Defeating Searing Pain

Helping an elderly gentleman deal with
Internal Hernia

Internal Hernias (IH) are a rare cause of acute abdomen and intestinal obstruction in adults. Among different types of Internal Hernias, Paracecal Hernia is a rare type. It is present as a lump in right iliac fossa with features of small bowel obstruction. Due to its rarity, non specific clinical findings and small window period to take action, a differential diagnosis of Internal Hernia must be kept in mind while approaching a patient with small bowel obstruction features. An urgent CT scan is advised before operating as it is a valuable aid to diagnose and operate subsequently. There might not be any previous history of herniation, strangulation or any specific risk factor / indication preceding herniation.

THE CASE

A 68-year old man came to the emergency unit of Nanavati Super Speciality Hospital, walking with difficulty while experiencing severe pain in the right iliac fossa since morning. The pain was mild at first but increased in severity since that morning with a score of 10/10 at admission. The pain was associated with nausea and vomiting. He had 3 episodes of vomiting during that day which was non projectile in nature and mostly food particles as the content. He had no history of fever or cough or trauma and didn’t display any co-morbidities such as: Diabetes Mellitus / Hypertension / Cardiac problems / chest condition.

There was no recent history of any drug use / abuse. On examination,the patient was febrile with blood pressure of 150/90 mm Hg, pulse rate of 112/min and a saturation of 98%. Patient was conscious and oriented. Systemic examination of cardiovascular system, respiratory system and central nervous system did not reveal any impairment. On abdominal examination, a tender, palpable mass in the right iliac fossa was noted. Guarding rigidity was present but abdominal scar or indication of previous trauma was absent. A computerized tomography (CT) scan of abdomen and pelvis was immediately taken.

THE PROCEDURE

In view of the clinical and imaging findings, the patient was shifted to the operation theatre immediately. Starting with a midline incision, ascending colon and cecum was pushed up. Small bowel and omentum were found to be adherent in RIF. The omentum was separated and the band of defect strangulating the bowel segment was released. Adhesiolysis was performed, detortion of bowel was done and approximately 2.5 feet of gangrenous segment was resected followed by end to end anastomosis in 2 layers. Thorough exploration of the contaminated cavity and peritoneal cavity was performed.

THE RESULT

The patient was not allowed to take anything orally for 2 days and was on IV fluids and medications. He was then started on liquids, gradually progressing to normal diet with removal of drain. His recovery was uneventful and was discharged on fifth post operative day with no complication

Dr. Manmohan Kamat
Sr. Consultant
General Surgery, Minimal
Access and Laparoscopic
Surgery
Nanavati Super Speciality
Hospital, Mumbai