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Littre hernia in children: A clinical aspect.

INTRODUCTION

Meckel's diverticulum (MD) is a congenital abnormality of the gastrointestinal tract. The incidence of MD in the community differs between 0.5%-4.5% (1,2). A diverticulum was defined by Friedrich Meckel in 1841, and hence, it is mentioned with his name. It is a real diverticulum (mucosa, submucosa, muscular layer, serosa), and it is generally asymptomatic. It may contain gastric and pancreatic ectopic mucosa that may cause hemorrhage and perforation (3). Littre hernia (LH) is a rare complication of the diverticula, and it is observed in less than 1% of MD cases. LH is reported with a rate of 12%-30% in umbilical hernia, 19%-30% in femoral hernia, and 50% in inguinal hernia. It is also stated that LH is mostly located on the right side of the inguinal hernia (4,5). In this research, we aim to present the prevalence of LH in our work and to present child LH cases with different clinical properties.

MATERIALS AND METHODS

We retrospectively analyzed the records of patients diagnosed and treated as hernia between December 1996 and December 2017. Incarcerated/Strangulated (I/S) hernias located in the inguinal or umbilical region were recorded. LH patients were also defined among the I/S patients. All the patients were evaluated with respect to age, gender, complaint, physical examination findings, radiological diagnoses, hernia type, treatment methods, hospitalization interval, and complications. The study protocol was approved by the Ethics Committee of Firat University School of Medicine (Approval Date: November 30, 2017; Decision No.: 03).

RESULTS

The data from 3758 patients (male/female ratio: 3221/537) operated surgically for hernia were analyzed in the 21-year period. Here, 3371 patients (90%) were diagnosed as having inguinal hernia and 387 (10%), umbilical hernia. Further, 403 of the inguinal hernia cases (10.7%) were diagnosed as I/S. I/S was not detected in umbilical hernias. Four of the I/S patients (0.09%) were diagnosed as having LH. All the LH patients were consulted into the emergency room (ER). Their average age was 18 months (range: 1 month to 4.5 years). The common complaints were inguinal swelling, anxiousness, and vomiting. I/S inguinal hernia was detected in the physical examination. Hernia reduction was partially performed in three male I/S cases in the ER and also under anesthesia in the operating theater. A reduction in the female case was unsuccessful. Three partially reduced cases were detected to have a fibrotic band in the diverticulum and hernia sac. Abdominal distention was observed in two cases. While a transverse surgical inguinal incision was preferred in two cases, the other two cases were preferred to be treated with laparotomy with a paramedian incision (Figure 1). Ileal resection/anastomosis was performed together with MD in three cases. In one case, MD was incidentally detected and only an MD wedge resection was sufficient for recovery. Hernia repair of two abdomen-incision cases was performed inside the abdomen; two other cases were repaired with the inguinal approach. The average hospitalization interval was 8.2 days (2-16 days). A wound infection was observed in one case (Table 1).

DISCUSSION

Meckel's diverticulum occurs as a result of the inability to obliterate the omphalomesenteric channel in the fifth week of fetal development, and it is generally diagnosed with a complication (1). Clinical findings frequently occur as hemorrhage, perforation, inflammation, and obstruction. It is rarely diagnosed as LH (0.05%-1%) (2,6). The incidence of LH was detected as 0.09% in this research.

Kline stated that LH is rarely observed during childhood (7). In addition, LH occurring without any complications is rare. LH is more commonly observed in boys, and it is observed more commonly during childhood, contrary to Kline (8). In our research, three cases were boys and they were within the age range in which I/S is more commonly observed. We also think that small male children have the tendency to LH. LH is the most frequently defined within inguinal hernia (2). In our research, one patient was defined as having a left inguinal hernia and the remaining three patients were defined as having a right inguinal hernia. One case was diagnosed during hernia repair without showing any complications. Although the clinical, pathological, and radiological properties of complicated MD are well known, it is very difficult to determine a companion of MD for obtaining a clinical perspective during the preoperative term and to discriminate it from other I/S hernia types. All of these cases have similar symptoms and complaints as I/S inguinal hernias, such as vomiting, anxiousness, and swelling in the groin region. Barium-contrasted investigations, ultrasonography, angiography, computerized tomography, and scintigraphy assist in their diagnosis (9,10). Ultrasonography can only define ulceration or general inflammation. It may not define other properties (11). As three of our patients were operated upon immediately, the hernia sac inside the bowel was defined using ultrasonography, but the overall LH definition was not performed. As mentioned in the literature, any of the cases could be preoperatively defined.

In complicated LH, MD shows inflammation inside the hernia sac with strangulation or with ulceration of the gastric mucosa, and it cannot be reduced with the adherence of a fibrotic band or self-adherence (12). The reduction was completely unsuccessfully in one of the cases in our research. Three partially reduced cases were detected to have a fibrotic band among the diverticulum and hernia sac. A known treatment approach of LH is the "wedge resection" of the diverticulum. However, in complicated LH cases, ileal resection-anastomosis should be performed in the presence of fibrosis, ulceration, or heterotopic tissue with ileal resection and anastomosis (2,8). Surgery started with an inguinal incision in one case, but as the incised part with exploration diverticulum could not be reduced on the internal and external ring levels, it was reduced with laparotomy inside the abdomen. We approached the second I/S case directly with laparotomy as it had the same examination properties on the basis of our previous experience. In this research, ileum resection with diverticulum excision was performed in 3 LH patients. A wedge-type diverticulum excision was made in the hernia sac in an uncomplicated case.

Hernia repair is performed with an inguinal transverse incision (6). We performed the inguinal hernia repair with an inguinal transverse incision in only two cases in our research. Intra-abdominal hernia repair was performed in two complicated LH cases that were previously treated with laparotomy. We assume that intra-abdominal repair in order to prevent repetitions and other complications is more appropriate as the hernia sac is highly edematous and fragile.

A limitation of this study is that the number of LH patients is low.

In conclusion, it may not be possible to define LH before the operation. Surgeons should consider LH in the differential diagnosis in unreducible I/S hernias. Ileal resection-anastomosis should be added to the treatment in complicated cases. Performing intra-abdominal hernia surgery may prevent complications in cases executed using laparotomy.

Ethics Committee Approval: Ethics committee approval was received for this study from the Ethics Committee of Firat University School of Medicine (Approval Date: November 30, 2017; Decision No.: 03).

Informed Consent: Written informed consent was obtained from the patients who participated in this study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept - U.B.; Design - T.T.; Supervision - A.K.; Resources - U.B., M.S.; Materials - U.B., T.T.; Data Collection and/or Processing - T.T., M.S.; Analysis and/or Interpretation - U.B., A.K.; Literature Search - U.B., T.T.; Writing Manuscript - U.B., T.T.; Critical Reviews - A.K., M.S.

Conflict of Interest: The authors have no conflict of interest to declare.

Financial Disclosure: The authors declared that this study has received no financial support.

REFERENCES

(1.) Moore TC. Omhalomesenteric duct malformations. Semin Pediatr Surg 1996; 5:116-23.

(2.) Messina M, Ferrucci E, Meucci D, Di Maqqio G, Molinaro F, Buonocore G. Littre's hernia in newborn infants: Report of two cases. Pediatr Surg Int 2005;21: 485-7. [CrossRef]

(3.) Lauschke H, Kaminski M, Stratmann H, Nimer A. Littre's hernia-clinical aspects and review of the history. Chirurg 1999; 70:953-6. [CrossRef]

(4.) Lucarini L, Balestrino E, Vassallo G. Strangulation of a Meckel diverticulum in a crural hernia (Littre's hernia). Case report of a male patient. Minn Med 1981; 72: 2997-8.

(5.) Watson LF. Hernia, 3rd ed. St. Louis: Mosby; 1948: 547-54.

(6.) Erdogan D, Karaman I, Aslan MK, Karaman A, Cavusoglu YH. Analysis of 3776 pediatric inguinal hernia and hydrocele cases in a tertiary center. J Pediatr Surg 2013; 48: 1767-72. [CrossRef]

(7.) Kline AH. Incerceration of Meckel's diverticulum in an inguinal hernia. J Pediatr 1958; 53: 479-80. [CrossRef]

(8.) Qin D, Liu G, Wang Z. Littre's hernia in a paediatric patient. Afr J Pediatr Surg 2014; 11: 351-3. [CrossRef]

(9.) Levy AD, Hobbs CM. From the archives of the AFIP. Meckel diverticulum: radiologic features with pathologic correlation. Radio-graphics 2004; 24: 565-87. [CrossRef]

(10.) Platon A, Gervaz P, Becker CD, Morel P, Poletti PA. Computed tomography of complicated Meckel's diverticulum in adults: a pictorial review. Insights Imag 2010; 1: 53-61. [CrossRef]

(11.) Beluffi L, Fattori A, Sebastiani M, Ena S, Rogheto M. Complicated Meckel's diverticulum: diagnostic and therapeuticproblems. Chir Gastroent 1986; 4: 705-12.

(12.) Baillie RC. Incarceration of a Meckel's inguinal hernia inan infant. Br J Surg 1958; 46: 459-61. [CrossRef]

Unal Bakal [iD], Tugay Tartar [iD], Mehmet Sarac [iD], Ahmet Kazez [iD]

Department of Pediatric Surgery, Firat University School of Medicine, Elazig, Turkey

Corresponding Author: Tugay Tartar; tugaytartar@gmail.com

Received: March 19, 2018 Accepted: June 9, 2018 Available online date: November 19, 2018

Cite this article as: Bakal U, Tartar T, Sarac M, Kazez A. Littre hernia in children: A clinical aspect. Turk J Gastroenterol 2019; 30:101-4

DOI: 10.5152/tjg.2018.18228
Table 1. Properties of the Littre hernia cases

                     Case 1          Case 2          Case 3

Gender               M               F               M
Age (month)          2               15              54
Complaints           Swelling in     Swelling in     Swelling in
                     both groin,     left groin,     right groin,
                     vomiting,       vomiting        vomiting
                     fever,
                     anxiousness
Physical             Bilateral       Left            Swelling
examination          inguinal        inguinal        in right
findings
                     hernia,         strangulated    inguinal
                     incarceration   hernia,
                     Decrease        decrease
                     in bowel        in bowel
                     sounds,         sounds,
                     abdominal       abdominal
                     distention      distention
Scrotal              +               -               +
adherence
Reduction            Partly          Unsuccessful    Partly
Intestinal           +               +               -
obstruction in
abdominal
radiography
Ultrasonography      Right           Right
                     inguinal        inguinal
                     strangulation   strangulation
                     of hernia       of hernia
Incision-Resection   Perforated      Perforated      Meckel
                     Meckel          Meckel          diverticulum
                     diverticulum    diverticulum    resection
                     and ileum       resection       with right
                     resection       and abscess     inguinal
                     at 30 cm        drainage        transverse
                     above the       with left       incision
                     caecum          inguinal
                     with right      transverse
                                     and left
                     paramedian      paramedian
                     incision        incision
Hernia repair        Bilateral       Abdominal       inguinal
                     abdominal       approach        approach
                     approach
Pathalogical         with            Necrotic and    Meckel
diagnosis            granulomatous   perforated
                     inflammation    Meckel          diverticulum
                     necrotic        diverticulum
                     Meckel
                     diverticulum
Hospitalising        11              16              2
period (days)
Complications        -               Wound           -
                                     infection
Follow-up            5               6               7
period (years)

                     Case 4

Gender               M
Age (month)          1
Complaints           Swelling in
                     right groin,
                     anxiousness
Physical             Right
examination          incarcerated
findings
                     inguinal
                     hernia,
                     left
                     hydrocele
Scrotal              +
adherence
Reduction            Partly
Intestinal           +
obstruction in
abdominal
radiography
Ultrasonography      Right
                     inguinal
                     strangulation
                     of hernia
Incision-Resection   Meckel
                     diverticulum
                     and ileum
                     resection
Hernia repair        Repair
                     from
                     inguinal
                     area
Pathalogical         with
diagnosis            granulomatous
                     inflammation
                     necrotic
                     Meckel
                     diverticulum
Hospitalising        5
period (days)
Complications        -
Follow-up            12
period (years)

M: male; F: female
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Article Details
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Title Annotation:ORIGINAL ARTICLE
Author:Bakal, Unal; Tartar, Tugay; Sarac, Mehmet; Kazez, Ahmet
Publication:Turkish Journal of Gastroenterology
Article Type:Report
Date:Jan 1, 2019
Words:1864
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