Pericecal fossa strangulated internal hernia.

Pericecal fossa internal hernias are a rare cause of intestinal obstruction, and high clinical suspicion is required to diagnose them.

CASE DESCRIPTION

Pericecal fossa internal hernias are extremely rare types of hernias, which can be difficult to diagnose preoperatively even on cross‐sectional imaging. We report a case of intraoperative diagnosis of a pericecal fossa strangulated small bowel internal herniation, aiming to highlight the relevant red‐flag symptoms and raise awareness among surgeons.

A 72‐year‐old Caucasian male patient presented to our surgical admissions unit with features of gastrointestinal obstruction, comprising of abdominal distension, vomiting, and sharp pain localized in the right iliac fossa. His past medical history was unremarkable, and he had no previous abdominopelvic surgery. Clinical examination revealed a moderately distended but soft abdomen, with tenderness in deep palpation in the right iliac fossa; no obvious external hernia was identified. His admission blood tests revealed normal C‐reactive protein (CRP) and serum lactate values and an elevated total white cell count with neutrophilic shift. Provisional diagnosis was that of intestinal obstruction, and hence, an urgent abdominopelvic computed tomography (CT) scan with intravenous contrast was performed for further assessment. The performed CT scan revealed the presence of small bowel obstruction with transition point in the distal ileum, localized in the right iliac fossa, with no obvious evidence of intestinal ischemia or perforation (Figures 1 and 2).

FIGURE 1

Axial view of the preoperative CT scan showing the site of the pericecal fossa internal hernia, along with the transition point of the obstruction, where the small bowel caliber changes abruptly (red arrow)

FIGURE 2

Coronal view of the preoperative CT scan, demonstrating features of small bowel obstruction (yellow arrows), as well as the retrocecal location of the internal hernia (red arrow)

The patient received a trial of conservative treatment with nasogastric tube decompression and complete restriction of any oral intake, as per his own wish to possibly avoid surgery. However, as the gastrointestinal obstruction symptoms were persistent, a decision was made to proceed with exploratory laparotomy within 24h hours from the time of admission. Due to the presence of distal small bowel obstruction on the CT scan, with multiple dilated small bowel loops proximally, we opted for upfront laparotomy rather than initial laparoscopic assessment, in order to avoid an iatrogenic small bowel injury due to excessive handling and traction with the laparoscopic graspers. Intraoperatively, an internal herniation of the distal ileum through a peritoneal defect in the paracecal fossa was identified, with the entrapped ileal segment demonstrating features of established hemorrhagic necrosis. The affected segment was released and resected, with performance subsequently of a side‐to‐side stapled anastomosis. The defect, through which the internal hernia occurred, was primarily closed with monofilament non‐absorbable 3‐0 ethilon sutures to reduce the possibility of future recurrence. Intraoperative photographs were not taken as the patient had not signed pre‐operatively the relevant consent form. Perioperatively, no change to the patient's regular medication was required, apart from the administration of 24 hours intravenous antibiotics (IV co‐amoxiclav 1.2 g TDS, as per relevant institutional policy). The patient had an uneventful recovery and was discharged in a stable condition. The histology of the resected ileal segment revealed the presence of ischemic changes with no other sinister pathology.

Our case highlights the need for high clinical suspicion of a pericecal hernia as cause of small bowel obstruction, when the transition point appears lateral to the cecal pole. Due to its rarity, this type of internal hernia can be problematic to diagnose with preoperative computed tomography. Therefore, we advise early surgical intervention in similar cases, with both diagnostic and therapeutic intent, in order to avoid necrosis of the herniated viscera.

ETHICS STATEMENT

Informed consent was obtained from the patient and is available upon request by the editorial office; no ethical committee approval was required for the publication of this case report.

CONFLICT OF INTEREST

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

AUTHOR CONTRIBUTIONS

CS, CK, and AA contributed to the clinical data collection and prepared the case report; AP, BP, and KM contributed to the design of the case report presentation and performed the final revision of the manuscript.