MECKEL'S DIVERTICULUM MASQUERADING AS AN INCARCERATED INGUINAL HERNIA; A PSEUDO-LITTRE HERNIA.
Bilal Koussayer*1, Hannah Zuercher1, Tara M. Barry2, Adham R. Saad2
1General Surgery, University of South Florida Morsani College of Medicine, Tampa, FL; 2Tampa General Hospital, Tampa, FL
Introduction:
Meckel's diverticulum (MD) is a gastrointestinal pathology due to incomplete vitelline duct formation during fetal development. A rare complication of MD is when the diverticulum protrudes into a hernia sac, called a Littre hernia. We present the case of an 83-year-old female who had what initially appeared to be an incarcerated right inguinal hernia based on imaging and physical exam findings. She was scheduled for robotic-assisted inguinal hernia repair and intraoperatively she was found to have a Meckel's diverticulum adherent to the right inguinal canal.
Patient Case:
This is an 83 year-old female with a history of aortic regurgitation, hypertension, hyperlipidemia, paroxysmal super ventricular tachycardia, transient ischemic attack, cervical cancer with hysterectomy, bilateral cataracts, and a former smoker initially presented to our hospital's ED for the worsening right lower quadrant (RLQ) pain radiating to the groin. Subsequently, a computed tomography angiography (CTA) scan revealed an inguinal hernia (Figure 2). Due to worsening symptoms, she was referred for a robotic-assisted right inguinal hernia repair. When the trocars were placed, peritoneal implants were found on the first portion of the duodenum and, therefore, were biopsied. In the RLQ, a piece of small bowel that was densely adherent to the right inguinal canal was identified. With further exploration, a MD densely adherent to the right inguinal canal was found (Figure 1). With this degree of adherence, the diverticulum most likely had ruptured. A small bowel resection was performed using the Endo GIA™ 60 mm stapler, ensuring to avoid narrowing the limb of jejunum. Pathological findings for the small bowel specimen were consistent with MD associated with serosal and sub serosal foreign material, as well as lymphocytic and foreign body giant cell inflammation, suggestive of prior rupture. The second specimen biopsied from the duodenal implant was classified as benign pancreatic acinar and ductal tissue, consistent with pancreatic heterotopia (PH).
Conclusion
Here we present a case of Pseudo-Littre Hernia; a Meckel's diverticulum presenting with symptoms of an incarcerated inguinal hernia with concurrent duodenal PH. These are both two rare findings with incidences of less than about 2% in the general population. Currently, the cause of PH is not well understood, hypothesized to potentially be congenital in origin. Although this patient's PH was an incidental finding, we suspect that it was a result of the perforated MD, given the presence of pancreatic tissue. Recently, with incidences of MD and PH occurring together, some hypothesize that a common signaling pathway may be the origin of PH. Additional research regarding the commonalities between MD and PH may be helpful for understanding the relationship between these two pathological etiologies.
Figure 1: Intraoperative visualizations of the Meckel's adherent to the inguinal canal.
Figure 2: CTA of patient preoperatively
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