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Case Report
AN UNUSUAL OUTCOME OF A GIANT VENTRAL
HERNIA
Dr. Muhammad Waheed (MBBS, FCPS, MRCPS), Dr. Muhammad al
Akeely (MBBS, CABS), Dr. Hammad al Qahtani (MBBS, FRCS),
Dr.AlSenani Mohammad Ibrahim (MBBS).
__________________________________________________
Abstract:
Hernias are routine general surgical problems which may present at any
age group regardless of their socioeconomic status. We present a rare
case. A complicated ventral hernia leading to short bowel is unusual and
rather extremely rare and to my knowledge only one case report is
available in the literature. This current case report describes a 54-year
old gentleman who presented in the hospital with a giant strangulated
ventral hernia causing massive bowel ischemia that ended up with short
bowel. The literature is reviewed on big abdominal wall hernias leading
to short bowel and short bowel syndrome is also presented.
Ventral hernia is a routine surgical problem with a significant economic
and public health consequences particularly if treated late or in neglected
patients. Strangulated hernias may lead to visceral damage that increases
the morbidity and mortality. These complications can be prevented if
diagnosed earlier when small, and repaired as a day case with good
outcome.
Case report.
A 54-year old male was admitted through accident and emergency
departmentat King Saud Medical City (KSMC) Riyadh, with a huge
ventral hernia in june 2013. The hernia had markedly increased in size
during the last one month and for the last one week had become stony
hard, painful and irreducible as in figure 1. These changes were also
associated with vomiting and absolute constipation. Detailed history also
depicts that patient had road-traffic accident 20 years back which
resulted in dysarthria and made him socially inactive. No other
significant past surgical and medical history was available. Patient was
not on any specific medication.
Examination revealed a dehydrated patient with a pulse rate of 104/ min,
but blood pressure within normal range. There was a huge ventral
hernia, about 25 x 30 cm almost equal to the size of a football, tense and
tender bulging more on the right side of the abdomen. Skin discoloration
overlying the hernia was also noted. Bowel sounds were not audible and
rectal examination was unremarkable.
Laboratory investigation revealed leukocytosis. Chest X-Ray showed no
air under diaphragm. The abdominal X-Ray showed dilated bowel loops
with few air fluid levels. A diagnosis of strangulated ventral hernia was
made.
The patient was resuscitated with isotonic fluids. Intravenous
cefuroxime and metronidazole were also given before surgery. After
resuscitation and consent and ICU bed arrangement patient was shifted
directly for operation from emergency without any further
investigations. Laparotomy revealed that almost the whole small bowel
and some part of the large bowel was out of the abdomen in the hernial
sac with some hemorrhagic fluid. There was a constriction at the
abdominal wall like a shelf and there was pressure over the mesentery
due to tight neck of the sac size about 5 x 5cm. The huge hernial sac was
opened containing offensive fluid, gangrenous bowel, mesentery and
omentum. The pressure within the hernial sac was so high that on
opening the sac haemorrhagic fluid came out like a shower. The
gangrenous area included most of the jejunum, whole of ileum, cecum,
ascending and proximal half of the transverse colon as in figure 2. The
constriction was divided and full trial was given to regain the viability of
the gut. A clear line of demarcation was established. Resection of
gangrenous bowel and omentum was carried out. Gangrenous sac was
also excised. After resection, only 60 cm of proximal jejunum remained
which was anastomosed to the remaining transverse colon. The patient
ended up with short bowel. Direct hernia repair was performed without
prosthetic mesh. Histopathology showed gangrenous bowel with clear
margins. Postoperative course was uneventful. Initially, TPN was started
and later on, overlapped with entral feeding gradually. There were few
episodes of diarrhea that was managed conservatively. The patient
tolerated the gradual increase of enteral feed and discharged from the
hospital after 30 days when he was completely off TPN, tolerating full
enteral feeds. Patient was regularly followed in the outpatient surgical
clinic with short bowel syndrome. He is on entral + normal diet
combination. He is passing four to five times of mixed consistency stool.
He lost about 30 kg weight during last 3 months. The dietary issues were
managed with the help of dietitian.
Figure 1
Huge Ventral Hernia with Skin changes.
Figure 2 Gangrenous Gut.
Discussion: Paraumblical hernia repair is one of most commonly practiced operation
in the department of surgery. Giant abdominal hernias are less
common[1]. Multiparous females are more likely to be affected.[2]
Generally, hernia cases are operated as a day case except for patient who
has comorbid condition. However, if patient has neglected the condition
of hernias, then these cases become challenging and need inpatient
care.[2] In the current case report, a male patient had an enormous
strangulated paraumblical hernia. According to the patient, he initially
had a small size hernia which gradually increased in size over a long
period of neglect. He had neglected his condition. When he had severe
symptoms of strangulated hernia, he presented in the hospital and
underwent laparotomy. Most of his gut was gangrenous and ultimately
patient ended up with a short bowel i.e.,only proximal jejunum
remained about 60 cm from the ligament of Trietz. Due to clear
demarcation of gut by tight band and rest of the area was free from
gangrene. Margins were quite healthy and bleeding profusely and
mesentry was also healthy in spared area .So it was decided not to put
patient for second look and to go clinically. Early surgical treatment for
such cases has good prognostic value.[3] This report describes a
neglected case of hernia which lead to increased morbidity and hospital
stay. Giant paraumlical hernia if strangulated may cause massive
mesenteric ischemia.[1]
syndrome caused by the surgical removal of a portion Short bowel
syndrome (SBS) other names are also short gut syndrome or
simply short gut) is a malabsorption disease of intestine caused by
the surgical removal of the small intestine, sometime due to the
complete dysfunction of a large segment of bowel.[3] Short bowel
syndrome usually develops when there is less than 2 meters (6.6 feet) of
the small intestine left to absorb sufficient nutrients.[7] Short bowel of the
bowel may be a temporary condition, due to the adaptive property of the
small intestine.[4] Nutrients are not properly absorbed into the body
(malabsorption) as a result Risk factors include diseases of the small
intestine that may require surgery, such as Crohn's disease. In
infants, necrotizing enterocolitis is a common cause.Although the
majority of cases are acquired, some children are born with a congenital
short bowel.[5] Short bowel syndrome can also be caused by disease or
injury that prevents the small intestine from functioning as it should
despite a normal length. Specific nutrient deficiencies may occur
depending on what sections of the small intestine were removed or are
not functioning properly. Sites of nutrient absorption in the small
intestine are the duodenum, the first section of the small intestine, where
iron is absorbed. The jejunum, the middle section of the small intestine,
where carbohydrates, proteins, fat, and vitamins are absorbed. The
ileum, the last section of the small intestine, where bile acids and
vitamin B12 are absorbed.
People with short bowel syndrome are also at risk for developing food
sensitivities.[5] Diarrhea is the main symptom of short bowel syndrome.
Diarrhea can lead to dehydration, malnutrition, and weight loss. Other
symptoms may include cramping, bloating, heartburn, weakness, and
fatigue.
Specific nutrient deficiencies may occur depending on what sections of
the small intestine were removed or are not functioning properly.
Practically there is no cure for short bowel syndrome.[5] In newborn
infants, the 4-year survival rate on parenteral nutrition is approximately
70%. In newborn infants with less than 10% of expected intestinal
length, 5 year survival is approximately 20%.[5] A high-calorie diet that
supplies key vitamins and minerals, as well as carbohydrates, proteins,
and fats. Vitamin B12, folic acid and increased iron in the diet to
treat anemia. The main treatment for short bowel syndrome is nutritional
support. Treatment may involve use of oral rehydration solutions,
parenteral nutrition, enteral nutrition, and medications. Oral rehydration
solutions consist of sugar and salt liquids. Parenteral nutrition delivers
fluids, electrolytes, and liquid nutrients into the bloodstream
intravenously—through a tube placed in a vein. Enteral nutrition
delivers liquid food to the stomach or small intestine through a feeding
tube.
Some studies suggest that much of the mortality is due to a complication
of the TPN, especially chronic liver disease.[7] Recent case reports have
shown promising results in a type of lipid TPN feed known as
Omegaven in which the risk of liver disease is lower. [6] In a process
called intestinal adaptation, physiological changes to the remaining
portion of the small intestine occur to increase its absorptive capacity.
These changes include: enlargement and lengthening of the villi found in
the lining. Increase in the diameter of the small intestine, slowdown in
peristalsis or movement of food through the small intestine.[9] Intestinal
adaptation can take up to 2 years to occur.[7] People with short bowel
syndrome are also at risk for developing food sensitivities.[9] Symptoms
of short bowel syndrome are usually addressed by prescription medicine.
These include:
Anti-diarrheal medicine (e.g. loperamide, codeine) to increase transient
time in intestine. Vitamin, mineral supplements and L-Glutamine
powder mixed with water. H2 blocker and proton pump inhibitors to
reduce stomach acid. Lactase supplement (to improve the bloating and
diarrhea associated with lactose intolerance). Surgery, including
intestinal lengthening, tapering, and small bowel transplant. Parenteral
nutrition (PN or TPN for total parenteral nutrition - nutrition
administered via intravenous line). Nutrition administered
via gastrostomy tube.[8][9]
Although promising, small intestine transplant has a mixed success rate,
with postoperative mortality rate of up to 30%. One-year and 4-year
survival rate are 90% and 60%, respectively.[8]
Acknowledgement: The author would like to express sincere thanks to all consultants of
units Prof. M. K Alam, Dr. M. Akeely, Dr. Hamad-al Qahtani and Prof.
Saleh al Salamah.
References: 1. Tesrini M, Mazaial R, Gurrado A, Lissinidi G, Piccinni G. Massive
mesenteric ischemia, resulting from a giant, strangulated umblical
hernia. Pub Med Int.surg.2007 Sept-Oct 92(5)296.
2. Online dictionary data segment.com> incarcerated citing Webster
1913.
3. Desarda MP (2003) surgical physiology of hernia repair. BMC Surg
3:2 doi 10./186/1471-2482-3-2.
4. Short bowel syndrome, orphanet, February 2012, retrieved November
16, 2012.
5. "Teduglutide", Orphan Drug Product Designations (database record)
(U.S. Food and Drug Administration), June 2000, retrieved
November 16, 2012.
6. Byrne, Theresa A.; Wilmore, Douglas W. et al. (November
2005), "Growth Hormone, Glutamine, and an Optimal Diet Reduces
Parenteral Nutrition in Patients With Short Bowel Syndrome: A
Prospective, Randomized, Placebo-Controlled, Double-Blind Clinical
Trial",Ann. Surg. 242 (5): 655–661.
7. Debra Sherman (October 16, 2012). Leslie Adler and Matthew Lewis,
ed. "FDA advisers back NPS's drug for short bowel syndrome".
Reuters. Retrieved November 16, 2012.
8. Innovation at Work: The STEP Procedure, Boston Children's
Hospital, Center for Advanced Intestinal Rehabilitation, retrieved
June 17, 2010.
9. Vanderhoof JA, Langnas AN (1997). "Short-bowel syndrome in
children and adults". Gastroenterology 113 (5): 1767–78.
doi:10.1053/gast.1997.v113.pm9352883. PMID 9352883.