Parietal peritoneal hernia after abdominal hysterectomy for forty years: A case report

Abstract

BACKGROUND

Internal hernia is a rare complication following abdominal surgery, primarily resulting from structural defects caused by anastomosis. We report a unique case of a late abdominal wall internal hernia highly suspected as resulting from insufficient peritoneal closure.

CASE SUMMARY

A 72-year-old woman presented with symptoms of intestinal obstruction 40 years after undergoing an abdominal hysterectomy. Abdominal computed tomography revealed a suspicious closed loop of intestine; then, a laparotomy was performed for suspected internal hernia. During the procedure, herniation of intestine into the preperitoneal space through a parietal peritoneal defect between rectus abdominis and sigmoid colon was identified. Intestinal reduction, resection of the ischemic segment and closure of the peritoneal defect were performed. The patient recovered well.

CONCLUSION

Non-closure of peritoneum might lead to late internal hernias. Meticulous peritoneal closure should be considered to prevent this potentially lethal complication.

Key Words: Peritoneal hernia; Internal hernia; Incisional hernia; Intestinal obstruction; Case report

Core Tip: We report a unique case of an abdominal wall internal hernia, a late complication that is highly suspected to be related to insufficient peritoneal closure. In the context of the current dominant practice of not closing the peritoneum, our case highlights a potential challenge in lower abdominal surgeries, particularly those involving organ resection or transabdominal preperitoneal inguinal herniorrhaphy. It emphasizes the need for heightened awareness among clinicians regarding long-term surgical outcomes, and advocates for meticulous peritoneal closure to prevent this potentially lethal issue, despite the limited existing evidence.

INTRODUCTION

Internal hernia is a rare condition related to either natural or acquired defects, which can lead to intestinal obstruction, ischemia, necrosis and even mortality. As a surgical complication, it accounts for 0.5% to 6% of various operations, primarily resulting from anastomosis[1-5]. Internal hernias occurring through abdominal wall peritoneal defects are extremely rare and have predominantly been reported as acute complications[6-8]. We describe a case of such a condition as a late complication occurring 40 years after a hysterectomy.

CASE PRESENTATION

Chief complaints

A 72-year-old woman complained of abdominal distension for three days.

History of present illness

A 72-year-old female presented to the emergency room with abdominal distension lasting for three days. She also complained about vomiting and a lack of flatus and defecation, but denied having had similar discomfort in the past.

History of past illness

She had undergone a hysterectomy via lower midline laparotomy 40 years previously, although no documentation regarding the operation was available.

Personal and family history

There is no relevant personal and family history.

Physical examination

Physical examination revealed mild abdominal distension with stable vital signs and no signs of peritoneal irritation.

Laboratory examinations

Blood tests indicated dehydration (hemoconcentration, pre-renal azotemia and hyperlactatemia) and signs of intra-abdominal infection (leukocytosis with left shift and hyperlactatemia).

Imaging examinations

Abdominal computed tomography (CT) revealed segmental dilation of the small bowel with a transitional zone of mid-ileum in right lower quadrant, as well as a segment of suspicious closed loop of the small bowel with edematous change and focal ascites in the left lower quadrant (Figure 1).

Figure 1 Pre-operative abdominal computed tomography scan. Abdominal computed tomography revealed segmental dilatation of the small bowel with a transitional zone (arrow), as well as a segment of suspicious closed loop of the small bowel (arrowhead).

FINAL DIAGNOSIS

The final diagnosis is high suspicion of internal herniation.

TREATMENT

The CT scan indicated suspicious internal herniation. Although the patient did not exhibit signs of peritoneal irritation and her vital signs were relatively stable, clinical deterioration could have been delayed due to obstruction of venous return from internal herniation. Considering its high risk of morbidity and mortality, low likelihood of spontaneous reduction and the patient’s advanced age with limited compensatory ability, exploratory laparotomy was recommended. After a thorough explanation and discussion, the patient and her family consented to surgery.

An urgent exploratory laparotomy was performed. After incising along the previous hysterectomy scar, a large segment of distal jejunum was found herniated into the preperitoneal space in the pelvis through a peritoneal defect at the prior scar, located between the rectus abdominis and sigmoid colon. A complete hernia sac under intact muscular integrity was identified (Figure 2A and B). Upon reviewing CT, the situation was also documented (Figure 2C) in a perspective drawing illustrating the spatial relationship of the hernia in a simple way (Figure 2D). The herniated intestine was reduced, and a ten-centimeter segment of bowel resection was performed due to suspected partial wall ischemic changes. The peritoneal defect (hernia sac) was closed using continuous non-absorbable sutures.

Figure 2 Findings of parietal peritoneal hernia. A: After laparotomy, a large segment of distal jejunum was found herniated into the retrorectus preperitoneal space; B: After reduction of the herniated intestine, a complete hernia sac was observed through a peritoneal defect on the prior scar; C: Pre-operative computed tomography showed the hernia sac located between the intact rectus abdominis (arrow) and sigmoid colon (arrowhead, representing part of the dome of the sac). The yellow line indicates the parietal peritoneum; D: This perspective drawing illustrates the spatial relationship of the hernia in a simple way.

OUTCOME AND FOLLOW-UP

The patient was transferred to intensive care unit for sepsis and atrial fibrillation with rapid ventricular response postoperatively. She had a smooth recovery from the sepsis, and her intake was gradually resumed with the postoperative course being largely normal, except for urinary retention due to deconditioning. She was discharged after two weeks.

DISCUSSION

Internal hernia is a rare, surgery-related condition that can be potentially lethal, possibly resulting from congenital or postoperative defects or weak points. The incidence varies between surgical procedures and methods of anastomosis, with significantly higher rates observed in upper gastrointestinal surgeries (0.7% to 6%)[1,2,4], lower rates in lower gastrointestinal surgeries (0.5% to 0.65%)[3,5], and even lower rates in other types of surgery. Most cases are caused by ring-structured defects produced by anastomosis[1-5]. Diagnosis is challenging due to non-specific clinical symptoms and findings, with accurate diagnosis requiring a high level of awareness from physicians.

In our case, we report an extremely rare presentation of an incisional internal hernia. The exact cause of this hernia was unclear and there were no records regarding the hysterectomy, particularly concerning peritonealization. However, it was assumed that a peritoneal defect - whether peritonealized or not - was created by the prior abdominal hysterectomy, leading to chronic migration of the intestine. This is similar to the acute complication of intestinal herniation through a small peritoneal defect after abdominal hysterectomy, as proposed by Kwon et al[6]. Other similar cases in transabdominal preperitoneal (TAPP) herniorrhaphy have also demonstrated acute herniations due to improper peritoneal approximation[7,8].

Peritoneal closure remains a topic of controversy, with a trend towards non-closure in both obstetric and non-obstetric surgeries in recent decades. In the case of acute peritoneal hernia after hysterectomy mentioned above, the surgeons ultimately decided to leave the peritoneum open and only closed the fascial layer[6]. The reasons favoring non-closure included equivalent major complications - such as mortality, burst abdomen, incisional hernia, and length of hospitalization - as well as shorter surgical times and reduced anesthesia exposure[9-11]. Similar findings regarding postoperative pain and recurrence have been observed in TAPP surgeries[12]. Our case highlights the possibility of a significant late complication of internal herniation, which can lead to high morbidity. Despite the limited evidence, we propose that non-peritonealization could result in peritoneal herniation with acute onset associated with smaller defects and late onset with larger ones.

Accordingly, parietal peritoneal hernia emerges as a possibly delayed challenge in the context of current practices of non-peritonealization or large-distance closure of the peritoneum. It is anticipated that this type of hernia might occur in lower abdominal surgeries involving organ resection such as hysterectomy or cystectomy, where there is no fascial restriction and additional preperitoneal space. Inguinal hernias following TAPP repair could also represent a potential source, given the disease-related space, a relatively weak abdominal wall, and compromised peritoneal integrity due to absorbable tacks or non-closure. Given the high morbidity and mortality associated with internal hernias compared to their low primary detection rates, we advocate for more meticulous closure of the peritoneum in these situations, even in light of the limited available evidence. Further investigation is necessary.

CONCLUSION

Non-closure of the peritoneum may lead to internal hernia developing over time. This late complication may pose an increasing challenge, especially in lower abdominal surgeries; accordingly, when treating patients with a long history of lower abdominal surgery, awareness needs to be raised and meticulous peritonealization should be considered to avoid this potentially lethal problem, even in the absence of extensive evidence. Further research into the long-term outcomes of non-closure of the peritoneum is necessary.