Internal hernia through an iatrogenic perforation in the falciform ligament a case report.

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6amp7 5th Street Radhakrishnan Salai Chennai Tamil Nadu India ndash 600004Re Hernia DOI101007s10029-008-0424-7

Internal hernia through an iatrogenic defect in the falciform ligament a case reportAuthors M Lakdawala middot SR Chaube middot Y Kazi middot A Bhasker middot A Kanchwala

Permission to publishI have checked the proofs of my article andq I have no corrections The article is ready to be published without changes

q I have a few corrections I am enclosing the following pagesq I have made many corrections Enclosed is the complete article

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Please note Images will appear in color online but will be printed in black and whiteArticleTitle Internal hernia through an iatrogenic defect in the falciform ligament a case reportArticle Sub-Title

Article CopyRight - Year Springer-Verlag 2008(This will be the copyright line in the final PDF)

Journal Name Hernia

Corresponding Author Family Name ChaubeParticle

Given Name S RSuffix

Division Department of Minimal Invasive Surgery

Organization Saifee Hospital

Address Room no 216 2nd floor 1517 Maharishi Karve Road Charni Road (East)400004 Mumbai India

Email shalilchaubegmailcom

Author Family Name LakdawalaParticle

Given Name MSuffix




Email

Author Family Name KaziParticle

Given Name YSuffix




Email

Author Family Name BhaskerParticle

Given Name ASuffix




Email

Author Family Name Kanchwala

Particle

Given Name ASuffix




Email

Schedule

Received 16 June 2008

Revised

Accepted 31 July 2008

Abstract The incidence of internal hernia through a defect in the falciform ligament mostly congenital is very rareIn this era of minimally invasive laparoscopic surgeries a few cases of internal hernia through an iatrogenicdefect in the falciform ligament have also been reported Here we present a case of a 65-year-old patient whopresented with acute small-bowel obstruction The patient had undergone a laparoscopic fundoplication4 years ago On diagnostic laparoscopy it was found that the cause of the intestinal obstruction was herniationof the small bowel through a window in the falciform ligament (which was probably created due to portinsertion during the previous surgery of laparoscopic fundoplication) The obstruction was relieved by thedivision of the falciform ligament

Keywords (separated by -) Internal hernia - Intestinal obstruction - Small-bowel obstruction - Falciform ligament - Iatrogenic etiology

Footnote Information

UNCORRECTEDPROOF

CASE REPORT1

2 Internal hernia through an iatrogenic defect in the falciform

3 ligament a case report

4 M Lakdawala S R Chaube Y Kazi

5 A Bhasker A Kanchwala

6 Received 16 June 2008 Accepted 31 July 20087 Springer-Verlag 2008

8 Abstract The incidence of internal hernia through a

9 defect in the falciform ligament mostly congenital is very

10 rare In this era of minimally invasive laparoscopic sur-

11 geries a few cases of internal hernia through an iatrogenic

12 defect in the falciform ligament have also been reported

13 Here we present a case of a 65-year-old patient who pre-

14 sented with acute small-bowel obstruction The patient had

15 undergone a laparoscopic fundoplication 4 years ago On

16 diagnostic laparoscopy it was found that the cause of the

17 intestinal obstruction was herniation of the small bowel

18 through a window in the falciform ligament (which was

19 probably created due to port insertion during the previous

20 surgery of laparoscopic fundoplication) The obstruction

21 was relieved by the division of the falciform ligament

22

23 Keywords Internal hernia Intestinal obstruction

24 Small-bowel obstruction Falciform ligament

25 Iatrogenic etiology

26

27 Introduction

28 Internal hernia is an uncommon cause of small-bowel

29 obstruction Intestinal obstruction due to internal hernia is

30 very dangerous It may present either silently or with dull

31 abdominal pain or with sudden acute abdominal pain Most

32internal small-bowel hernias occur due to iatrogenic mes-

33enteric defects (ie Petersonrsquos pseudo-Petersonrsquos etc)

34caused by previous surgeries Here we describe a case of

35internal hernia through an iatrogenic defect in the falciform

36ligament which was diagnosed intra-operatively

37Case report

38A 65-year-old lady was admitted with complaints of

39ndash Sudden onset of continuous vomiting 10ndash12 times

40bilious since 24 h

41ndash Colicky abdominal pain

42ndash Constipation

43ndash Central abdominal distension

44No other relevant contributory history other than her

45past history of laparoscopic fundoplication performed

464 years ago for gastro-esophageal reflux disease

47The patient was previously asymptomatic until this

48episode

49On examination the patient had a pulse rate of 96min

50and blood pressure of 13080 mmHg

51Per abdomen abdominal distension was present The

52bowel sounds were hyper-peristaltic

53Per rectal examination was empty

54Other systemic examinations were normal

55Investigations

56ndash Complete blood count normal

57ndash Routine biochemistry normal

58ndash Electrolytes normal

59ndash X-ray chest normal

60ndash X-ray abdominal multiple air fluid levels and dis-

61tended small-bowel loops

A1 M Lakdawala S R Chaube (amp) Y Kazi A Bhasker

A2 A Kanchwala

A3 Department of Minimal Invasive Surgery

A4 Saifee Hospital Room no 216 2nd floor

A5 1517 Maharishi Karve Road Charni Road (East)

A6 Mumbai 400004 India

A7 e-mail shalilchaubegmailcom

123Journal Large 10029 Dispatch 16-8-2008 Pages 3

Article No 424h LE h TYPESET

MS Code 08 133 h CP h DISK4 4

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DOI 101007s10029-008-0424-7

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62 ndash Computed tomography abdomen moderate dilatation

63 of small-bowel loops

64 Treatment

65 The patient was started on conservative management

66 ie nil by mouth nasogastric tube decompression and

67 intravenous fluids However she did not settle even after 3

68 days of conservative treatment so the decision for diag-

69 nostic laparoscopy to be performed was taken

70 Findings of laparoscopy

71 ndash Distended small-bowel loops

72 ndash Few omental adhesions with the port site of previous

73 surgery

74 ndash Herniated small-bowel loop (Fig 1) through a defect in

75 the falciform ligament (which was probably created

76 due to port insertion during the previous surgery of

77 laparoscopic fundoplication)

78 ndash The bowel was distended proximally with an abrupt

79 cut-off distally

80 ndash The rest of the bowel was not distended distally

81 ndash No other cause of intestinal obstruction was seen

82 The falciform ligament was cut (Fig 2) to release the

83 herniated bowel loop

84 The patient had an uneventful post-operative recovery

85 Discussion

86 An internal hernia is defined as an abnormal protrusion of a

87 viscus through a normal or abnormal opening within the

88 boundaries of the peritoneal cavity

89 The incidence [6] of internal hernias is 02ndash2 and

90 most of them are asymptomatic The hernial orifice may be

91a pre-existing anatomic structure such as the foramen of

92Winslow or a pathological defect of congenital or acquired

93origin Internal hernia is an infrequent cause of small-

94bowel obstruction with a reported incidence of up to 58

95of all cases of intestinal obstruction [6]

96The different types of internal hernia and their relative

97incidences [4] are

98ndash Paraduodenal (left[ right) 53

99ndash Foramen of Winslow 8

100ndash Transmesenteric 8

101ndash Transomental 1ndash4

102ndash Pericaecal 13

103ndash Intersigmoid 6

104ndash Supravesical and pelvic 6

105ndash Pelvic hernias include hernias through the broad

106ligament (4ndash5) perirectal fossa and fossa of Douglas

107Hernia through the falciform ligament is very rare and

108accounts for 02 of internal hernias [7] A congenital [2

1097] etiology for these defects is probable attributable to

110malformation and incomplete development of the falciform

111ligament

112A study of the literature showed a few individual case

113reports of internal hernia through congenital defects of the

114falciform ligament Gullino et al [3] reported on a series of

11514 cases of internal hernias of which two were hernias

116through an anomalous orifice from the absence of the fal-

117ciform ligament of the liver In recent years a few cases of

118internal hernia through the falciform ligament due to an

119iatrogenic defect created post-laparoscopic surgery [1 5]

120has also been reported

121In the above-described case the defect in the falciform

122ligament did not appear to be congenital and could prob-

123ably be attributed to the port placement and the port

124cannula being passed across the falciform ligament duringFig 1 Herniated small bowel through a defect in the falciform

ligament

Fig 2 Division of the falciform ligament

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125 the surgery of laparoscopic fundoplication that the patient

126 had undergone in the past

127 References

128 1 Charles A Shaikh AA Domingo S et al (2005) Falciform ligament129 hernia after laparoscopic cholecystectomy a rare case and review130 of the literature Am Surg 71(4)359ndash361131 2 Corberi O Crespi G Deho E et al (1979) Internal abdominal132 hernia caused by anomaly of the falciform ligament (a case report)133 Chir Ital 31(6)1354ndash1359

1343 Gullino D Giordano O Gullino E (1993) Internal hernia of the135abdomen Apropos of 14 cases J Chir (Paris) 130(4)179ndash1951364 Kohli A Choudhury HS Rajput D (2006) Internal hernia a case137report Ind J Radiol Imag 16(4)563ndash5661385 Malas MB Katkhouda N (2002) Internal hernia as a complication139of laparoscopic nissen fundoplication Surg Laparosc Endosc140Percutan Tech 12(2)115ndash1161416 Zissin R Hertz M Gayer G et al (2005) Congenital internal hernia142as a cause of small bowel obstruction CT findings in 11 adult143patients Br J Radiol 78796ndash8021447 Wiseman S (2000) Internal herniation through a defect in the145falciform ligament a case report and review of the world146literature Hernia 4(2)117ndash120

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Fax to +44 870 622 1325 (UK) or +44 870 762 8807 (UK)To Springer Correction Team

6amp7 5th Street Radhakrishnan Salai Chennai Tamil Nadu India ndash 600004Re Hernia DOI101007s10029-008-0424-7

Internal hernia through an iatrogenic defect in the falciform ligament a case reportAuthors M Lakdawala middot SR Chaube middot Y Kazi middot A Bhasker middot A Kanchwala

Permission to publishI have checked the proofs of my article andq I have no corrections The article is ready to be published without changes

q I have a few corrections I am enclosing the following pagesq I have made many corrections Enclosed is the complete article

Date signature ______________________________________________________________________________




Journal Name Hernia








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55Investigations








A2 A Kanchwala









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64 Treatment









73 surgery






79 cut-off distally






85 Discussion


























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127 References



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64 Treatment









73 surgery






79 cut-off distally






85 Discussion


























111ligament














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127 References



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Internal hernia through an iatrogenic perforation in the falciform ligament a case report.

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