A Totally Laparoscopic Approach for a Rare Case of Incarcerated Littre’s Hernia

Abstract

Introduction:

Meckel’s diverticulum is an embryological remnant of vitelline duct and is usually located at an average distance of 60 cm from the ileocecal junction. It is found in 2% of the overall population. ¹ According to Lequet et al., the lifetime probability of developing complications is approximately 4% and decreases with aging. ¹ The most common complications include gastrointestinal bleeding, intestinal obstruction, diverticulitis, and perforation. ² Among the causes of obstruction, the so-called Littre’s hernia is a rare form of hernia involving Meckel’s diverticulum. ^2,3 Littre’s hernia is mostly femoral, but it can also be inguinal or umbilical. ⁴ Due to the rarity of its presentation, the exact incidence of this condition is extremely difficult to estimate, due to a lack of data in the literature. Laparoscopic approach is recommended in elective inguinal and femoral hernia repair, since it results in significantly lower recurrence rate and less postoperative pain than anterior repair. ⁵ This approach can be a useful tool in emergency settings, ⁶ even in the case of fragile patients, in whom laparoscopy has proven to be associated with lower postoperative morbidity and mortality. ⁷ Moreover, another useful tool in emergency situations can be the indocyanine green (ICG), which can help visualize bowel vascularization, thus enabling the surgeon to perform a tailored intestinal resection when necessary. ^8,9

Materials and Methods:

A 90-year-old woman presented in the clinic complaining of painful tumefaction in the left inguinal–femoral region. The patient had previously undergone hysterectomy, ovariectomy, and appendectomy, and had already been diagnosed with hypertension and atrial fibrillation, for which she was being treated with apixaban. After surgical assessment, a diagnosis of incarcerated left femoral hernia with initial intestinal occlusion was made. Emergency laparoscopic repair of hernial defect was recommended.

Results:

After accessing the abdominal cavity through the placement of three 5 mm trocars, a left femoral hernia was identified. The bowel was reduced into the abdomen, discovering that the Meckel’s diverticulum was incarcerated into the femoral ring. By using ICG, the vitality of the ileum and the Meckel’s was evaluated: due to an ischemic suffering, a tangential resection of the Meckel’s diverticulum was accordingly performed with an endoGIA, and no more resections were necessary. So ICG helped guide decision making and avoid an extensive resection, anastomosis, and ostomy. Fluid leakage from the hernial defect was observed, and for this reason, a direct plastic of the hernial defect was performed. Operative time was 70 minutes. The only complication that occurred after surgery was a left inguinal hematoma, probably due to the restart of anticoagulant therapy, which was treated nonoperatively.

Conclusions:

The video shows the emergency laparoscopic ICG-guided treatment of an incarcerated Littre’s hernia. Laparoscopic surgery represents a safe and effective approach for diagnosis and treatment of many conditions, even in emergency settings and with fragile patients, and ICG can help in decision-making process, especially in emergency situations.

Author Contributions:

M.T. and G.P. reviewed the literature and wrote the article and prepared the video. M.T., G.P., and G.M. contributed equally to this work, article conception, and draft. F.A. and G.M. critically revised the article and contributed with important scientific knowledge giving the final approval.

Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.

The authors declare no conflicts of interest.

Runtime of video:

8 mins 53 secs.