Laparoscopic treatment of obstructed internal supravesical hernia: A cases series and rewiev of the literature

Abstract

Introductioninternal supravesical hernia (ISH) is an exceptional subtype of internal hernia often presenting with small bowel obstruction (SBO). Its rarity makes preoperative suspicion and diagnosis very difficult in an emergency setting.Methodswe retrospectively analyzed the database of patients admitted in a single center emergency unit for small bowel occlusion (SBO) in virgin abdomen and treated by surgery from August 2013 to October 2018. The patients with intraoperative diagnosis of ISH were included in this study.Resultsfrom 29 patients with virgin abdomen submitted to surgery for SBO, two cases of ISH were recorded. In both cases preoperative diagnosis was made by CT scan and urgent treatment was successfully performed by laparoscopy, reducing the entrapped small bowel and closing the hernia's ring by continuous suture. No intestinal resection was needed.Discussionurgent laparotomic repair of obstructive ISH is the standard treatment although laparoscopic approach has also been described in a small number of cases. We reported our experience on two cases in which totally laparoscopic treatment was successfully performed in patients with stable hemodynamic parameters thanks to early diagnosis and limited intestinal distension. By an extensive analysis of the international literature, clinical, diagnostic and therapeutic aspects of this form of internal hernia were discussed.ConclusionCT scan facilitates early ISH preoperative diagnosis, reducing the risk of small bowel resection and increasing the chances of minimally invasive laparoscopic treatment.

Supravesical hernias: a systematic review of the literature

“…13,17,22,41 The existence of such symptoms may be attributed to the bladder compression caused by the dilated trapped small bowel loops. These results totally correspond to those of Marco et al 6 Groin pain and swelling emerged in 21.1% of cases, all representing external SHs. Differential diagnosis from true direct inguinal hernias before surgery is very difficult.…”

“…Authors mostly implemented conventional suture reinforcement techniques rather than the application of a mesh (14.3%). The latter is totally consistent with the observations of Marco et al 6 These findings, however, should not imply that laparoscopic approach or mesh use are inferior, as they might just represent the considerable number of included cases, reported long before surgeons became accustomed to such techniques. Although there is still no standardized approach most authors are recently in favour of laparoscopic procedures due to the clearer vision of the operating field, especially in cases of hemodynamically stable patients with a timely diagnosis.…”

“…Thirty-four studies met our inclusion criteria and were included in this systematic review. 3,6,7, Figure 1 presents the detailed trial flow of this study. They were published from 1904 to 2020 with the majority of them being published after 2009.…”

“…In case of an internal SH, herniated small bowel loops protrude through the supravesical fossa into the space around the urinary bladder and are usually compressed by its wall causing closedloop obstruction. 6,42 On the other hand, all cases of external SHs presented as direct inguinal hernias and the transversalis fascia was the point of bowel compression. 21 Mild urinary symptoms were described in only 15.8% of patients and in cases, primarily, of the internal type.…”

“…5 The internal type, however, more often manifests as intestinal obstruction, due to incarceration or even strangulation of the viscera contained in the hernial sac, and rarely mild urinary symptoms. 6 Internal SHs more frequently result in incarceration or even strangulation of the viscera contained in the hernial sac. While computed tomography (CT) is suggested as a useful tool for preoperative diagnosis, the existence of such a rare hernia is usually verified intraoperatively.…”