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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 11  |  Issue : 3  |  Page : 134-137

A rare case report of right hepatic lobe herniation through an incisional anterolateral abdominal wall hernia following an open choledochotomy with a concise literature review


1 Department of General Surgery, Al-Bassel Hospital, Tartous, Syrian Arab Republic
2 Faculty of Medicine, Tishreen University, Lattakia, Syrian Arab Republic

Date of Web Publication24-Sep-2018

Correspondence Address:
Amjad Soltany
Faculty of Medicine, Tishreen University, Lattakia
Syrian Arab Republic
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HMJ.HMJ_16_18

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  Abstract 


Hepatic herniation through an incisional anterolateral abdominal wall hernia is an extremely rare condition. Here, we are reporting a case of hepatic herniation through the anterolateral abdominal wall which had been managed conservatively in a 75-year-old female patient. In addition, we are presenting a brief summary of all previously indexed reported cases to help other surgeons in managing similar rare cases the optimal way.

Keywords: Conservative therapy, incisional hernia, right hepatic lobe herniation


How to cite this article:
Mahmoud S, Soltany A. A rare case report of right hepatic lobe herniation through an incisional anterolateral abdominal wall hernia following an open choledochotomy with a concise literature review. Hamdan Med J 2018;11:134-7

How to cite this URL:
Mahmoud S, Soltany A. A rare case report of right hepatic lobe herniation through an incisional anterolateral abdominal wall hernia following an open choledochotomy with a concise literature review. Hamdan Med J [serial online] 2018 [cited 2019 Mar 18];11:134-7. Available from: http://www.hamdanjournal.org/text.asp?2018/11/3/134/236266




  Introduction Top


According to multiple surgical cases, the incidence rate of incisional hernias after abdominal surgeries fluctuates within the range 2%–11%,[1] and because of this relatively high prevalence, we should always consider these hernias seriously. However, the medical literature is still insufficient regarding incisional hepatic herniations. Therefore, we are reporting a rare case of a ventral incisional hernia with subcutaneous hepatic herniation and discussing why we believe that the conservative management is the most beneficial for our patient.


  Case Report Top


A 75-year-old female presented with non-painful swelling in the right upper quadrant (RUQ). This swelling had reached gradually its present size over the past 3 months. However, the patient was afebrile and did not suffer from vomiting, nausea or itching. The patient is known to be diabetic (Type 2) and a heavy smoker. Her medical history revealed two previous abdominal surgeries, a laparoscopic cholecystectomy 10 years ago and an open choledochotomy with a biliary intestinal anastomosis the following year. Neither postoperative wound infection nor other complications happened.

Physical examination revealed that there was no jaundice, but there was a right Kocher subcostal incision scar with an incisional hernia including a palpable mass at the RUQ. This mass was 6 cm × 6 cm in size, firm, not tender and not reducible by palpation. The patient's abdominal muscles were greatly relaxed and loose, and that is because the patient gave natural birth to 13 children. Bowel sounds were active. No other significant clinical findings in her physical examination were found and laboratory work-up (complete blood cell, total and direct bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, albumin, blood urea and prothrombin time) was within normal, except her high blood glucose levels (180 mg/dl).

Abdominal computed tomography showed the right lobe of liver herniating through the anterolateral abdominal wall at the RUQ, forming a wide herniation, but there was no hepatomegaly. In addition, we could notice both intrahepatic and extrahepatic pneumobilia [Figure 1] and [Figure 2].
Figure 1: Abdominal computed tomography scan (axial section) showing the liver herniating with both intrahepatic and extrahepatic pneumobilia

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Figure 2: Abdominal computed tomography scan (coronal section) showing a wide herniation of the anterolateral abdominal wall with herniation of the right hepatic lobe

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  Discussion Top


Diaphragmatic hepatic herniations are known to occur as congenital defects or after traumatic injuries;[2],[3] on the other hand, the entity of having a hepatic lobe among a subcutaneous incisional herniation – as in our case – is still considered a rare medical phenomenon. Therefore, we are presenting risk factors for incisional hernias in addition to symptoms and management of hepatic herniations.

For a better understanding of our case, we have classified all the related cases of this condition in [Table 1].[1],[2],[4],[5],[6],[7],[8]
Table 1: Summary of all the cases of acquired liver herniation through the abdominal wall

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Numerous risk factors for incisional herniation are well described, such as obesity, poor nutrition, wound infection, age >60 years, increased intra-abdominal pressure, diabetes mellitus and smoking.[5],[9] In our case, the patient had only three risk factors: diabetes, smoking and age (75 years).

As shown in [Table 1], we notice that 12 patients of 14 are female, so we could probably consider the female gender as a risk factor for hepatic herniations as the female hormones may cause laxity in body ligaments [10],[11] like hepatic ligaments which fix the liver in its place. Furthermore, we could observe that our patient had previous high levels of female hormones because of her high number (13) of childbirths. Besides, we could see that 13 of 14 cases are postoperative and the overall cases occurred in a relatively old age.

Hepatic herniation symptoms may vary among patients, including abdominal pain, nausea, vomiting, jaundice, dyspnea, confusion and discomfort.[4] However, our patient was completely asymptomatic, except for her fear of this palpable firm mass.

The left hepatic lobe is the most common lobe that is prone to herniate through abdominal wall.[4] Interestingly, in our case, which is the second reported case following a choledochtomy, the hepatic herniated part was the right lobe [Table 1].

Although this hernia may suddenly incarcerate,[1],[7] conservative therapy should be the treatment of choice, especially in patients with minimal symptoms or no symptoms.[4] In our case, the patient was asymptomatic; there were no limits of physical activities to any extent, and the herniation was wide because of the greatly relaxed abdominal muscles. Concerning the asymptomatic pneumobili, it was an iatrogenic result following the performed open choledochotomy with the anastomosis.[12] Consequently, we had chosen the conservative option for our patient, with a constant follow-up. Nevertheless, we should always consider the surgical treatment, especially in patients with more severe symptoms.[4] Surgical management varies according to symptoms:

  • Pain, discomfort and limitations in patient's important daily activities: this happens especially when the hernia orifice is small and tight, here, we repair the hernia after we confirm that the blood supply for the incisional hepatic part is good
  • Indicators for the incidence of acute liver failure like liver enzymes elevation and confusion caused by encephalopathy:[1] this usually occurs because of ischaemia, here we should cut off the ischaemic hepatic part and then repair the hernia regularly.


Actually, it is not easy to evaluate the outcomes and the accurate percentage of recurrence after surgical repairing for such rare incisional hepatic hernias, so – in case of surgical options – we suggest to use botulinum toxin A for selected huge complex hernias as an adjunct to abdominal wall reconstruction (neither open nor laparoscopic surgery), as this procedure facilitates the primary fascial closure [13] and this may reduce the recurrence that could occur after regular surgical management of these rare hepatic hernias.[6]


  Conclusion Top


Regrettably, the entire medical literature – as mentioned before – on our subject is rather restricted, leaving a space for evaluating the exact etiology and risk factors for hepatic hernias in addition to determining the optimal surgical management – in case we go with surgical options – to reconstruct the abdominal wall after hepatic herniations. We think that this optimal management should involve working on fixing the hepatic ligaments surgically to reduce the occurrence as possible as we can.

Eventually, we still emphasize that the treatment choice should be based on the patient's condition and symptoms with a strict follow-up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eken H, Isik A, Buyukakincak S, Yilmaz I, Firat D, Cimen O, et al. Incarceration of the hepatic lobe in incisional hernia: A case report. Ann Med Surg (Lond) 2015;4:208-10.  Back to cited text no. 1
    
2.
Tekin F, Arslan A, Gunsar F. Herniation of the liver: An extremely rare entity. J Coll Physicians Surg Pak 2014;24 Suppl 3:S186-7.  Back to cited text no. 2
    
3.
Nuño-Guzmán CM, Arróniz-Jáuregui J, Espejo I, Valle-González J, Butus H, Molina-Romo A, et al. Left hepatic lobe herniation through an incisional anterior abdominal wall hernia and right adrenal myelolipoma: A case report and review of the literature. J Med Case Rep 2012;6:4.  Back to cited text no. 3
    
4.
Al Ani AH, Al Badra MY, Al Kaisy S, Abdulmoneim H, Abdulhakim H, Al Jowher Z, et al. Left hepatic lobe herniating through sternotomy incision. Ann Surg Perioper Care 2017;2:1030.  Back to cited text no. 4
    
5.
Neelamraju Lakshmi H, Saini D, Om P, Bagree R. A ventral incisional hernia with herniation of the left hepatic lobe and review of the literature. BMJ Case Rep 2015;2015. pii: bcr2014207162.  Back to cited text no. 5
    
6.
Nodarian T, Sariali E, Khiami F, Pascal-Mousselard H, Catonné Y. Iliac crest bone graft harvesting complications: A case of liver herniation. Orthop Traumatol Surg Res 2010;96:593-6.  Back to cited text no. 6
    
7.
Salemis NS, Nisotakis K, Gourgiotis S, Tsohataridis E. Segmental liver incarceration through a recurrent incisional lumbar Hernia. Hepatobiliary Pancreat Dis Int 2007;6:442-4.  Back to cited text no. 7
    
8.
Govindaraj E, Meti RM, Ravikiran HR. A rare case of incisional hernia with herniation of liver: A case report and review of literature. Int J Biomed Res 2015;6:131-2.  Back to cited text no. 8
    
9.
Mutwali IM. Incisional Hernia: Risk factors, incidence, pathogenesis, prevention and complications. Sudan Med Monit 2014;9:81-6.  Back to cited text no. 9
  [Full text]  
10.
Reese ME, Casey E. Hormonal influence on the neuromusculoskeletal system in pregnancy. In: Fitzgerald C, Segal N, editors. Musculoskeletal Health in Pregnancy and Postpartum. An Evidence-Based Guide for Clinicians. Ch. 2. Springer. DOI: 10.1007/978-3-319-14319-4_2.  Back to cited text no. 10
    
11.
Leblanc DR, Schneider M, Angele P, Vollmer G, Docheva D. The effect of estrogen on tendon and ligament metabolism and function. J Steroid Biochem Mol Biol 2017;172:106-16.  Back to cited text no. 11
    
12.
Pate A, Amin F, Nuqui M, Agarwala A, Chendrasekhar A. Intrahepatic air: Pneumobilia vs. portal venous gas. Internet J Surg 2008;21:2.  Back to cited text no. 12
    
13.
Soltanizadeh S, Helgstrand F, Jorgensen LN. Botulinum toxin A as an adjunct to abdominal wall reconstruction for incisional hernia. Plast Reconstr Surg Glob Open 2017;5:e1358.  Back to cited text no. 13
    


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  [Table 1]



 

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