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CASE REPORT OPEN ACCESSInternational Journal of Surgery Case
Reports 10 (2015) 1719
Contents lists available at ScienceDirect
International Journal of Surgery Case Reports
journa l h omepage: www.caserepor ts .com
Meckels diverticulum mesentery along with its bhernial sac: A
rare case of internal herniation
Paras K. P andDivya Sha Department o ab Department o
a r t i c l
Article history:Received 5 OcReceived in reAccepted 4
MaAvailable onlin
Keywords:Adhesion bandInternal herniationMeckels
diverticulumMesentery of MeckelsObstruction
is ttic. Ittussue of iy of Mls di
. Diveanastomosis was done.DISCUSSION: Internal herniation by MD
leading to SBO is an extremely rare complication. In
literature,cases of internal hernia through mesentry of Meckels
diverticulum, through mesodiverticular band,adhesion of inamed end
of MD to corresponding base of mesentry, brous cord extending upto
umblicalwall have been reported but in our case, patient had both
adhesion band along with internal herniation
1. Introdu
Meckelsmalformatiof omphaloweek of geswho develobe bowel oother
umbicommon prtomatic cas
Corresponical College &
E-mail add
http://dx.doi.o2210-2612/ (http://creativinto sac formed by
unusual mesentry of the meckels diverticulum and the adhesion band.
Preoperativediagnosis is often difcult with only 612% of cases
diagnosed correctly. Surgical intervention is indicatedfor patients
with intestinal obstruction or high risk of
incarceration.CONCLUSION: Meckels diverticulum causing internal
hernia is rare event. Its presentation due to hernia-tion of bowel
loops into sac formed by mesentery attached to diverticulum and the
adhesion is rarest, withnon specic signs and symptoms. Early
diagnosis and prompt treatment prevent further complications.
2015 Published by Elsevier Ltd. on behalf of Surgical Associates
Ltd. This is an open access articleunder the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
ction
diverticulum (MD) is the most common congenitalon of
gastrointestinal tract [14]. It is the remanantmesenteric duct
which is normally obliterated by 7thtation. Most patients are
asymptomatic. Those patientsps symptoms are due to its
complications which couldbstruction, hemorrhage, diverticulitis,
perforation orlical lesions [1,3,4]. Small bowel obstruction is the
mostesentation in adults accounting for 1/3rd of all symp-es
[4].
ding author at: Associate Professor Department of Surgery, Govt.
Med-Rajindra Hospital Patiala, India. Tel.: +91 9814507559.ress:
[email protected] (P.K. Pandove).
2. Case report
A 14 year old male presented to Emergency with complaint ofpain
abdomen with history of constipation with passage of atus,vomiting
(56 episodes) and mild abdominal distension since 3days. Patient
also gave history of minor blunt trauma abdomen4 days back and
subsequently, a day later patient developed thesymptoms. On
abdominal examination, the abdomen was soft, nontender and bowel
sounds were present with soft stools on per rectalexamination.
Ultrasound abdomen revealed dilated gut loops withuid in pelvis
suggestive of SBO. X-ray abdomen revealed multipleair uid
levels.
Fluid resuscitation and antibiotics were started and patient
wasput on conservative management and patient had relief of
symp-toms with passage of stools and atus but again after 2
daysdeveloped the features of SBO for which exploratory
laparotomywas undertaken for the persistent feature of SBO.
Intra-operatively,jejunum was collapsed with proximal ileal loop
distension. About50 cm s away from ileo-caecal junction, was
herniated loops ofbowel through unusual mesentery of Meckels
extending from base
rg/10.1016/j.ijscr.2015.03.0052015 Published by Elsevier Ltd. on
behalf of Surgical Associates Ltd. This is an open access article
under the CC BY-NC-ND
licenseecommons.org/licenses/by-nc-nd/4.0/).andovea,, Ashish
Moudgil a, Megha Pandovea, Chardab, Vijay K. Shardaa
f Surgery, Rajindra Hospital/Government Medical College, Patiala
147001, Punjab, Indif Obs & Gynecology Rajindra Hospital
Patiala, India
e i n f o
tober 2014vised form 4 March 2015rch 2015e 7 March 2015
a b s t r a c t
INTRODUCTION: Meckels diverticulumever, only 2% of cases are
symptomavolvulus, adhesions, Littres hernia, inCASE PRESENTATION:
An unusual casnia sac formed by unusual mesenterband, extending
from tip of the Meckeing to small bowel obstruction (SBO)and
forming a
rashekhara,
he most common congenital gastrointestinal anomaly. How- can
cause intestinal obstruction by various mechanisms
assception.nternal herniation of small bowel loops into complete
her-eckels diverticulum which was present upto the adhesive
verticulum to the adjacent mesentery of small intestine
lead-rticulectomy with resection of adjacent ileum with
ileo-ileal
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CASE REPORT OPEN ACCESS18 P.K. Pandove et al. / International
Journal of Surgery Case Reports 10 (2015) 1719
Fig. 1. Showinloops and uid
Fig. 2. Anothehernial sac and
Fig. 3. Showinadhesion bandmouth.
of diverticucent mesena complete lum along win such a w
Careful mand the banwith its metomy with ileo-ileal antoneal
toilePost operattomatic in sectopic gas
fter rattachg hernial sac formed by the unusual mesentery with
herniated bowel and Meckels diverticulum encircling the sac.
Fig. 4. Aand the r view showing Meckels diverticulum arising
from ileum along with its contents.
g two parts of sac with its content, one formed by mesentery
along with its mouth and other by mesentery along diverticulum with
its
lum to the band which was running from its tip to adja-try
encircling the herniated loops of intestine forminghernial sac
(Figs. 13). The attachment of the diverticu-ith its adhesive band
was rotated over the hernial sac
ay thus giving the appearance of bilobed sac (Fig. 5b).anual
reduction of herniated loops was done (Fig. 4)
d was released which revealed Meckels diverticulumsentery
forming the hernial sac (Fig. 5a). Diverticulec-its mesentery and
adjacent portion of the ileum withastomosis was done in single
layer. After proper peri-ting, abdomen was closed over an abdominal
drain.ive period was uneventful and patient remained
asymp-ubsequent follow ups. Biopsy of diverticulum revealedtric and
pancreatic tissue with inammatory cells.
Fig. 5. (a) Aftetery. (b) Show
3. Discussi
Meckelsduct. It norfetal life. If includes Meto the abdoor an
umbligenital gast13% of the[3] but symdiverticuluerotrophic the
ileum, s[6] and recartery [7]. Mnding at laplications wbleeding,
deduction of hernial contents, showing diverticulum, adhesion
banded mesentery.r division of the band showing the diverticulum
and attached mesen-ing bilobed appearance of the sac.
on
diverticulum is the remnant of the Vitello intestinalmally
regresses between the fth and seventh week ofthis regression fails,
various anomalies can occur whichckels diverticulum with/without
brous cord attached
minal wall, an umblical intestinal stula, enterocystomacal
adenoma [3,4]. Of these MD is the most common con-rointestinal
anomaly. MD is present in approximately
population with equal incidence in males and femalesptoms are
commonly present in males [5]. It is a truem containing all layers
of the ileal wall containing het-tissue [5]. It arises from the
anti-mesenteric border ofituated between 30 and 150 cm s from
ileo-caecal valveeiving its blood supply from a remnant of the
vitellineost of these are clinically silent and often an
incidentalparotomy. Symptoms arises when associated with com-hich
occurs in 4% of cases [5] including gastrointestinal
iverticulitis, and small bowel obstruction [25]. Clinical
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CASE REPORT OPEN ACCESSP.K. Pandove et al. / International
Journal of Surgery Case Reports 10 (2015) 1719 19
manifestations of complicated M.D. are frequently non specic
andcan mimic other pathologic conditions such as appendicitis,
crohnsdisease, cholecystitis and peptic ulcer [7]. Various
mechanisms bywhich it can cause intestinal obstruction [3,5,6].
Volvulus of small intestine around brous band extending
fromMeckels diverticulum to umbilicus.
Intussusception. Littres hernia: incarceration of the
diverticulum in inguinal and
femoral hernia. Entrapment of small bowel beneath
mesodiverticular band. Adhesions secondary to diverticulitis.
Enterolithiasis causing impaction inammation. Herniation of gut
through loop formed by adhesion band extend-
ing between the diverticulum and base of the mesentery. Neoplasm
obstruction. Bezoar lodged in diverticulum in Y shaped pantaloons
pattern [7].
Internal accounts oncommonly,herniation tion [8] andsymptoms,
inal surgerydiverticulumcases have binamed engas et al. [7Jain and
Sahing upto umBut in our cof diverticution of gut diverticulumnot
been reoften difcuAbdominal which can center ultracystic lesionThe
use of bthe obstrucstandard imof obstructiing of bowevessels
maysituation ancomplicatiotomy. Surgiobstructionsurgical
resherniation.
4. Conclusion
Meckels diverticulum causing internal hernia and
intestinalobstruction is rare event. Its presentation due to
herniation ofbowel loops into sac formed by mesentery attached to
diverticulumand the adhesion is rarest, with non specic signs and
symptoms.Therefore, there is high mortality rates associated with
this type ofinternal hernia [2]. Early diagnosis and prompt
treatment preventfurther complications and prolonged
hospitalization.
Conict of interest
There is no conict of interest among all the authors.
Presentation details
None.
g de
fund
t of
ittentionritt
journ
nces
. Lin, d of M. Maiaerticuarjis,lt: Me. Aggagnosisging 3ain,
S.erticu.S. Srire preapaziatzid
erticu. Chenrnal h. Dali
Meck. Hawrnal h
scint940
Open AccesThis article undepermits un any mcredited.hernia
caused by entrapment of the small intestinely 0.54.1% of intestinal
obstruction cases [1]. Most
it occurs through mesentry of small intestine. Internalby MD
leading to SBO is an extremely rare complica-
it should be considered in patients with obstructiveespecially
in younger people without previous abdom-. A case of internal
hernia through mesentry of Meckels
has been reported by Dalinka et al. [9]. Several othereen
reported of internal herniation due to adhesion ofd of MD to
corresponding base of mesentry by Papazio-] and Lin et al. [1],
through mesodiverticular band byi [5] and Srinivas and Cullen [6],
brous cord extend-blical wall by Maia et al. [2] and Aggarwal et
al. [4].
ase patient had both adhesion band extending from tiplum to
adjacent mesentry along with internal hernia-into a sac formed by
unusual mesentry of the meckels
and the adhesion band. Such unusual presentation hasported so
far in the literature. Preoperative diagnosis islt with only 612%
of cases diagnosed correctly [10].radiographs may be useful if
enteroliths are present,be seen as peripheral calcication with a
radiolucentsonograms may suggest evidence of a round or tubular,
however, this can often mimic a dilated bowel loop.arium studies is
limited, due to poor barium lling of
ted bowel [7]. Computed tomography is usually the goldaging
modality however, identifying MD as the causeon can be difcult.
Though, in internal hernia, cluster-l loops and stretched crowded
and engorged mesenteric
be suggestive features [2]. However, due to emergencyd
limitations of the imaging modalities in identifyingns of MD,
typically the diagnosis is made only at laparo-cal intervention is
indicated for patients with intestinal
or high risk of incarceration. The treatment option isection
with diverticulectomy and reduction of internal
Fundin
Self
Consen
Wrpublicaof the wof this
Refere
[1] C.Wban
[2] D.Sdiv
[3] Y. Nadu
[4] B.KdiaIma
[5] V. Jdiv
[6] G.Na ra
[7] B. PAtmdiv
[8] C.Ainte
[9] M.Kof a
[10] H.Binteand938
s is published Open Access at sciencedirect.com. It is
distributed restricted non commercial use, distribution, and
reproduction in tails
ed.
patient
informed consent was obtained from the patient for of this case
report and accompanying images. A copyen consent is available for
review by the Editor-in-Chiefal on request.
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r the IJSCR Supplemental terms and conditions, whichedium,
provided the original authors and source are
Meckels diverticulum mesentery along with its band forming a
hernial sac: A rare case of internal herniation1 Introduction2 Case
report3 Discussion4 ConclusionConflict of interestPresentation
detailsFunding detailsConsent of patientReferences