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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 5  |  Issue : 1  |  Page : 46-48

Small bowel obstruction due to internal herniation of jejunum through a congenital defect in the falciform ligament in a primigravida


1 Department of Surgery, St. Martha's Hospital, Nrupatunga Road, Bengaluru, Karnataka, India
2 Department of Surgery; Division of Research, St. Martha's Hospital, Nrupatunga Road, Bengaluru, Karnataka, India

Date of Web Publication13-Mar-2015

Correspondence Address:
S B Ramakrishnaiah
St. Martha's Hospital, Surgery, No. 5, Nrupatunga Road, Bangalore - 560 001, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.153161

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  Abstract 

Small bowel obstruction due to internal herniation of jejunum through a congenital defect in the falciform ligament is a rare occurrence. Literature search shows not more than 14 cases of internal herniation of the small bowel through a congenital defect of the falciform ligament; and there are no reports of challenges faced in the diagnosis of herniation in pregnant patients. Here, we describe a rare case of internal hernia which posed significant diagnostic dilemma as the patient was 20 weeks primigravida. With restriction on the use of imaging tools, diagnosis of small bowel obstruction due to internal herniation through the falciform ligament was done by combining clinical findings with magnetic resonance imaging (MRI) and laparoscopy. The intestinal obstruction was resolved laparoscopically. The recovery was uneventful and the patient was discharged on postoperative day 4. The diagnosis of internal hernia as a cause of intestinal obstruction is usually difficult especially in the pregnant patient. However, careful examination and appropriate investigations will suggest the diagnosis which if promptly treated would be attended by a satisfactory outcome.

Keywords: Congenital defect, falciform ligament, internal hernia, laparoscopic management, pregnancy


How to cite this article:
Ramakrishnaiah S B, Giridhar-Boggaram S, Paul-Satyaseela M. Small bowel obstruction due to internal herniation of jejunum through a congenital defect in the falciform ligament in a primigravida . Arch Int Surg 2015;5:46-8

How to cite this URL:
Ramakrishnaiah S B, Giridhar-Boggaram S, Paul-Satyaseela M. Small bowel obstruction due to internal herniation of jejunum through a congenital defect in the falciform ligament in a primigravida . Arch Int Surg [serial online] 2015 [cited 2021 May 12];5:46-8. Available from: https://www.archintsurg.org/text.asp?2015/5/1/46/153161


  Introduction Top


An internal hernia is defined as an abnormal protrusion of viscous through an opening within the boundaries of the peritoneal cavity with subsequent strangulation. Although internal hernias have an overall incidence of less than 1%, they constitute up to 5.8% of all small bowel obstructions, which, if left untreated, have been reported to have an overall mortality exceeding 50%, especially if there is strangulation. [1] Based on the anatomic location, internal hernias are divided into various types such as paraduodenal (50-55%), pericecal (10-15%), foramen of Winslow (6-10%), transmesenteric and transmesocolic (8-10%), paravesical (<4%), and intersigmoid (4%). Internal herniation can also occur through the falciform ligament, though this remains a rare entity. Failure to consider this etiology may result in delayed operative intervention and increased morbidity and mortality. [2]

Here, we describe a rare case of internal hernia which posed significant diagnostic dilemma as the patient was 20 weeks primigravida. Employing of X-ray, computed tomography (CT), or contrast-X-ray were not the options due to this condition. [3] It is in the diagnosis and resolution of the clinical condition by laparoscopy that the case is unique and is reported as rare.


  Case Report Top


A 31-year-old primigravida visited our hospital with 20 weeks amenorrhea having complaints of upper and peri-umbilical abdominal, nonradiating pain since 3 days; colicky which increases after taking food; seven to eight episodes of nonprojectile vomiting; abdominal distension for 1 day; and not having passed stools for 2 days. All other parameters were normal, without other comorbidities recorded, and the patient was asymptomatic until this episode. The routine blood and urine tests were normal and the ultrasonography showed small bowel dilatation with reduced peristalsis. She had no history of any previous surgery.

Clinically, the abdomen was distended and tender it was a case, it was a case of subacute intestinal obstruction. Magnetic resonance imaging (MRI) showed the possibility of small bowel obstruction in the epigastric region [Figure 1]. Initially we adopted conservative management, and when the patient showed no improvement, she was prepared for diagnostic laparoscopy. The laparoscopic procedure was conducted under combined spinal epidural anesthesia. A 5 mm port at Palmar's point was used as the primary port of entry. Two secondary ports were inserted under vision - 5 mm umbilical, and 10 mm left lumbar ports. During laparoscopy we observed the small bowel (jejunal) obstruction. The cause of this obstruction was a congenital defect in the falciform ligament causing intestinal obstruction [Figure 2](4)]. On proximal side the small bowel was distended and edematous; there were no necrotic patches seen, and free fluid in the abdomen was minimal. On the distal side of the defect through which the jejunum had herniated, there was the collapsed loop. These observations confirmed the cause and site of obstruction. There was no evidence of previous operation; hence this defect could potentially be attributed to congenital etiology.
Figure 1: MRI and Laparoscopic images showing the region of herniation (1) Site of herniation; (2). Dilated intestinal loop; (3). Collapsed intestinal loop

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Figure 2: (4). Falciform ligament

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In addition, we observed Meckel's diverticulum, and the gravid uterus, that was approximately 20 weeks extending to the umbilicus. The (jejunal) herniation was reduced and the bowel was inspected to confirm the resolution of the obstruction [[Figure 3] (5)]. The distal collapsed loops filled up after the bowel was reduced, with normal peristalsis. Falciform ligament was further divided, thereby obliterating the congenital defect and preventing any future herniation [[Figure 4] (6)]. After the surgery, normal fetal heart sounds were recorded, the port sites were closed and the patient was shifted in stable condition. She was discharged on the 4 th postoperative day. The patient later delivered a normal healthy female baby through cesarean section, and both the baby and mother were doing well.
Figure 3: (5). Division of Falciform ligament

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Figure 4: (6). Image representing the released loops of bowel - after division of Falciform ligament

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  Discussion Top


Hernia through the falciform ligament is very rare and accounts for 0.2% of internal hernias and most of them are asymptomatic. A congenital etiology for these defects is rare, attributable to malformation and incomplete development of the falciform ligament. [4],[5] Only few case reports of internal hernia through congenital defects of the falciform ligament have been reported. Though there are few reports of hernia, [6],[7],[8] most are due to iatrogenic defects created post-laparoscopic surgery, except a few that were through an anomalous orifice in the falciform ligament of the liver. In the case described in this report, we discovered the herniation of the jejunum through the falciform ligament, and the diagnostic challenge faced due to the coexistence of pregnancy. Internal hernias are more often reported in early childhood or late pregnancy. [9] There is one report of internal hernia during pregnancy due to anomalous opening in the falciform ligament where the patient with 37 weeks pregnancy underwent cesarean section followed by laparotomy. [10] Armstrong emphasized that the use of CT scan is very important to confirm bowel strangulation and determine the precise location. [11] But in the case reported here, CT or contrast X-ray could not be used as per the guidelines put forth by the American College of Obstetrics and Gynecologists, [3] since the patient was primigravida 20 weeks. Hence by combining clinical signs with MRI, [3] the hernia was diagnosed and released using laparoscopic technique. To our knowledge, this is the first case reported of a primigravida patient presenting with intestinal obstruction due to herniation of the jejunum through a congenital defect in the falciform ligament that has been successfully managed by laparoscopy.


  Conclusion Top


The diagnosis of internal hernia as a cause of intestinal obstruction is usually difficult especially in pregnant patient. However, careful examination and appropriate investigations will suggest the diagnosis, which if promptly treated would be attended by a satisfactory outcome. The same condition can also be managed by minimally invasive surgery.


  Acknowledgements Top


Dr. Poornima Murthy, Department of Obstetrics and Gynecology for timely referring of the patient to Department of Surgery.

 
  References Top

1.
Martin LC, Merkle EM, Thompson WM. Review of internal hernias: Radiographic and clinical findings. AJR Am J Roentgenol 2006;186:703-17.  Back to cited text no. 1
    
2.
Egle J, Gupta A, Mittal V, Orfanou P, Silapaswan S. Internal hernias through the falciform ligament: A case series and comprehensive literature review of an increasingly common pathology. Hernia 2013;17:95-100.  Back to cited text no. 2
    
3.
American College of Obstetrics and Gynecologists. Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol 2004;104:647-51.  Back to cited text no. 3
    
4.
Zissin R, Hertz M, Gayer G, Paran H, Osadchy A. Congenital internal hernia as a cause of small bowel obstruction: CT findings in 11 adult patients. Br J Radiol 2005;78:796-802.  Back to cited text no. 4
    
5.
Corberi O, Crespi G, Deho` E, Pugliese R, Sarcina A, Stefanoni G, et al. Internal abdominal hernia caused by anomaly of the falciform ligament (a case report). Chir Ital 1979;31:1354-9.  Back to cited text no. 5
    
6.
Kohli A, Choudhury HS, Rajput D. Internal hernia: A case report. Indian J Radiol Imaging 2006;16:563-6.  Back to cited text no. 6
  Medknow Journal  
7.
Gullino D, Giordano O, Gullino E. Internal hernia of the abdomen. Apropos of 14 cases. J Chir (Paris) 1993;130:179-95.  Back to cited text no. 7
    
8.
Lakdawala M, Chaube SR, Kazi Y, Bhasker A, Kanchwala A. Internal hernia through an iatrogenic defect in the falciform ligament: A case report. Hernia 2009;13:217-9.  Back to cited text no. 8
    
9.
Shiozaki H, Sakurai S, Sudo K, Shimada G, Inoue H, Ohigashi S, et al. Pre-operative diagnosis and successful surgery of a strangulated internal hernia through a defect in the falciform ligament: A case report. J Med Case Rep 2012;6:206.  Back to cited text no. 9
    
10.
Imamura A, Hasegawa K, Nakamoto H, Matsui K, Kamiya T, Takai S, et al. Internal hernia during pregnancy due to anomalous opening in the falciform ligament. J Jap Pract Surg Soc 1997;58:1659-63.  Back to cited text no. 10
    
11.
Armstrong O. Internal hernia through the falciform ligament. Hernia 2013;17:815-6.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
Acknowledgements
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