Pre-operative diagnosis and successful surgery of a strangulated internal hernia through a defect in the falciform ligament: a case report

Abstract

IntroductionInternal hernia within the falciform ligament is exceedingly rare. A literature search revealed only 14 cases of internal herniation of the small bowel through a congenital defect of the falciform ligament, most of which were found intra-operatively.Case presentationA 77-year-old Japanese woman presented to our emergency department with sudden hematemesis, occurring at least four to five times over a 12-hour period. No ulcer or gastrointestinal bleeding was detected on gastroendoscopy. A 40mm mass in the inferior lobe of the right lung was found on a chest X-ray, and our patient’s symptoms were therefore initially ascribed to aspirated blood from lung tumor-associated hemoptysis. However, our patient continued to show signs of severe abdominal pain and decreased urine output despite aggressive hydration, leading her examining physicians to search for a possibly severe, occult abdominal pathology. On emergent computed tomography imaging, we found an acute strangulated internal hernia within the falciform ligament. Diagnosis was made by helical computed tomography, permitting rapid surgical intervention.ConclusionsOur findings on computed tomography imaging assisted with the pre-operative diagnosis and enabled us to make a rapid surgical intervention. Early diagnosis may help preclude significant strangulation with unnecessary resection.

Strangulated Falciform Hernia

“…Suspicion of falciform hernia is considered if a closed-loop of the intestine is seen in front or slightly caudal to the liver. A dilated intestinal loop between the liver and the abdominal wall should provoke suspicion of falciform hernia [ 4 ]. In a review of 37 cases of falciform ligament herniation by Egle et al, only five were diagnosed preoperatively, emphasizing the diagnostic difficulty.…”

Congenital internal hernia through defect in the falciform ligament in adult: A case report and review of the literature

“…Furthermore, that ileal loop had thickened wall, decreased contrast enhancement with perivisceral fluid: these signs are suggestive of vascular suffering. On the base of these findings was performed the suspect of an internal hernia in the site of falciform ligament [17] , [18] , [19] , [20] . Nevertheless, because of the preoperative diagnosis is very difficult, laparoscopic approach is mandatory and superior to other diagnostic tools, infact in up to 40% of patients it also can correct an erroneous preoperative diagnosis and exclude other abdominal pathological phenomena; plus the laparoscopic approach allows therapeutic correction of the defect during the same intervention [14] .…”

Ileocolic Atresia due to Internal Herniation through the Falciform Ligament Defect

“…Hypoplasia of the falciform ligament gives rise to the noted defect during this process. [3] Over the ensuing 5 weeks, the intestinal tube, separable into cephalad and caudal limbs, rotates counter clockwise and returns to its familiar position in the abdomen. The superior mesenteric artery (SMA) gives rise to the ileocolic, right colic, and middle colic arteries, which supply the ileocecal region, the ascending colon, and the proximal transverse colon, respectively.…”