Surgical images: soft tissue

Herniation is a common complication of stomal surgery. This case represents the first case reported of gallbladder incarceration in a parastomal hernia.

In this case, a 73-year-old woman with an ileal conduit placed in the right lower quadrant came to hospital with acute incarceration of a parastomal hernia. Abnormal lab values for her included a white blood cell count of 19.0 х10⁹/L (77% neutrophils) and total bilirubin concentration of 1.7 mg /dL, but at presentation the patient had no symptoms of bowel obstruction.

Surgical exploration revealed a hernia sac containing a 12-cm, inflamed gallbladder (Fig. 1). Because the gallbladder, cystic duct and cystic artery were all accessible through the hernia, cholecystectomy was performed without extension of the incision and the hernia was locally repaired (Fig. 2).

FIG. 1. The inflamed gallbladder.

FIG. 2. Repair of the hernia.

In rare circumstances the gallbladder can be hypermobile, leading to torsion.¹ Incarceration of gallbladder has previously been documented in a ventral hernia in one case,² and Spigelian hernia in another.³ The gallbladder has even been found in an inguinal hernia.⁴ These cases illustrate that in rare circumstances, the gallbladder can be extraordinarily mobile, allowing for its involvement in abdominal hernias remote from the right upper quadrant, as occurred in our case. Although unusual, this case should help broaden the surgeon's differential when such problems must be considered.

Submissions to Surgical Images, soft-tissue section, should be sent to the section editors: Dr. David P. Girvan, Victoria Hospital Corporation, PO Box 5375, Station B, London ON N6A 5A5 or Dr. Nis Schmidt, Department of Surgery, St. Paul's Hospital, 1081 Burrard St., Vancouver BC V6Z 1Y6.

Competing interests: None declared.

Correspondence to: Dr. Jacques Heppell, Department of Surgery, Mayo Clinic Scottsdale, 13400 E Shea Blvd., Scottsdale AZ 85259; fax 480 301-8414; heppell.jacques@mayo.edu