LETTERS TO THE EDITOR

 

Littré´s hernia: unusual find in inguino-scrotal hernial repair

Hernia de Littré: hallazgo inusitado en la reparación de una hernia inguino-escrotal

 

 

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Key words: Littré's hernia. Inguinoscrotal hernia. Abdominal wall.

Palabras clave: Hernia de Litré. Hernia inguino-escrotal. Pared abdominal.

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Dear Editor,

Littré's hernia is caused by the protrusion of Meckel's diverticulum through an orifice in the abdominal wall. Alexis de Littré (1700) described ileal diverticula and attributed them to the traction realized on the ileum, conflicting with the description that August Gottlieb Richter gave in the year 1785. Both descriptions ignored the embryological origin mentioned later by Johann Friedrich Meckel in 1809. Note that Sir Frederic Treves (1897) distinguished between Littré's hernia and Richter's hernia (a lateral pinch in the small intestine, but without Meckel's diverticulum).

Meckel's diverticulum is a remnant of the proximal portion of the omphalomesenteric duct, which links the embryonic intestine with the umbilical bladder until the fifth week of gestation. It arises from the antimesenteric surface of the ileum, near the ileocecal valve, generally at a distance of about 30 to 90 cm. It usually measures from 4 to 6 cm in length and 2 cm in diameter.

The incidence of Meckel's diverticulum is 2% and normally it is not symptomatic. Only 4-6% of cases will produce symptoms (more frequent during infancy), the principal manifestation being rectal bleeding, sometimes massive, due to the presence of gastric mucosa. Obstruction, intussusception and, more rarely, diverticulum to bladder fistulae and tumours may occur.

The incidence of Littré's hernia is unknown and not many cases are found in the literature.

We present a case of elective surgery in which we found a Meckel's diverticulum in a large groin hernia.

 

Clinical case

A 75-year-old male patient, with a history of intervention for gastric ulcer and cardiopathy, and carrying a pacemaker, was admitted for an elective hernioplasty for a large groin hernia that had been present for more than 10 years.

The patient had never referred to the clinic or shown symptomatology that would have indicated the presence of Meckel's diverticulum. He had the appropriate preoperative test and all the complementary exams were normal.

During the surgical intervention we discovered an inguino-scrotal plus direct hernia with a large hernia sac containing some of the small intestine (approximately 50 cm). During the exam we located a Meckel's diverticulum measuring 7 cm in length and 2 cm in diameter (Fig. 1).

 

We carried out a wide V-wedge resection before hernioplasty by standard techniques.

The patient recovered well postoperatively and was discharged 24 hours after the intervention without incident.

 

Discussion

Littré's hernia is caused by the protrusion of Meckel's diverticulum through a herniary orifice. Its incidence is unknown. The most usual locations of Littré's hernia are: inguinal (50%), umbilical (20%) and femoral (20%). Incarceration, strangulation, necrosis and perforation are rare. In children, the majority of cases are located in umbilical hernias.

Because of its low incidence, Littré's hernia is generally unsuspected. Factors that may assist in diagnosis include: gastrointestinal bleeding, the most frequent haemorrhage in children, and occlusive symptoms in adults. Although these symptoms are indistinguishable from Richter's hernia because the digestive transit remains, vomiting and pain are common manifestations, but present at a slower rate.

The imaging method of choice for the diagnosis of Meckel's diverticulum is the computerized tomography (CT). This would typically find increased soft tissue density, occlusion or intussusception or a cystic mass. There are no cases in the literature of preoperative diagnosis by imaging of an incarcerated Littré's hernia in adults.

Surgery is the treatment of choice for Meckel's diverticulum in urgent or elective hernia repair.

The repair of a Littré's hernia consists initially of resecting the diverticulum, which has to be realized in a wide-V wedge in cases of incidental discovery and in segmental resection if it is urgent, because bleeding (principal urgency) due to the hypertrophy of the gastric mucosa in the diverticulum can be situated in the mesenteric edge of the ileum. With special emphasis on avoiding contamination of the surgical field, we carry out hernioplasty or herniorrhaphy according to surgeon's criteria. To date, numerous cases of diagnosis and treatment of Littré's hernia by laparoscopy have been described. Using a transabdominal approach (TAPP) it is possible to carry out the dissection and resection of Meckel's diverticulum and to continue with the repair. We conclude that this is a safe and efficient technique for the treatment of this pathology.

 

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Authors admit financial support from Fundación Dr. Ramon Vilallonga for the work realisation (www.fundacioramonvilallonga.org)

 

A. Biel¹, R. Vilallonga^1,2, I. López de Cenarruzabeitia¹, N. Rodríguez¹ and M. Armengol^1
1General Surgery Department and ²Endrocrine and Metabolic Surgery.
Vall d'Hebron Hospital. Autonomous University of Barcelona. Spain

 

Recommended references

1. Akin M, Kurukahvecioglu O, Tezcaner T, Anadol AZ, Onur K. Acute hemiscrotum due to inguinoscrotal Littre hernia: a case report. Am J Emerg Med 2008; 26(8): 973.e3-4.        [ Links ]

2. Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P. Littre hernia: surgical anatomy, embryology, and technique of repair. Am Surg 2006; 72(3): 238-43.        [ Links ]

3. Sinha R. Bowel obstruction due to Littre hernia: CT diagnosis. Abdom Imaging 2005; 30(6): 682-4.         [ Links ]

4. Mirza MS. Incarcerated Littre's femoral hernia: case report and review of the literature. J Ayub Med Coll Abbottabad 2007; 19(2): 60-1.        [ Links ]

5. Smart N, Immanuel A, Mercer-Jones M. Laparoscopic repair of a Littre's hernia with porcine dermal collagen implant (Permacol). Hernia 2007; 11(4): 373-6.        [ Links ]