Asian Journal of Case Reports in Surgery 2(2): 1-4, 2019; Article no.AJCRS.46765 Primary Supravesical Hernia Presented as Direct Inguinal Hernia with an Unusual Internal Opening – A Case Report Devajit Chowlek Shyam1* 1Bethany Hospital, Nongrim Hills, Shillong, Meghalaya, 793003, India. Author’s contribution The sole author designed, analysed, interpreted and prepared the manuscript. Article Information DOI: 10.9734/AJCRS/2019/v2i230092 Editor(s): (1) Dr. Georgios Tsoulfas, Associate Professor, Aristoteleion University of Thessaloniki, Thessaloniki, Greece. Reviewers: (1) Ashrarur Rahman Mitul, Dhaka Shishu (Children) Hospital & Bangladesh Institute of Child Health, Bangladesh. (2) Rahul Gupta, Synergy Institute of Medical Sciences, India. Complete Peer review History: http://www.sdiarticle3.com/review-history/46765 Received 05 January 2019 Accepted 20 January 2019 Case Study Published 20 February 2019 ABSTRACT Introduction: Supravesical hernia (SVH) or paravesical hernia is a rare condition and it is believed to be caused due to Weakness between the transversus abdominis aponeurosis and the transversalis fascia. They are mainly acquired and usually associated with inguinal hernia. The external and the internal variety of SVH is commonly presented as direct inguinal hernia and intestinal obstruction or undiagnosed abdominal pain respectively. Case Report: A 40 year old male was posted for TransAbdominal PrePeritoneal (TAPP) hernia repair for a direct inguinal hernia. Intraoperatively we diagnosed him with a supravesical hernia with an unusual internal opening over the medial umbilical ligament. Discussion: SVH is a rare variety of pelvic hernia which protrudes through Supra Vesical or Paravesical Fossa (SVF). SVF is an area above the urinary bladder between the median umbilical ligament and medial umbilical ligament. CT/MRI sometimes helps in obtaining the diagnosis but mainly it was made intraoperatively. Simple closure of the internal opening is sufficed for treating this form of hernia. Conclusion: Preoperative diagnosis of SVH is difficult to establish. CT/MRI can sometimes diagnose internal SVH but in majority, the diagnosis was made intraoperatively. Whenever we are dealing with direct inguinal hernia we should be aware of the possibility of this rare form of hernia especially if there is any difference in anatomical relation during surgery. _____________________________________________________________________________________________________ *Corresponding author: E-mail: [email protected]; Shyam; AJCRS, 2(2): 1-4, 2019; Article no.AJCRS.46765 Keywords: Supravesical fossa; Supravesical hernia; medial inguinal fossa; intestinal obstruction. 1. INTRODUCTION We refashioned 15 × 15 polypropylene mesh into 12 × 15 cm size, and we used one or two Supravesical fossa (SFV) is the area between absorbable tackers each to fix the mesh with the median and medial umbilical ligaments [1] Cooper’s ligament, medial border of rectus and hernia which develop from this fossa are muscle, medial and lateral space to epigastric termed as Supravesical hernia (SVH) or vessels. Postoperative hospital stay was paravesical hernia [2]. It is a rare condition, and uneventful. The Patient was on regular follow up Sir Astley Cooper reported the first case of for his associated hemorrhoid problem and till his Supravesical hernia in 1804 [1]. They can be recent follow up that is 2 years post surgery there classified as external and internal variety [1]. was no evidence of recurrence and no other Preoperative Diagnosis is difficult [3] and the complications associated with laparoscopic external and internal variety is usually presented hernia surgery. as direct inguinal hernia and intestinal obstruction or undiagnosed abdominal pain 3. DISCUSSION respectively [1,2]. Here we present a case of primary supravesical hernia with an unusual SVH though rare is one of the common varieties internal opening presenting as a direct inguinal of pelvic hernia which protrudes through Supra hernia. Vesical or Paravesical Fossa (SVF) [4]. SVF is an area between the right and left medial 2. CASE REPORT umbilical ligaments (above and laterally) and bounded inferiorly by peritoneal reflection from A 40 yr old male came to my outpatient clinic the abdominal wall to the dome of the urinary with complaints of swelling over the right groin for bladder [2]. The urachus divides the fossa into 4 months and pain around the anal verge for 5 the right and the left SVF [3]. days. Swelling over the groin was associated Weakness between the transversus abdominis with pain over right lower abdomen and it aponeurosis and the transversalis fascia can be disappears on lying down. The Patient gave a the cause of SVH [2]. Primary SVH is very rare history of occasional constipation and chronic compared to secondary SVH [5], which are smoking for 28 years. There was no history of mostly acquired and usually associated with an chronic cough, difficulty in passing urine, inguinal hernia or followed by surgery [3]. bleeding per rectum or any surgical intervention or trauma in the past. Physical examination There are two variants of SVH: the external revealed a 4 cm soft oval swelling above the variety which occurs in the superior portion of the inguinal ligament. The swelling was reducible SFV is due to the laxity of the vesical and positive for cough impulse test. During Ring preperitoneal tissues whereas the internal type occlusion test the swelling became prominent extends into the space of Retzius [1,2]. The over the superficial inguinal ring region. internal variety was classified by Skandalakis as Congested external hemorrhoids were seen at 3 anterior, lateral or posterior SVH based on the o’clock position on Perianal examination, which relationship of the hernia sac to the bladder [2]. was firm and tender. Apart from the usual Posterior PVH is the rarest among these three preoperative investigation we routinely don’t varieties [5]. advice any radiological investigation, especially for an uncomplicated inguinal hernia. Patient The external variety usually present as direct opted surgery on a later date hence conservative inguinal hernia whereas the internal variety of management was started for the congested SVH present either with intestinal obstruction or external haemorrhoid. After 2 weeks the patient as undiagnosed abdominal pain [1,2]. As direct was posted for TransAbdominal PrePeritoneal inguinal hernia is a clinical diagnosis we do not (TAPP) hernia repair with a diagnosis of advice radiological investigation in all the cases. direct inguinal hernia. After creating a Preoperative diagnosis of SVH is difficult to pneumoperitoneum small bulge was seen over establish [1]. CT/MRI can sometimes suggest the superficial inguinal ring area. Intraoperative internal SVH by showing herniated small bowel findings were as follows: bilateral normal deep loops near the urinary bladder with distorted ring and no herniation at the Hesselbach’s bladder wall [3]. After reviewing the literature we triangle. Bladder area appears normal. We came across various suggestions like CT/MRI followed the usual steps of TAPP in this case. scan, Diagnostic laparoscopy, Cystoscopy and 2 Shyam; AJCRS, 2(2): 1-4, 2019; Article no.AJCRS.46765 Fig. 1. Intraoperative picture showing abnormal site of hernia orifice (HO). SVR- Supravesical region, MUL- Medial Umbilical Ligament, HT- Hesselbach’s triangle, DR- Deep ring, VD- Vas Deferens and SV-Spermatic Vessels Herniography to establish the diagnosis but SVH 4. CONCLUSION is mainly diagnosed intraoperatively in most of the circumstances [6]. Sozen et al. [7] operated a Only one case of SVH with an internal opening patient for direct inguinal hernia with the over the medial umbilical fold has been reported conventional inguinal approach. Intraoperatively so far [11] and this rarity makes our case unique. it was found out to be an external variety of SVH. The main concern of SVH is the preoperative The same patient was readmitted after 8 hours diagnosis. If we know the diagnosis with features of intestinal obstruction. Exploratory preoperatively, SVH can be manage by laparotomy revealed a concomitant internal SVH conventional open or laparoscopic approach. as the cause of intestinal obstruction. Only hitch is that the Conventional open approach or TEP might miss the diagnosis. In Simple closure of the hernial defect with conclusion, whenever we deal with direct inguinal continuous or interrupted non absorbable hernia we should be aware of the possibility of stitches is sufficient without excision of this rare form of hernia specially if there is any the hernia sec [8,9]. Exploratory laparotomy and difference in anatomical relation during surgery. laparoscopic techniques are both mentioned in the literature as the treatment approach [3]. In CONSENT AND ETHICAL APPROVAL 2016 Lee and Choi reported one of the largest case series on SVH and its management with As per university standard guideline participant TAPP approached. They repaired all cases with consent and ethical approval has been collected TAPP approach using smaller size mesh and and preserved by the authors. intracorporeal suturing of the defect [10]. In our case, due to patient’s history of chronic smoking COMPETING INTERESTS and constipation along with weakness of the parietal wall over the inguinal region we decided Author has declared that no competing interests to go ahead with the TAPP with usual size mesh. exist. 3 Shyam; AJCRS, 2(2): 1-4, 2019; Article no.AJCRS.46765 REFERENCES 7. Sozen I,