Incarcerated ovarian hernia in the umbilicus

Abstract

This case regards a morbidly obese lady presenting with a massive ovarian tumour herniating through the umbilicus. Six months previously she had suffered from a life-threatening pulmonary embolus requiring supportive ventilation at the same hospital. Herniation of the ovary directly into the umbilicus is very rare and here we provide pictoral evidence and advice regarding the management of this patient.A 55-year-old post-menopausal Maori lady was admitted under the surgeons with a 7-day history of tenderness and redness in her umbilicus, with worsening abdominal pain, lethargy and urine retention. Six months previously, she had been on the intensive care unit at the same hospital with nearfatal massive pulmonary and right ventricular emboli, which were treated with streptokinase infusion and significant respiratory support. Abdominal examination at the time was reported as "nothing abnormal".She was referred to the gynaecologists following abdominal ultrasound and CT scanning. Abdominal examination revealed a morbidly obese woman of 158 Kg (Basal Metabolic Index (BMI) of 45) (Fig. 1), with massive abdominal distension secondary to a solid mass thought to be arising from an ovary. There appeared to be an incarcerated herniation of the mass through the umbilicus, causing a localised tender spot at the base of the umbilicus. The patient was unable to stand unaided, and complained that her abdominal girth had been increasing for 2 years, despite advice by previous medical staff to lose weight to reduce her size.Tumour markers were elevated, with a CA125 of 224 kU/l, haemoglobin of 7.03 mmol/l but otherwise normal renal and liver function tests. Chest X-ray did not reveal any extraperitoneal masses, and abdominal CT scan showed a 41 cm × 33 cm mass, consisting of mainly fat but also some calcified areas and septae.Following anaesthetic review and an informed discussion regarding the significant risks associated with surgery, the patient was booked for midline laparotomy. The midline incision site was marked preoperatively (Fig. 1).At operation, in a left lateral tilt, entry into the abdomen was difficult due to a loss of the natural tissue plains secondary to inflammation and adhesions between the mass and the anterior abdominal wall. A lobule of tumour was found to be herniating through the umbilicus, causing a true umbilical hernia (Fig. 2). Following extensive dissection, a right oophorectomy was performed. The entire umbilicus was removed and the rectus sheath resutured. The uterus and remaining ovary were left in situ to minimise on table operative time and the risks of haemorrhage. Thromboprophylaxis was continued with high-dose subcutaneous low molecular weight heparin until the day of discharge, 7 days post-operatively.

Acute abdomen secondary to ovarian tumour incarcerated in an umbilical hernia: A case report

“…Two other cases of dermoid cyst presenting as incarcerated umbilical hernia were reported by Wolfson et al [ 5 ] in 1991 and Edmonds et al [ 6 ] in 2007. In the case reported by Wolfson et al ., [ 5 ] the patient was a 30-year-old lady and she had bilateral ovarian tumours that were confirmed to be dermoid cysts by histology.…”

“…However, our index case had bilateral ovarian cystectomy. The case reported by Edmonds et al [ 6 ] was an obese 55-year-old woman who had a part of 41 cm × 33 cm dermoid cyst that was incarcerated in an umbilical hernia. She had right oophorectomy performed.…”