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Incarcerated Gallbladder in Inguinal Hernia: a Case Report and Literature

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Incarcerated Gallbladder in Inguinal Hernia: a Case Report and Literature Tajti Jr. et al. BMC Gastroenterol (2020) 20:425 https://doi.org/10.1186/s12876-020-01569-5 CASE REPORT Open Access Incarcerated gallbladder in inguinal hernia: a case report and literature review János Tajti Jr., József Pieler, Szabolcs Ábrahám, Zsolt Simonka, Attila Paszt and György Lázár* Abstract Background: Treating hernias is one of the oldest challenges in surgery. The gallbladder as content in the case of abdominal hernias has only been reported in a few cases in the current literature. Cholecyst has only been described in the content of an inguinofemoral hernia in one case to date. Case presentation: A 73-year-old female patient was admitted to the Emergency Department due to complaints in the right inguinal area, which had started 1 day earlier. The patient complained of cramp-like abdominal pain and nausea. Physical examination confrmed an apple-sized, irreducible hernia in the right inguinal region. Abdominal ultrasound confrmed an oedematous intestinal loop in a 70-mm-long hernial sac, with no circulation detected. Abdominal X-ray showed no signs of passage disorder. White blood cell count and C-reactive protein level were elevated, and hepatic enzymes were normal in the laboratory fndings. Exploration was performed via an inguinal incision on the right side, an uncertain cystic structure was found in the hernial sac, and several small abnormal masses were palpated there. The abdominal cavity was explored from the middle midline laparotomy. During the exploration, the content of the hernial sac was found to be the fundus of the signifcantly ptotic, large gallbladder. Cholecystectomy and Bassini’s repair of the inguinal hernia were performed safely. Conclusions: Following a review of the literature, it can be concluded that the fnding of incarcerated gallbladder in the content of an inguinal hernia is a rare fnding. No other similar emergency case and successful surgical interven- tion have been reported before. Keywords: Incarcerated gallbladder, Hernia, Gallbladder strangulation, Case report Background Meckel’s diverticulum [2] found by Alexandre Littré and Treating hernias is a routine and common surgical inter- an infamed appendix described by Claudius Amyand [3] vention and one of the oldest surgical challenges in the should be emphasised from the literature. However, a world. gallbladder as content in the case of inguinal hernias has Te majority, 80%, of hernias of the abdominal wall are only been reported in one case in the current literature inguinal hernias [1]. Te most common hernial contents [4]. After reviewing the literature, we have concluded that are the following: the greater omentum and certain intes- an incarcerated gallbladder in the content of an ingui- tinal segments (the small bowel, appendix, colon, urinary nal hernia is a rare fnding, with no other similar cases bladder, ovary and fallopian tube). In addition to surgical reported before to the best of the authors’ knowledge. methods that have been modifed several times over time, Our case report summarizes the diagnosis, surgical a number of rare hernial contents have been described; a treatment and perioperative care of this rare case in rela- tion to a review of the current literature. *Correspondence: [email protected]; [email protected] Department of Surgery, University of Szeged, Semmelweis u. 8., Szeged 6725, Hungary © The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Tajti Jr. et al. BMC Gastroenterol (2020) 20:425 Page 2 of 4 Case presentation was found. An abdominal X-ray showed no signs of intes- In our case report, a 73-year-old female patient was tinal obstruction. White blood cell count was 13.62 G/l, admitted to the Emergency Department for complaints C-reactive protein was 26.6 mg/l, and hepatic enzymes in the right inguinal area, which had started one day ear- were normal in the patient’s laboratory fndings. Te lier. Te patient complained of cramp-like abdominal physical and ultrasound examinations unequivocally con- pain and nausea. Bowel movements were normal, and the frmed an incarcerated right inguinal hernia, which was patient had no fever. From the patient’s medical history sufcient for a vital indication of acute surgical interven- we should highlight that a right inguinal hernia had been tion considering the very high cardiovascular risks. diagnosed years before. At that time surgical consulta- Exploration was performed via an inguinal incision on tion had also been involved. However, due to the patient’s the right side. In contrast to the abdominal ultrasound severe cardiovascular co-morbidities (aortic, mitral and fnding, an uncertain cystic structure was found in the tricuspid valve insufciency, right heart failure and low hernial sac and several small, solid, abnormal masses ejection fraction of 22%), the cardiology and preanesthe- were palpated in this structure (Fig. 2a). Te lesion sia consultations determined elective surgical interven- seemed to be a gynaecological lesion, not an intesti- tion to be very high-risk and the elective operation was nal loop. As regards the uncertain, bizarre fnding, the therefore contraindicated. In addition the patient had abdominal cavity was explored from the middle midline hysterectomy, appendectomy, Alzheimer’s disease and laparotomy. During the exploration, the content of the cholelithiasis in her medical history. hernial sac was found to be the fundus of the signif- Te physical examination confrmed an apple-sized, cantly ptotic, large gallbladder containing cube-shaped irreducible hernia with tenderness to abdominal palpa- stones palpated earlier during the inguinal exploration. tion in the right inguinal region. Skin redness was not An intramural haemorrhage was observed in this region detected. Scars from the midline laparotomy and McBur- of the gallbladder, but no clear necrosis was detected ney’s incision were observed. Abdominal ultrasound con- (Fig. 2b). Tere were no signs of infammation in the frmed an oedematous intestinal loop in a 70-mm-long hilum of the gallbladder during the surgery. Terefore, hernial sac protruding via a 30-mm hernial orifce in the a retrograde cholecystectomy and Bassini’s repair of the projection of the palpated lesion (Fig. 1). Fluid was seen inguinal hernia were performed safely, and according to in the intestinal loop, with no circulation detected there. our Department protocol a fne silicone drain was left in Neither free abdominal fuid nor a dilated biliary duct the omental foramen of Winslow. Fig. 1 Preoperative abdominal ultrasound showed an oedematous intestinal loop in a 70-mm-long hernial sac protruding via a 30-mm hernial orifce Tajti Jr. et al. BMC Gastroenterol (2020) 20:425 Page 3 of 4 Fig. 2 Intraoperative fndings. a The incarcerated gallbladder detected during inguinal exploration. b Ptotic gallbladder elevated from median laparotomy. c Specimen Cephalosporin and metronidazole antibiotic ther- Until now, only Rodrigues et al. published a case report apy and prophylaxis of thrombosis with low molecular where the gallbladder had been described in the content weight heparin were administered during the periopera- of an inguinofemoral hernia [4]. Te gallbladder was tive period. Temporary confusion developed during the detected in the femoral canal of an elderly female patient postoperative period due to the patient’s Alzheimer’s with inguinal complaints. Repair of the abdominal wall disease and the stress of the acute surgery; however, no and cholecystectomy were performed electively in this surgical or other organic lesion was found in the back- case [4]. In most patients, the gallbladder was found in ground. Te drain was removed on the frst postoperative parastomal hernias [9–13], with strangulation of the her- day, and oral nutrition was started gradually. Follow-up nia leading to cholecystitis; there was only one case in laboratory fndings showed no signifcant abnormalities. which no infammation was observed. Cholecystectomy Te patient was discharged on the fourth postoperative was performed in all cases, except for a case report by day, with no signs of infammation in the wounds, nor- Frankl et al., where successful conservative therapy was mal passage and no complaints. During the nine-month- administered after repositioning a hernial sac around a long follow-up visits, the sutures were removed and the transversostoma in an elderly patient in a poor general patient had no signifcant complaints. Recurrent hernia condition with polymorbidities [9]. In some cases, the was not detected. Histology of the gallbladder showed gallbladder was described in hernias developing in the acute cholecystitis with incipient haemorrhagic necrosis epigastric region or in surgical scars [14–16]. in the 210-mm-long sample (Fig. 2c). In the majority of the cases, the surgical method used was laparotomy. Only Paolino et al. and Trotta et al. reported cases of laparoscopies, and, in their cases, the Discussion and conclusions gallbladder was found in the content of hernias of the Incarcerated inguinal hernias are among one of the anterior abdominal wall.
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