Figure 1
Patient - prepared for surgery
Aspect of the hernia before surgery.
Herniation of the liver through sternotomy incision
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsItsaso Barral1, Jose Angel Torena1, Arantza Olaizola2
Connected authors
90 years, female
Clinical History
Female patient, 90 years old. The patient presented at the Emergency Department with epigastric pain, nausea and vomiting. History of hernia after sternotomy.
Imaging Findings
CT with intravenous contrast was performed in venous and late phases, in which an epigastric hernia containing part of the left hepatic lobe was observed.
The herniated liver parenchyma showed hypodense appearance in venous phase (Fig.1 and 2) and isodensity in late phase, due to vascular compromise. Hernia contained minimal free fluid (Fig. 3).
The patient underwent emergency surgery, the hernia was reduced and repaired with a mesh. The evolution was satisfactory, and the patient was discharged four days later.
The herniated liver parenchyma showed hypodense appearance in venous phase (Fig.1 and 2) and isodensity in late phase, due to vascular compromise. Hernia contained minimal free fluid (Fig. 3).
The patient underwent emergency surgery, the hernia was reduced and repaired with a mesh. The evolution was satisfactory, and the patient was discharged four days later.
Discussion
Herniation of the liver is uncommon. Hepatic herniation through the abdominal wall is a very rare phenomenon. Liver herniation through subxiphoid incision is a rare complication after median sternotomy. Most cases have been secondary to trauma (associated with diaphragmatic rupture) and congenital diaphragmatic hernias have also been described [1].
Herniation of the liver through the sternotomy incision usually occurs 2 to 3 years after surgery. The most frequent risk factors are obesity, postoperative infection and female gender [3].
The clinical presentation of liver herniation through an anterior abdominal wall hernia tends to be non-acute, probably because the hernial orifice is usually large and this makes strangulation of herniated contents difficult [1].
The most common symptoms are abdominal pain, nausea and vomiting and an epigastric hernia on physical examination [1].
The CT is the indicated imaging technique to diagnose and assess the extent and characteristics of the hernia. CT with intravenous contrast also helps us to know the situation and viability of the hepatic parenchyma [3].
The treatment of these hernias will depend on clinical condition of the patient. In asymptomatic patients conservative treatment can be performed, and in cases where symptoms are present surgical treatment is the method of choice. Surgery is performed to correct the defect wall (open surgery or laparoscopy) [2].
Herniation of the liver through the sternotomy incision usually occurs 2 to 3 years after surgery. The most frequent risk factors are obesity, postoperative infection and female gender [3].
The clinical presentation of liver herniation through an anterior abdominal wall hernia tends to be non-acute, probably because the hernial orifice is usually large and this makes strangulation of herniated contents difficult [1].
The most common symptoms are abdominal pain, nausea and vomiting and an epigastric hernia on physical examination [1].
The CT is the indicated imaging technique to diagnose and assess the extent and characteristics of the hernia. CT with intravenous contrast also helps us to know the situation and viability of the hepatic parenchyma [3].
The treatment of these hernias will depend on clinical condition of the patient. In asymptomatic patients conservative treatment can be performed, and in cases where symptoms are present surgical treatment is the method of choice. Surgery is performed to correct the defect wall (open surgery or laparoscopy) [2].
Differential Diagnosis List
Herniation of the liver through sternotomy incision
Abdominal wall neoplasia
Abdominal wall haematoma
Final Diagnosis
Herniation of the liver through sternotomy incision
References
[1] Carlos M Nuño-Guzmán, José Arróniz-Jáuregui, Ismael Espejo, Jesús Valle-González, Hernán Butus, Alejandro Molina-Romo, Rodrigo I Orranti-Ortega (2012) Lefthepatic lobe herniation through an incisional anterior abdominal wall hernia and right adrenal myelolipoma: a case report and review of the literature. Journal of medical case reports 10;6(1):4 (PMID: 22234036)
[2] Warbrick-Smith J, Chana P, Hewes J. (2012) Herniation of the liver via an incisional abdominal wall defect. BMJ Case Reports 2012-007355. (PMID: 23188862)
[3] Rodríguez-Hermosa JI, Ruiz-Feliú B, Roig-García J, Gironès-Vilà J, Planellas-Giné P, Ortuño-Muro P, Codina-Cazador A. (2008) Hepatic evisceration after cholecystectomy in a superobese patient. Obes Surg (PMID: 18506554)
Case information
| URL: | https://www.eurorad.org/case/11591 |
| DOI: | 10.1594/EURORAD/CASE.11591 |
| ISSN: | 1563-4086 |
Figure 2
Patient- during surgery
Herniated liver during surgery.
Figure 3
Patient- during surgery, side-view
Herniated liver during surgery.
Figure 4
CT venous phase axial
Liver herniation through epigastric hernia.
Herniated parenchyma showed hypodense appearence.
Figure 5
CT venous phase sagittal
Liver herniation through epigastric hernia.
Figure 6
CT late phase axial
Herniated liver parenchyma showed isodense appearence.
Minimal free fluid in the hernia.
Patient - prepared for surgery
Aspect of the hernia before surgery.
Olaizola A, Department of Surgery, Hospital Bidasoa, Hondarribia.
Olaizola A, Department of Surgery, Hospital Bidasoa, Hondarribia.
Patient- during surgery
Herniated liver during surgery.
Olaizola A, Department of Surgery, Hospital Bidasoa, Hondarribia.
Olaizola A, Department of Surgery, Hospital Bidasoa, Hondarribia.
Patient- during surgery, side-view
Herniated liver during surgery.
Olaizola A, Department of Surgery, Hospital Bidasoa, Hondarribia.
Olaizola A, Department of Surgery, Hospital Bidasoa, Hondarribia.
CT venous phase axial
Liver herniation through epigastric hernia.
Herniated parenchyma showed hypodense appearence.
Torena,J.A. Departmente of Radiology, Hospital Bidasoa, Hondarribia
Torena,J.A. Departmente of Radiology, Hospital Bidasoa, Hondarribia
CT venous phase sagittal
Liver herniation through epigastric hernia.
Torena,J.A. Department of Radiology, Hospital Bidasoa, Hondarribia
Torena,J.A. Department of Radiology, Hospital Bidasoa, Hondarribia
CT late phase axial
Herniated liver parenchyma showed isodense appearence.
Minimal free fluid in the hernia.
Torena, J.A. Department of Radiology, Hospital Bidasoa, Hondarribia.
Torena, J.A. Department of Radiology, Hospital Bidasoa, Hondarribia.