A 47-year-old woman presented to the emergency department with an 8-hour history of continuous and diffuse abdominal pain, together with vomiting, first feeding and subsequently bilious.
The patient has only two cesarean sections as a personal history.
In the emergency department she has a blood pressure of 122/85 mmHg, a heart rate of 91 beats per minute and an axillary temperature of 35.9 oC.
Abdominal examination revealed a scar from an infraumbilical midline laparotomy, the presence of decreased sounds, and diffuse pain on palpation without clear signs of peritoneal irritation.
There are no inguinal or crural hernias.
Blood tests showed only a blood glucose of 122 mg/dL, leukocytosis of 15,240 uL, together with neutrophilia of 93%, with the rest of the normal parameters.
A simple abdominal X-ray is compatible with subocclusion of the small intestine, and colitis.
Emergency computed tomography revealed small bowel loops and suggested the possibility of intestinal torsion.
1.
The findings in the complementary examinations, together with the clinical worsening of the patient during the observation and study period, increasing vomiting and abdominal pain, as well as the appearance of signs of peritoneal irritation in the lower hemiabdomen was explored.
The diagnostic suspicion at this time is intestinal occlusion due to adhesions, and the time elapsed since admission to the emergency room is 16 h.
Under general anesthesia, an exploratory laparotomy was performed, identifying in the patient's pelvis a laparoscopic small intestine loop and a direct photographic monitor, this asgross is in the right of Figure 3 (morphated color).
The left part of this image corresponds to the pre-herniary ileum (normal pink), between the intra-operative seal there is a better understanding of the visible orifice of the right ileum which is attached to the hernia 4 anatomy
The large dilation of small bowel loops greatly reduces the workspace required to manipulate surgical instruments by laparoscopy.
This fact, together with the risk of perforation when handling the necrotic loop, as well as the impossibility of safely identifying the anatomical structures, requires a conversion to open surgery.
The conversion is performed by means of an iterative infraumbilical laparotomy and it is seen that the cause of the obstruction and malformation of the ileon uterus is an internal hernia through the leaves of the broad ligament.
Reduced hernia, resection of 25 cm of necrotic ileum and reconstruction with manual termino-terminal anastomosis were performed.
Closure was performed over the hernia orifice with 0/0 continuous silk suture.
The postoperative period is normal and the patient is discharged with good clinical status 11 days after admission.
Postoperative follow-up after one month is correct.
