Case Description
A 77-year old Caucasian female patient presented to our acute surgical
take with features of gastrointestinal obstruction, comprising of
abdominal distension, vomiting and sharp pain localised in the left
iliac fossa. She had a complex medical history comprising of congestive
heart failure, hypertension, diabetes mellitus and previous right knee
and hip replacements, along with extraction of left iliac bone graft for
spinal surgery. Clinical examination revealed a moderately distended but
soft abdomen, with tenderness in deep palpation in the left iliac fossa;
no obvious external hernia was identified. Provisional diagnosis was
that of intestinal obstruction and hence an urgent abdominopelvic
computed tomography (CT) scan with intravenous contrast was performed
for further assessment. The performed CT scan revealed the presence of
closed loop colonic obstruction between a competent ileoceal valve and
the distal descending colon, which had herniated through the left iliac
bone, with no obvious evidence of intestinal ischemia or perforation
(Figures 1 & 2). The patient was scheduled for emergency laparotomy and
intraoperatively there was no concern regarding the viability of the
colon, after the reduction of the herniated segment. The defect was
closed with the use of synthetic polypropylene mesh and no colonic
resection was eventually required. The patient had an uneventful
recovery and was discharged in a stable condition, with no evidence of
recurrence at 6 months postoperatively.
Our case highlights the need for high clinical suspicion of a transiliac
bone hernia in patients with previous relevant orthopaedic
interventions, who present with features of gastrointestinal
obstruction, as highlighted by the previous very limited reports in the
literature1,2. Since clinical examination is usually
insufficient to establish the diagnosis, we advocate urgent performance
of abdominopelvic computed tomography for diagnostic and pre-operative
planning purposes, followed by prompt surgical intervention, with
liberal use of prosthetic mesh to reduce the chance of recurrence of the
hernia.
Acknowledgments: None to be declared by the authors