Spontaneous posterior rectus sheath hernia: a case report

Abstract

BackgroundHernias of the posterior rectus sheath are very rare abdominal wall hernias with only a handful of cases reported in the literature to date. As an uncommon disease, it is important to recognize and report this case in order to enhance scientific knowledge of this disease.Case presentationThis case report presents a spontaneous posterior rectus sheath herniation in a 79-year-old white man with previous abdominal surgery for appendicitis. His herniation was discovered incidentally during an examination for his chief complaints of lower abdominal pain and diarrhea which were later diagnosed as Salmonella-related gastroenteritis. A computed tomography scan of his abdomen and pelvis showed abdominal wall hernia with loops of small bowel extending into his rectus abdominis muscle. In this case, it was decided to leave the situation alone for now due to no evidence of bowel obstruction and the low risk of this hernia getting strangulated, which otherwise would have warranted urgent surgery.ConclusionsThis report adds to the limited stock of available literature on this unusual issue and strengthens the evidence base on the best approach to support informed clinical decision making. The significant clinical implication of such case reports is increased identification rate of rare clinical conditions which otherwise often go unnoticed.

Laparoscopic approach for a spontaneous posterior rectus sheath hernia

“…Spontaneous posterior rectus sheath hernias were first documented in 1937 and there are only 10 cases published in the literature [2, 3, 5]. They belong to the group of interparietal hernias in which the hernia sac lies between the layers of the abdominal wall [4].…”

“…The rectus abdominis muscle is enclosed within the rectus sheath which is formed by the aponeuroses of the lateral abdominal muscles [3]. Its anterior layer consists of the external oblique aponeurosis supplemented by the anterior aponeurotic layer of the internal oblique aponeurosis, whereas its posterior layer is formed by the aponeurosis of the transversus abdominis muscle and the posterior aponeurotic layer of the internal oblique aponeurosis up to the level of the arcuate line.…”

“…Despite the fact that the most vulnerable part is below the arcuate line, the majority of the reported cases, including ours, occurred in the supraumbilical region [1–3]. The theory behind the formation of these hernias is that they appear at the sites of reduced resistance such as where the neurovascular structures pass through the aponeurosis [4, 7].…”

“…When they cause symptoms, these are frequently nonspecific (pain, distension, and vomiting) and the hernia is not identified by the physical examination [2, 5]. In the majority of the reported cases, the hernia was diagnosed by CT scan [2, 3]. This is the best diagnostic modality to identify the cause of small bowel obstruction and provides good anatomic detail of the abdominal wall which allows to detect hernias that aren’t clinically evident and their complications.…”

“…A posterior rectus sheath hernia is a very rare type of abdominal wall hernia, described only in a few published cases [2, 3]. These hernias are considered interparietal because the sac lies between the layers of the abdominal wall [3, 4]. The majority of these hernias are postsurgical or posttraumatic, with limited spontaneous cases being reported in the literature [2].…”