Defeating Searing Pain
Helping an elderly gentleman deal with
Internal Hernias (IH) are a rare cause of acute abdomen and intestinal
obstruction in adults. Among different types of Internal Hernias, Paracecal
Hernia is a rare type. It is present as a lump in right iliac fossa with
features of small bowel obstruction. Due to its rarity, non specific clinical
findings and small window period to take action, a differential diagnosis
of Internal Hernia must be kept in mind while approaching a patient with
small bowel obstruction features. An urgent CT scan is advised before
operating as it is a valuable aid to diagnose and operate subsequently.
There might not be any previous history of herniation, strangulation or
any specific risk factor / indication preceding herniation.
A 68-year old man came to the emergency unit of Nanavati Super
Speciality Hospital, walking with difficulty while experiencing severe
pain in the right iliac fossa since morning. The pain was mild at first
but increased in severity since that morning with a score of 10/10 at
admission. The pain was associated with nausea and vomiting. He had
3 episodes of vomiting during that day which was non projectile in
nature and mostly food particles as the content. He had no history of
fever or cough or trauma and didn’t display any co-morbidities such as:
Diabetes Mellitus / Hypertension / Cardiac problems / chest condition.
There was no recent history of any drug use / abuse. On examination,the
patient was febrile with blood pressure of 150/90 mm Hg, pulse rate of
112/min and a saturation of 98%. Patient was conscious and oriented.
Systemic examination of cardiovascular system, respiratory system
and central nervous system did not reveal any impairment. On
abdominal examination, a tender, palpable mass in the right iliac
fossa was noted. Guarding rigidity was present but abdominal scar or
indication of previous trauma was absent. A computerized tomography
(CT) scan of abdomen and pelvis was immediately taken.
In view of the clinical and imaging findings, the patient was shifted to
the operation theatre immediately. Starting with a midline incision,
ascending colon and cecum was pushed up. Small bowel and omentum
were found to be adherent in RIF. The omentum was separated and the
band of defect strangulating the bowel segment was released. Adhesiolysis
was performed, detortion of bowel was done and approximately 2.5 feet of
gangrenous segment was resected followed by end to end anastomosis in
2 layers. Thorough exploration of the contaminated cavity and peritoneal
cavity was performed.
The patient was not allowed to take anything orally for 2 days and was on IV
fluids and medications. He was then started on liquids, gradually progressing
to normal diet with removal of drain. His recovery was uneventful and was
discharged on fifth post operative day with no complication
Dr. Manmohan Kamat
General Surgery, Minimal
Access and Laparoscopic
Nanavati Super Speciality