Supravesical Hernia E a Rare Cause of Intestinal Obstruction

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Provided by Elsevier - Publisher Connector International Journal of Surgery (2008) 6, 471e472

www.theijs.com

CASE REPORT Supravesical hernia e A rare cause of intestinal obstruction

Balakrishnan Saravanan*, Manoj Kumar A. Paramu, Elanchezhian Ranganathan

Ysbyty Gwynedd, General Surgery, 10 Caecilmelyn, Penrhosgarnedd, Bangor LL57 NB, Wales, UK

Available online 10 July 2006

KEYWORDS Abstract Supravesical hernia is an unusual type of hernia. It is of two types: internal and ex- Supravesical hernia; ternal [Skandalakis JE, Gray SW, Burns WB, Sangmalee U, Sorg JL. Internal and external supra- Intestinal obstruction vesical hernia. Am Surg 1976 Feb;42(2):142e6]. We are reporting a case of internal supravesical hernia, in a 62-year-old gentleman to call attention to the entity, as a rare cause of intestinal obstruction. ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Introduction Abdominal X-ray revealed dilated small bowel loops. A pro- visional diagnosis of small bowel obstruction was made. Exploratory laparotomy was done through midline incision Supravesical hernia is rare. The first case of supravesical after adequate fluid resuscitation. It revealed a loop of ileum hernia, according to Keynes, was reported by Sir Astley Cooper herniating through a pouch in the supravesical fossa (Fig. 1). in 1804. It is of two types: internal and external. The internal The hernial ring was a 1 2 cm defect in the prevesical type is more difficult to diagnose and commonly presents as fascia. Digital exploration of defect after reduction of intestinal obstruction or undiagnosed abdominal pain. incarcerated bowel, revealed the sac to run medially and Case report inferiorly to depress the wall of the bladder. The pregan- grenous loop of ileum with doubtful viability was resected and an end-to-end anastomosis was performed. The A 62-year-old gentleman, presented with a twelve hour pouch was closed with 1-0 prolene interrupted stitches. history of colicky abdominal pain and vomiting. On exam- Post-operative period was uneventful and the patient was ination, he was dehydrated with a pulse rate of 104/min, discharged on the seventh post-operative day. BP 130/80 mm Hg and temperature 37.7 C. Abdominal examination revealed central abdominal distension and tenderness on deep palpation in the hypogastric region. Discussion Full blood count and biochemical profile were normal. The supravesical fossa is the area of abdominal wall * Tel.: þ44 1248 354458. between remnant of urachus (median umbilical ligament) E-mail address: [email protected] (B. Saravanan). and remnant of left or right umbilical artery (medial

Figure 2 Diagram showing anatomical location of supravesical hernia.

Conclusion

The present case illustrates a cause of small bowel obstruction that is particularly difficult to diagnose pre- Figure 1 Intraoperative picture showing hernial ring and operatively. The diagnosis was made only at the time of loop of bowel released from the ring. surgical laparotomy as with majority of the recorded cases.8e11 We suggest that, a supravesical defect inciden- tally found during routine surgical exploration of the pelvis, umbilical ligament). The inferior boundary is formed by should be sutured, to avoid incarceration of the bowel. The a peritoneal fold, part of which is the transverse fold of the case reiterates the difficulty in diagnosing this rare hernia bladder (Fig. 2). and calls attention to the entity as an unusual cause of The fossa may go on to form a deep diverticulum. These small bowel obstruction. supravesical diverticula may herniate in several directions. Those in the superior portion of the supravesical fossa usually result in external hernias, while those arising in the References inferomedial part may become lodged in the prevesical space of retzius to form an internal hernia. The internal 1. Skandalakis JE, Gray SW, Burns WB, Sangmalee U, Sorg JL. Internal e hernia in turn can be prevesical, paravesical, lateral or and external supravesical hernia. Am Surg 1976 Feb;42(2):142 6. intravesical.1e3 When the bladder apex is weakened by 2. Sawyers JL, Stephenson Jr SE. Internal supravesical hernia: report of the first successful operative repair of the intravesical a defective closure of the urachus, the diverticulum may type. Surgery 1957 Aug;42(2):368e74. herniate directly into the bladder forming intravesical 3. Barnes DR, Dreyer BJ. Internal supravesical hernia: report of 2,3 type of internal supravesical hernia. a case presenting with bladder symptoms. Br J Surg 1953 Mar; Pre-operative diagnosis of this condition is very difficult. 40(163):508e9. In our case, the diagnosis was made only during laparotomy. 4. Sasaya T, Yamaguchi A, Isogai M, Harada T, Kaneoka Y, Suzuki M. In patients presenting with small bowel obstruction, without Supravesical hernia: CT diagnosis. Abdom Imaging 2001 JaneFeb; any history of previous abdominal operations and no obvious 26(1):89e91. external hernias are detected, pre-operative investigations 5. Chou CK, Liu GC, Chen LT, Jaw TS. The use of MRI in bowel ob- e may be very helpful in diagnosing this condition. struction. Abdom Imaging 1993;18(2):131 5. CT4 or MRI5 scan may possibly diagnose this condition. 6. Gullmo A. Herniography. The diagnosis of hernia in the groin and incompetence of the pouch of Douglas and pelvic floor. Acta Cystoscopy2 may show a tunnel shaped deformity in the Radiol Suppl 1980;361:1e76. bladder wall. Supravesical hernia can be seen on herniogra- 7. Mehran A, Szomstein S, Soto F, Rosenthal R. Laparoscopic repair 6 phy and in the consecutive series of 1000 cases, Gullmo de- of an internal strangulated supravesical hernia. Surg Endosc scribed 183 external and 1 internal supravesical hernia. 2004 Mar;18(3):554e6. However, this method of investigation is relatively new 8. Koksoy FN, Soybir GR, Bulut TM, Yalcin O, Aker Y, Kose H. Inter- and not widely available, which may explain the paucity nal supravesical hernia: report of a case. Am Surg 1995 Nov; of reports of supravesical hernias. This condition has been 61(11):1023e4. reported to be diagnosed and treated laparoscopically.7 9. Sozen I, Nobel J. Inguinal mass due to an external supravesical The majority of the recorded cases have been subjected hernia and acute abdomen due to an internal supravesical her- to an exploratory laparotomy. The treatment is release of nia: a case report and review of the literature. Hernia 2004 Dec; 8(4):389e92. the intestinal obstruction and closing the hernial defect. 10. Abdullah TI, Pearson HJ. Strangulated internal supravesical her- Most authors advise against attempts to excise the hernial nia: a diagnostic problem. Eur J Surg 1997 Nov;163(11):875e6. sac and think that freshening the edges of the ring, with 11. Tretbar LL, Gustafson GE. Internal supravesical hernia: a rare closure of the defect using continuous or interrupted hernia causing small bowel obstruction. Am J Surg 1968 Dec; stitches with non-absorbable sutures is sufficient.2,8 116(6):907e8.