A CASE OF LITTRÉ’S HERNIA AT ZINDER NATIONAL HOSPITAL, ZINDER, NIGER

Abstract

The presence of a Meckel's diverticulum in a hernia sac is known as Littré’s hernia. We report a case of Littré’s hernia in an 18-year old young man because of the uncommon condition.

An 18-year old young patient was admitted to the Emergency Surgical Department of Zinder National Hospital, Zinder, Niger with a painful inguinoscrotal swelling of three days duration. The diagnosis of strangulated right inguinoscrotal hernia was made. At surgery, a Meckel's diverticulum was found at the antimesenteric border of the ileum in the hernia sac, the bowel loop was not viable. Resection of the non-viable ileal loop with the Meckel’s diverticulum attached to it was performed with an end-to-end ileal anastomosis. The hernia defect in the groin was repaired according to Bassini procedure. The postoperative recovery was uneventful and the patient was followed up for 5 months without symptoms.

Conclusion

Littre hernia is uncommon and difficult to diagnose; it is often an incidental finding at surgery which should ensure complete resection of the Meckel’s diverticulum in order to prevent future complications.

Introduction

Littré's hernia is defined as the protrusion of a loop of ileum containing a Meckel's diverticulum in a hernia sac1^-8. Meckel’s diverticulum is an embryonic remnant resulting from incomplete obliteration of the vitello-intestinal duct9. Its prevalence is low, occuring in 0.3 to 3% of the population3, 10^-12. Many complications of Meckel’s diverticulum have been described, but its location in a hernia sac remains uncommon4, 7^-10,12,13. We report the case of an 18-year old patient treated by resection and anastomosis of non-viable Littré's hernia.

Case Report

An 18-year old man with a history of right-sided inguino-scrotal swelling of 12 months duration was admitted to the Surgical Emergency Department of Zinder National Hospital, Zinder, Niger for a sudden onset of pain in the swelling of three days duration. He was found to be afebrile with a tender right inguino-scrotal hernia which was not reducible; the abdominal examination was otherwise unremarkable. A diagnosis of a right-side strangulated inguino-scrotal hernia was made. Blood count, renal function and blood sugar levels were normal.

At surgery via a right-side inguinal approach, a non-viabel Meckel's diverticulum measuring 5cm long, attached to the antimesenteric border of the ileum was found in the hernia sac (Fig. 1). The loop of ileum containing the Meckel’s diverticulum was resected and an end-to-end anastomosis was effected while Bassini repair of the posterior wall of the hernia was done. The patient made good recovery and was discharged on the 7^th post-operative day; he has been followed up for 5 months without symptoms.

Discussion

In 1700, the French anatomist Alexis de Littré described for the first time the presence of an intestinal diverticulum in an inguinal hernia sac1,2,8. In 1809, Johann Friedrich Meckel classified the different varieties of intestinal diverticula; the most important of these, representing an incomplete obliteration of the omphalomesenteric duct was name after him2,10. It was in 1841 that he reported a case of strangulated femoral hernia containing Merckel’s diverticulum which was called Littré’s hernia2.

Meckel’s diverticulum is one of the most common congenital anomalies of the gastrointestinal tract10,12. It is the consequence of an incomplete resorption of the vitelline or omphalo-mesenteric duct which is normally present in the 6 - 8 weeks of embryonic life10,11>. Although the anatomic localization of Meckel’s diverticulum varies, it usually occurs within 100 centimeters proximal to the ileocaecal junction 3,8,12. There is a male predominance (sex ratio of 2)9,10. In most cases, it is an incidental finding5,11. Approximately 4% of MD leads to complications (gastrointestinal bleeding, diverticulitis, intestinal obstruction and perforation9,11. Various factors have been associated with a greater risk of complications and they include the male gender, age (under 10 years), the length of the diverticulum (> 2-4 cm), the presence of gastric or pancreatic heterotopic tissue in the diverticulum9,11,14. The finding of a Meckel’s diverticulum in a strangulated hernia is an uncommon finding3,9,11. Meckel’s diverticulum has been found in the umbilical, inguinal and femoral hernia but Littré’s hernia is commonly located in right-side inguinal canal in over 50% of cases3,5,8,9,11.

Clinically, there are no specific signs to recognize a Littré’s hernia preoperatively3,5. Symptoms usually progress slower when strangulated hernia contains only a Meckel’s diverticulum without vascular compromise3,6,11. In some cases, there is just an inflammation of the skin over the hernia which can leads to enterocutaneous fistula if the patient is not treated on time11.

Ultrasonography does not offer further information indicating the presence of a Littré’s hernia5,10,14 while computed tomographic scan could demonstrate Meckel’s diverticulum as a blind-ending tubular formation communicating with the distal ileum. However, even with CT scan, it remains difficult to distinguish a Littré’s hernia from Amyand’s hernia (vermiform appendix within a hernia sac) especially if the hernia is in the right side 5,14.

Treatment of Littré’s hernia is surgical with resection of Meckel’s diverticulum is the rule because of the risk of complications3^-13. Some authors prefer wedge resection of Meckel’s diverticulum3,5,11. Carlioz9 recommende a large, T-shaped wedge which takes away an ileal segment on both sides of the diverticulum in order to leave no residual heterotopic tissue which could lead to complications in the future. Proponents of the wedge resection justify their choice by the lack of studies comparing the outcome of wedge resection as against resection and anastomosis3. Repair of the wedge or the end-to-end anastomosis restores digestive continuity3,5,11; the posterior wall of the hernia is repaired accordingly3^-5.

Conclusions

Littre hernia is uncommon and difficult to diagnose; it is often an incidental finding at surgery which should ensure complete resection of the Meckel’s diverticulum in order to prevent future complications.

Figure 1. The Meckel's diverticulum mobilized out of the inguinal hernia sac.