarcerated Amyand’s hernia, the decision to perform an appendectomy in addition to hernia repair with or without mesh will depend on intraoperative findings.

Symptomatic reponible umbilical hernia in the rabbit

A case of umbilical hernia in a 7-month-old female rabbit was presented to the Surgery Clinic of the Veterinary Faculty, University of Sarajevo. The owner noticed inappetence and lethargy four days before arrival at the clinic. Clinical parameters on physical examination were within the physiological range. Bruxism and lethargy were noted as signs of discomfort due to gas accumulation in colon. A reponible, nonpainful mass in the umbilical scar area was palpated but intestinal peristalsis was not altered. General anesthesia was induced by intramuscular administration of ketamine with medetomidine and maintained with isoflurane. Surgical treatment of hernia included the peritoneal sac dissection and amputation, repositioning of small intestines, and correction of abdominal wall defect. Intraoperative multimodal analgesia approach was used to reduce inhalant anesthesia requirements and to prevent pain-related and stress-related complications. In this case report we described a surgical and veterinary treatment of the reponible umbilical hernia in a rabbit.

Recurrent Spigelian Hernia: case report

The protrusion of adipose tissue, peritoneal sac or abdominal viscera in the anterolateral region of the abdomen can configure the so-called Spigelian hernia. A 53-year-old patient with comorbidities is admitted for reoperation of Spiegel's hernia. Aging and the presence of obesity, multiparity and previous surgery may have predisposed the appearance of this type of hernia. For recurrence, obesity may have been a contributing factor, although factors related to the surgical procedure and the hernia itself should also be considered. Spiegel's hernia is a rare abdominal hernia whose treatment is surgery, bearing in mind the risks of recurrence and the possibilities of mitigating them.

Abdominal Cocoon Syndrome (ACS) or Idiopathic Sclerosing Peritonitis: An Extremely Rare Cause of Intestinal Obstruction

Introduction: Abdominal cocoon syndrome is an extremely rare cause of intestinal obstruction in which loops of small bowel are encapsulated by a fibro-collagenous membrane. This condition is also known in the literature as sclerosing peritonitis, and in the majority of cases, it has no known cause. The majority of patients exhibit long-standing signs and symptoms of partial intestinal obstruction. Presentation of case: A 15-year-old female patient presented with complete intestinal obstruction with no known co-morbidity and no history of prior laparotomy. Intraoperatively, the entire small bowel was found to be encapsulated by a dense fibrous sac. The peritoneal sac was excised, followed by lysis of the inter-loop adhesions with appendicectomy done at the same time. Discussion: Most patients with abdominal cocoon syndrome present with features of recurrent acute or chronic small bowel obstruction secondary to kinking and/or compression of the intestines within the constricting cocoon. An abdominal mass may also be present due to an encapsulated cluster of dilated small bowel loops. Conclusions: Abdominal cocoon is a rare condition causing intestinal obstruction, and diagnosis requires a high index of suspicion because of the non-specific clinical picture. Contrast-enhanced CT-scan (CT) of the abdomen is a useful radiological tool to aid in preoperative diagnosis. Peritoneal sac excision and adhesiolysis is the treatment, and the outcome is usually satisfactory.

V-031 VICRYL MESH WITH ATRAUMATIC FIXATION AS A TECHNICAL RESOURCE FOR DIFFICULT POSTERIOR CLOSURE IN E-TEP APPROACH

Abstract Aim To present a technical resource as a possible solution to the posterior defect that does not allow primary closure in the e-TEP approach for ventral hernias, and which may represent an alternative to transverse abdominis release. Material and Methods This is a 44-year-old woman with obesity and previous hysterectomy via infraumbilical median laparotomy. She presented with an M3W1 in incisional hernia with a 4 cm defect containing the transverse colon. Results After performing a retromuscular dissection according to the Rives-Stoppa technique, it was found that there was a continuous tear in the most cranial area of the posterior layer, which was not corrected with the primary suture. It was therefore decided to place an absorbable vicryl mesh to cover the defect, fixed atraumatically with cyanoacrylate. Conclusion During a minimally invasive ventral hernia repair, closure of the peritoneal sac can be technically complex. This leads to exposure of the retromuscular polypropylene mesh, which would come into contact with the visceral bundle, and possible herniation of intestinal contents through the posterior defect. In these cases, one of the most proposed option is the release of the transverse abdominal muscle, but it could increase the technical difficulty and surgical time. As an alternative to this, we propose the placement of an absorbable vicryl mesh, covering the defect, fixed atraumatically with cyanoacrylate. This, as shown in this case, ensures posterior coverage of the mesh and does not hinder subsequent extension of the mesh.

EP-325 Congenital peritoneal encapsulation rare pathology for Acute intestinal Obstruction

Abstract Background Congenital peritoneal encapsulation (CPE) is a rare, congenital entity in which the small bowel is surrounded by an accessory peritoneal membrane. This condition is usually asymptomatic and rarely causes intestinal obstruction. This report highlights this rare congenital anomaly as a cause of intestinal obstruction. Case A 28-year-old fit man presented to A&E with classical features of intestinal obstruction. Abdominal CT scan showed features of mechanical small bowel with 360-degree rotated mesentery, and a suspicion of closed loop obstruction. An emergency laparotomy was performed. A large congenial peritoneal sac, wrapped the small bowel from D-J flexure to proximal part of ileum, and this sac was rotated 360 degrees with multiple adhesions and a single band to the left lateral wall. Early ischemic changes were noted, along with congested mesentery. The sac was opened, dissected and adhesiolysis was performed. The thick solitary band was released. There was immediate restoration of the blood supply and the bowel was viable. Patient recovered and discharged home on day 3 Discussion and conclusion Worldwide, only 50 cases on CPE have been published till date, with the maximum reported from the UK. The other common conditions that mimic CPE are internal paradodenal hernia, abdominal cocoon and sclerosing encapsulating peritonitis. Young patients with abdominal pain and feature of closed loop high small bowel obstruction on CT scan will need a high index of suspicion, before confirming the diagnosis. At this point, it will remain a rare occurrence and an incidental finding at laparotomy.

Primary Sclerosing Encapsulating Peritonitis in an Adult Male: A Case Report

Introduction: Primary sclerosing encapsulating peritonitis (PSEP), also referred to as “cocoon abdomen”, is a rare but potentially devastating disease. It is defined as the encapsulation of a segment of the small bowel by a fibro-collagenous membrane leading to acute or sub-acute small bowel obstruction. Though the exact etiology and pathophysiology of this debilitating medical condition are still controversial, PSEP has been reported to be associated with multiple congenital developmental abnormalities. Diagnosis of PSEP is usually delayed as the disease is relatively rare and commonly present with non-specific symptoms associated with non-specific laboratory findings and non-conclusive radiologic features. Patient Concerns: We present a 42-year-old male patient presenting for elective abdominal laparoscopy for his four-year recurrent abdominal pain. Diagnosis: Preoperative diagnosis of PSEP as the cause of his chronic abdominal pain was not made until at laparotomy where a thick fibrotic peritoneal sac encasing the entire small bowel was found. Interventions: Excision of the fibrotic sac with extensive adhesiolysis were done by the general surgeon. Outcomes: The patient experienced a ten-day period of post op ileus after which he had a complete recovery. Conclusion: With the increasing number of cases suffering from this condition being reported in literature, surgeons must be aware of this debilitating disease in the differential diagnosis of abdominal obstruction.

Supraumbilical gastroschisis

Gastroschisis is a rare congenital defect of the ventral abdominal wall through which abdominal contents herniate outside of the body without a peritoneal sac. The most common location of the defect is to the right of the umbilicus, however, there have been case reports of defects in alternate locations along the abdominal wall, particularly on the left side. Here we describe a case of a baby born with a gastroschisis-like defect in the midline supraumbilical abdominal wall, the only such case described in the literature, to our knowledge. The defect was small with herniated bowel and loss of domain in the abdomen requiring delayed closure with a silo. Cases of gastroschisis in unusual locations bring into question the pathogenesis of such defects, a topic which remains controversial.

Variant Mixed-Type Inguinal Hernia: A Cadaveric Case Report

During cadaveric dissection of an 84-year-old male, a previously undocumented mixed-type (direct/indirect) inguinal hernia was found within the spermatic cord. Unlike typical indirect hernias, it did not originate from the deep inguinal ring. Instead, the hernia penetrated the abdominal wall medial to the inferior epigastric vessels, through the wall of the spermatic cord, and continued distally into the scrotum within the spermatic cord. The hernia consisted of a peritoneal sac containing compressed omental tissue. This sac protruded through a weakening in the abdominal wall and into the spermatic cord, but not beyond the superficial ring. The hernia observed presents with characteristics of both direct and indirect inguinal hernias. Consequently, it cannot be classified in the traditional way. This appears to be the first reported instance of this type of hernia.

When transversus abdominis release (TAR) is not enough during the repair of large midline incisional hernias: the double peritoneal flap to the rescue.

Transversus abdominis release (TAR) is becoming an increasingly popular approach to incisional hernia repair. As the technique has been applied to more complex hernias, it appears insufficient for repairing large defects due to the impossibility to achieve a tension-free reapproximation of the peritoneum and/or the linea alba, then a bridged repair with interposed omentum, reabsorbable or coated prosthesis frequently leaving the mesh in contact with the subcutaneous space, has been proposed. To overcome these setbacks, we have developed the double peritoneal flap-TAR (DPF-TAR) technique, which entails placement of a retromuscular mesh completely isolated from either peritoneal cavity and subcutaneous space by joining both peritoneal sac halves into a double-bridged design. Of 19 patients, 17 (89%) were available for the study. Median transverse diameter of the hernia was 13,3cm (10-17), and 10 (53%) cases had a complete failure of the linea alba. Five (26%) patients developed a surgical site occurrence (SSO). With a median follow-up of 11 (4-28) months, one (5,8%) recurrence and four (23,5%) wound bulging were diagnosed. We suggest that DPF-TAR approach can provide an effective repair using native tissues to isolate the retromuscular mesh, with acceptable failure and SSOs rates. By avoiding the need for a steep learning curve, this method may constitute a handy complement to the surgeon's armory for difficult reconstructions of the abdominal wall.

COMPARISON STUDY OF EXCISION VERSUS INVAGINATION OF HERNIAL SAC IN MANAGEMENT OF INDIRECT INGUINAL HERNIA

INTRODUCTION:The new concept is that ligature of richly innervated and vascularized peritoneal sac is responsible for increased postoperative pain and other complications without any advantage in terms of recurrence rate. It is mainly due to the fact that ligation of richly innervated and well vascularised peritoneum produces a miniature peritonitis contributing to the post-operative discomfort and other complications. Aim of our study was to compare the difference in outcome of two different techniques of indirect inguinal hernia sac management. MATERIAL AND METHODS: Our study included open Lichtenstein tension free inguinal hernioplasty patients, 20patients in each group (Groups I underwent invagination of hernial sac, Group II underwent excision and high ligation of hernia sac). The lower limit of age was 18 years. All patients who underwent open Lichtenstein tension free inguinal hernioplasty with indirect inguinal hernia and without any comorbidities were included in the study. Data was tabulated and analysed by using SPSS for windows 7 software. RESULTS: Most common presenting complaints were swelling with or without associated dragging pain. Both groups were comparable in age, BMI, occupation, side of hernia, length of incision, operative time and operative ndings. The mean operative time was 50 +_ 5minutes and 60 +_10 minutes in Group A and B respectively. There was no difference in mean VAS score at 6, 12, 24 hours and 7th day, but it was signicantly higher in Group B on 21st day. Insignicant difference in complications rate was seen between the two groups. CONCLUSION: The method of invagination of sac is better than the excision of sac with ligation or transxation in reducing the incidence of chronic postoperative pain and decreased operative time after open Lichtenstein repair of indirect incomplete hernia.

Incisional Hernias with Loss of Abdominal Domain: A New Look to an Older Issue or the Elephant in the Living Room. Literature Review.

Incisional hernia (IH) is a postoperative defect of the abdominal wall through which the contents of the peritoneal cavity are externalized beneath the skin in a peritoneal sac. IH differs in anatomic complexity, but also in its associated comorbidities and surgical history. As IH enlarges, complications occur and these become part of its natural history. The goal of the study is to review the impact of loss of domain upon abdominal wall before and after abdominal wall reconstruction. The absence of anatomical and functional linea alba leads to a combination of muscular disturbances, chronic respiratory and gastrointestinal conditions, and psychosocial issues. The pathophysiological changes are also due to the decrease of the intra-abdominal pressure (IAP). During repair, the sudden reintroduction of the viscera into an unprepared cavity leads to a sudden increase in cavity volume and an increase in IAP with fatal pathophysiological implications. For an optimal repair, preoperatively, the abdominal wall must be augmented by achieving the following objectives: reducing the volume of the sac contents, optimizing compliance, enlargement of the container. At the same time, for the optimal repair, the following must be taken into account: increased knowledge about this condition to manage systemic and local changes, CT scan evaluation, monitoring IAP, plateau pressure (PP), and Positive End Expiratory Pressure (PEEP). In conclusion, the goals can be achieved by systemic optimization with a multidisciplinary team, using Preoperative Progressive Pneumoperitoneum (PPP) and/or Botox (BTX), and abdominal wall reconstruction through a mesh with augmented component separation technique.

Congenital peritoneal encapsulation and superior mesenteric vein thrombosis: A case report

Congenital peritoneal encapsulation is a rare entity characterized by an accessory peritoneal membrane that forms during embryonic development. Congenital peritoneal encapsulation is generally asymptomatic but can cause intermittent, colicky abdominal pain related to subacute small bowel obstruction. Diagnosis is made incidentally or upon surgical exploration for chronic abdominal complaints as preoperative imaging is typically nonspecific. We report a case of a 49-year-old male with epigastric abdominal pain, constipation, and superior mesenteric vein thrombosis on imaging. Upon exploratory laparotomy, the small bowel was covered by an accessory peritoneal sac consistent with congenital peritoneal encapsulation. The accessory sac was excised completely, and the patient recovered well. Although rarely causing significant gastrointestinal symptoms, congenital peritoneal encapsulation is an anomaly that requires surgical intervention.

A “sacless hernia” with the orifice obscured by a preperitoneal lipoma: A case report

Introduction and importanceWith the widespread use of laparoscopic inguinal hernia repair, it is known that some clinically evident inguinal hernias lack a peritoneal sac and are referred to as “sacless hernias”.Presentation of caseA 61-year-old man presented with a left inguinal bulge. On physical examination, the diagnosis of bilateral inguinal hernias was made, and laparoscopic transabdominal repair was performed. Intraoperatively, the left peritoneal hernia orifice was not identified from the peritoneal cavity and there was only a lipoma. Pressing the lipoma with forceps from inside the peritoneum confirmed the presence of a hernia. The preperitoneal space was opened and the hernia orifice revealed.DiscussionThe terminology and definition of sacless hernias are poorly defined, even though this is not a rare condition. Consistent with Russell's dogma, there are arguments that any prolapse can only be called a hernia if there is an accompanying peritoneal sac. The proportion of patients with sacless hernias and pure cord lipomas are very similar and these conditions are often confused. Detailed and repeated physical examination may distinguish a sacless hernia from a pure lipoma. A watchful waiting strategy is useful and ensures safety.ConclusionOnce the diagnosis of inguinal hernia is made on physical examination, open the preperitoneal cavity if a peritoneal hernia orifice was not identified during laparoscopy.

Peritoneum, the multifunctional membrane

Introduction: Not only atraumatic surgical technique, precise bleeding control, removal foreign materials from the abdomen, but also avoiding desiccation or mechanical damage of peritoneal surface at abdominal surgery mean today evidence based expectation. Peritoneum with its extensive surface and special histological structure represents an important factor in normal physiological processes, furthermore as “Guard of abdomen” it has an important role to localise inflammatory reactions, useful as dialysing surface and provides also possibility for hyperthermic abdominal chemotherapy in tumour treatment. Largest part of peritoneal sac covers small intestine and colon. To prevent postoperative complications it is necessary to avoid desiccation of intestinal tract at laparoscopic and at open procedures as well – consequently “rehyration” is a routine recommendation today. Desiccation of intestinal tract results postoperative adhesions, furthermore damage of serosa will increase permeability of intestine wall and can result perforation. All the surgical recommendations suggest keeping intestine moist, whereas there are only a few real studies in surgical literature to support or to deny this theory. Our study reviews the pathophysiological and surgical respects of this situation and summarizes the results of latest researches of combined functions of peritoneum.