Littre hernia in children: A clinical aspect.
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).
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).
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.
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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; email@example.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
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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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Bakal, Unal; Tartar, Tugay; Sarac, Mehmet; Kazez, Ahmet|
|Publication:||Turkish Journal of Gastroenterology|
|Date:||Jan 1, 2019|
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