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CASE REPORT
Year : 2021  |  Volume : 54  |  Issue : 6  |  Page : 241-243

Intersigmoid hernia: A rare cause of acute intestinal obstruction


Department of General and Digestive Surgery, University Hospital Fattouma Bourguiba of Monastir, University of Monastir, Monastir, Tunisia

Date of Submission03-Jul-2021
Date of Decision02-Aug-2021
Date of Acceptance14-Oct-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Hanen Zenati
Department of General and Digestive Surgery, University Hospital Fattouma Bourguiba of Monastir, University of Monastir, Monastir
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_148_21

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  Abstract 


Intersigmoid hernia (ISH) is a protrusion of the small bowel into the intersigmoid fossa. It is well known to be a rare condition. Recent reports reveal that the preoperative differentiation of ISHs is difficult and the diagnosis is often confirmed during the laparotomic exploration. This article reports a case of an ISH presenting with symptoms of bowel obstruction. Computed tomography scan revealed that dilated small bowel loops are probably related to an incarcerated ileal retrocolic loop in left iliac fossa. This case was confirmed at surgery.

Keywords: Internal hernia, intersigmoid fossa, intersigmoid hernia


How to cite this article:
Zenati H, Moussa A, Trimech W, Ben Hassine H, Korbi I, Noomen F, Zouari K. Intersigmoid hernia: A rare cause of acute intestinal obstruction. Formos J Surg 2021;54:241-3

How to cite this URL:
Zenati H, Moussa A, Trimech W, Ben Hassine H, Korbi I, Noomen F, Zouari K. Intersigmoid hernia: A rare cause of acute intestinal obstruction. Formos J Surg [serial online] 2021 [cited 2022 Jan 16];54:241-3. Available from: https://www.e-fjs.org/text.asp?2021/54/6/241/331635




  Introduction Top


Intersigmoid hernia arising in the congenital fossa located in the attachment of the lateral aspect of the sigmoid mesocolon to the posterior abdominal wall. The intersigmoid hernia (ISH) is part of a rare group of three internal hernias known as sigmoid mesocolon hernias. It represents only 6% among the mesosigmoid hernia. Clinically, they present with small bowel obstruction and are rarely diagnosed preoperatively. However, the absence of previous surgery with no external hernia should raise suspicions of the diagnosis.


  Case Report Top


We report a case of a 60-year-old male diabetic, hypertensive and having a history of hypothyroidism presented with lower abdominal pain on the left side evolving for 3 days with concomitant vomiting and the patient had not passed flatus or feces for 1 day. There was no history of previous laparotomy. The abdomen was slightly distended with tenderness on the left side but soft without peritoneal signs. Laboratory data were unremarkable. Abdominal X-rays showed distension of small bowels with air-fluid levels [Figure 1]. Computed tomography (CT) scan revealed that dilated small bowel loops are probably related to an incarcerated ileal retrocolic loop in left iliac fossa) [Figure 2]. A nasogastric tube was inserted as a conservative treatment but a repeat straight X-ray abdomen has revealed multiple air-fluid levels), so the patient was subjected to exploratory laparotomy. We have found a loop of ileal bowel incarcerated in a 3 cm sized defect lateral to the sigmoid colon at 3 m from ileocecal valve [Figure 3]. The herniated loop was gently extracted out. The fossa was closed by 2-0 vicryl [Figure 4]. The affected ileal segment was inspected meticulously. Apart from the mild constriction ring over the bowel wall, there was no vascular or luminal compromise [Figure 5]. The patient made an uneventful recovery.
Figure 1: Abdominal X-ray of the patient demonstrating small bowel loops with multiple air fluid levels

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Figure 2: (a) Axial view of computed tomography (CT) scan showing dilated small bowel loops with an incarcerated ileal retrocolic loop in left iliac fossa (b) Axial view of CT including inferior mesenteric artery, and inferior mesenteric vein (c) Coronal view of CT with blind loop of small intestine

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Figure 3: (a) Intersigmoid defect 3 cm in diameter after herniated bowel was extracted from it (b) Cartoon sketch about peropérative findings

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Figure 4: Rent being closed

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Figure 5: Strangulated loop of bowel with constriction ring seen after delivery from the intersigmoid fossa

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  Discussion Top


Internal hernias are defined as protrusion of a viscus through a normal or an abnormal peritoneal or mesenteric aperture within the confines of the peritoneal cavity.[1],[2]

Herniation involving the sigmoid mesocolon accounts for about 6% of all internal hernias.[3]

Benson and Killen classified herniation of the sigmoid mesocolon into three types: (1) ISHs, (2) transmesosigmoid hernias, and (3) intramesosigmoid hernias.[3] On the basis of this classification, the present case was classified as an ISH.

ISH is a rare condition of intestinal obstruction due to intestinal incarceration in an abnormal fossa at the attachment of the left leaf of the sigmoid mesocolon to the retroperitoneum.[4],[5]

The diagnosis of internal hernia is very difficult, due to the lack of specific signs and symptoms, the diagnosis is confusing and is usually made late and per-operatively.[2],[6]

It should be considered for patients with signs and symptoms of intestinal obstruction in the absence of any intraabdominal pathology as inflammatory intestinal disease or pervious intervention as external hernia or previous laparotomy.[2],[7]

Subsequent CT scanning facilitated the differential diagnosis of small bowel obstruction secondary to internal hernia and prompt surgical intervention following this prevented further morbidity or mortality.[8],[9]

Conservative management should be abandoned early or avoided if the patient's symptoms are suggestive of internal hernia. These patients must receive CT scanning early to aid diagnosis and timely surgical intervention thus minimizing the time-dependent risk of bowel strangulation, ischemia, and infarction.[8]

The surgical management of internal hernia should be prompt and same in the line of management of obstructed hernia. It includes reduction of herniated structures, resection of ischemic intestinal segments (if any), and closure of the hernial orifice.[2],[4]


  Conclusion Top


When faced with a clinical condition of acute intestinal obstruction in which there is a possibility of internal hernia, the surgeon must proceed to laparotomy as early as possible, with no priority for specific diagnosis of the cause of obstruction. This policy aims at reducing the risk of intestinal ischemia, necrosis, perforation and decreasing postoperative morbidity and mortality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chiarini S, Ruscelli P, Cirocchi R, D'Andrea V, Sensi B, Santoro A, et al. Intersigmoid hernia: A forgotten diagnosis – A systematic review of the literature over anatomical, diagnostic, surgical, and medicolegal aspects. Derlet R, éditeur. Emerg Med Int 2020;2020:4:1-4. doi: 10.1155/2020/4891796.  Back to cited text no. 1
    
2.
Kambe H, Kitamura K, Kaihara S. A case report of intersigmoid hernia treated using laparoscopic surgery. Int J Surg Case Rep 2021;81:105822.  Back to cited text no. 2
    
3.
Benson JR, Killen DA. An internal hernia involving the sigmoid mesocolon. Ann Surg 1964;159:382-4.  Back to cited text no. 3
    
4.
Tatsuta K, Miyazaki S, Nishiwaki Y. Emergency laparoscopic approach without sufficient preoperative decompression for intersigmoid hernia: A case report. Int J Surg Case Rep 2019;64:54-7.  Back to cited text no. 4
    
5.
Harikumar KV, Chirukandath R, Krishnan SK, Shyamlal B. Intraoperative surprise in a case of small bowel Obstruction: Sigmoid mesocolic hernia-intersigmoid hernia: Case report. Ann Clin Case Rep 2021;6:1907.  Back to cited text no. 5
    
6.
Lanzetta MM, Masserelli A, Addeo G, Cozzi D, Maggialetti N, Danti G, et al. Internal hernias: A difficult diagnostic challenge. Review of CT signs and clinical findings. Acta Biomed 2019;90:20-37.  Back to cited text no. 6
    
7.
Nakaseko Y, Haruki K, Neki K, Hashizume R, Eto K, Yanaga K. Laparoscopy-assisted repair for intersigmoid hernia. Case Rep Gastroenterol 2020;14:675-82.  Back to cited text no. 7
    
8.
Kayano H, Nomura E, Kuramoto T, Yatabe K, Yoshii H, Yokoyama D, et al. Two cases of laparoscopic diagnosis and treatment of intersigmoid hernia. Tokai J Exp Clin Med 2017;42:109-14.  Back to cited text no. 8
    
9.
Kumagai K, Yoshioka M, Iida M, Kudoh K, Uchinami H, Watanabe T, et al. Usefulness of oblique multiplanar images on multi-detector computed tomography for diagnosing intersigmoid hernia. Visc Med 2016;32:437-40.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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