Pre-operative diagnosis and successful surgery of a strangulated internal hernia through a defect in the falciform ligament: a case report

Abstract

Introduction: Internal hernia within the falciform ligament is exceedingly rare. A literature search revealed only 14 cases of internal herniation of the small bowel through a congenital defect of the falciform ligament, most of which were found intra-operatively.

Case presentation: A 77-year-old Japanese woman presented to our emergency department with sudden hematemesis, occurring at least four to five times over a 12-hour period. No ulcer or gastrointestinal bleeding was detected on gastroendoscopy. A 40mm mass in the inferior lobe of the right lung was found on a chest X-ray, and our patient's symptoms were therefore initially ascribed to aspirated blood from lung tumor-associated hemoptysis. However, our patient continued to show signs of severe abdominal pain and decreased urine output despite aggressive hydration, leading her examining physicians to search for a possibly severe, occult abdominal pathology. On emergent computed tomography imaging, we found an acute strangulated internal hernia within the falciform ligament. Diagnosis was made by helical computed tomography, permitting rapid surgical intervention.

Conclusions: Our findings on computed tomography imaging assisted with the pre-operative diagnosis and enabled us to make a rapid surgical intervention. Early diagnosis may help preclude significant strangulation with unnecessary resection.

Figure 1

Pre-operative abdominal helical computed tomography (CT): coronal view. A membranous structure (1) was visualized in the center of the upper abdomen between the diaphragm and the left lobe of the liver, and dilated, edematous intestine (2) was seen on the right side of it, while air-dilated intestine (3) was seen on the left side and in lower abdomen.

Figure 2

Pre-operative abdominal helical computed tomography (CT): horizontal view 1. On horizontal views, a closed loop of intestine (4) was identified against the liver (S4 and S5); the membranous structure (5) was identified as the falciform ligament in the center of the abdomen. On the left side, dilation of proximal intestines (6) and collapse of distal intestine (7) was seen.

Figure 3

Pre-operative abdominal helical computed tomography (CT): horizontal view 2. Another cephalic horizontal view showed the strangulated distal intestine through a hilar defect (8) in the falciform ligament.