Clinical History
Our patient was admitted with abdominal pain and vomiting. There was a swelling felt in the epigastric region over the region of the previous laparotomy scar. Clinical diagnosis of intestinal obstruction was made. On imaging it turned out to be an incarcerated incisional hernia.
Imaging Findings
The lady had a previous laparotomy and anterior resection for a sigmoid cancer 12 years ago. She was admitted with acute onset epigastric and para-umbilical pain with swelling in the epigastric region over the region of previous laparotomy scar. She also had bouts of vomiting associated with constipation.
On examination, there was a tender swelling felt over the epigastric region. The overlying skin however was normal. Initial investigations in the form of plain abdominal radiographs fail to reveal any obvious abnormality.
She subsequently underwent a CT scan of the abdomen which showed small bowel obstruction secondary to an incarcerated inscional hernia in the epigastric region. She underwent a laparotomy and hernia repair.
Discussion
An incisional hernia, also called as ventral hernia, is a bulge or protrusion that occurs near or directly along a prior abdominal surgical incision. The incidence of incisional hernias is between 0.5-13.9% [1]. An incarcerated hernia is a hernia which is no longer reducible. The vascular supply of the bowel is however not compromised. Bowel obstruction is common.
Most incisional hernias are easily recognized by careful inspection and palpation. However, there are several situations whereby an accurate clinical diagnosis may be difficult or impossible. In obese patients, for example, the abundant subcutaneous fat can prevent the palpation of a deeply seated peritoneal defect and the protruding intestinal loop or greater omentum. The detection of an incisional hernia by physical examination alone may also be difficult in patients with abdominal pain and distension or in the presence of keloid or thick panniculus. Furthermore, the herniated segments occasionally dissect and hide between muscular, aponeurotic, and fascial layers of the abdominal wall. These hernias often present with localized swelling and tenderness adjacent to the surgical scar, but their actual content and internal orifice are seldom palpable [2]. Under these circumstances, evaluation of the abdominal wall by sonography or CT can provide the correct diagnosis [3].
Tailored helical CT evaluation for suspected high-grade small bowel obstruction is best performed without oral contrast material. Patients with high-grade small bowel obstruction already have large amounts of fluid in the bowel that acts as a natural contrast agent. The essential helical CT finding in small bowel obstruction is a definable transition from dilated to decompressed small bowel. Careful inspection of the transition point and luminal contents of the bowel will often reveal the underlying cause of obstruction. Hernias are usually seen in the inguinal region or abdominal wall. Abdominal wall hernias account for the great majority of external hernias. A congenital or acquired weakness or defect in the muscular layers of the abdominal wall produces the potential hernia site [4].
Differential Diagnosis List
Incarcerated Incisional Hernia
Final Diagnosis
Incarcerated Incisional Hernia
