|Year : 2015 | Volume
| Issue : 2 | Page : 50-52
Baldev Singh, Daksh Mahajan, Ashish Kumar, Sudhir Khichy
Department of Surgery, Government Medical College, Amritsar, Punjab, India
|Date of Web Publication||1-Feb-2016|
Department of Surgery, Government Medical College, Amritsar, Punjab
Source of Support: None, Conflict of Interest: None
Maydl's hernia is a very rare type of a hernia and at times presents as a deceptive condition in a strangulated hernia. There is a paucity of reference to this condition in the literature though it is mentioned in few standard textbooks with little detail. It is also known by other names – “Hernia in W,” “double loop hernia” and “retrograde strangulation.” The Maydl's hernia appears to describe the only three-dimensional spatial anatomical relation of gut loops without reflection of etiology whether a hernia is sliding or not. This arrangement may be present in all types of inguinal hernias as and when hernia ring offers passage of sufficient length of gut through it. This happens when there is an alternate double entry and double exit of gut loops into the hernia sac from a peritoneal cavity that is Entry, Exit-Entry, Exit that may be remembered as a 4E sequence of gut loops. Though, all the gut loops of “W” may be strangulated, but intra-peritoneal loops are first to strangulate.
Keywords: Maydl's hernia, resection and anastomosis, strangulation of hernia
|How to cite this article:|
Singh B, Mahajan D, Kumar A, Khichy S. Maydl's hernia. Saudi Surg J 2015;3:50-2
| Introduction|| |
Maydl's hernia is one of the rare presentation of strangulated inguinal hernia. The importance of this type of a hernia is that the danger of strangulated segment being missed due to the error of judgment made by the presence of two healthy loops in the hernia sac.
| Case Report|| |
A 50-year-old male admitted in an emergency with a history of longstanding (>10 years) right inguinal hernia (RIH). Absolute constipation, occasional vomiting, the presence of a large irreducible, painful, tender swelling in the right inguinoscrotal region for 5 days clinically diagnosed as complicated RIH. Vitals, higher functions, and routine investigations were normal. Patient operated on the same evening of admission.
Exploration was done through a generous right inguinal incision over the hernial swelling. Hernia sac opened, serosanguinous fluid mopped, avoiding spillage into the wound with sterilized gauze sponges, two constriction rings at the external inguinal ring and internal inguinal ring released and holding the contents of the sac, the loops of the gut. Internal ring widened upwards and medially parallel to the inferior epigastric vessels. Four loops of gut present within the sac forming “W” like pattern with inner two loops running intra-peritoneal with firm inseparable adhesions between the two central loops [Figure 1]. Adhesiolysis causing more damage to the gut walls. Central adherent loops of gut along with mesentery were swollen, red, and friable with dilatation of proximal gut loop and normal caliber of the distal gut loop. The adherent, red swollen, dilated loops of gut resected and end to end, interrupted, single layer anastomosis performed between two healthy ends of the gut loops after cheatle split procedure over the distal loop remove the disparity of the caliber of proximal and distal gut loop ends [Figure 2]. Drain placed in peritoneal cavity and gut loops restored to the abdominal cavity. Hernia defect repair deferred for later. Wound closed in layers. The postoperative period uneventful and patient discharged on 10th postoperative day.
|Figure 1: Per-operative finding of formation of “W” like arrangement of gut loops|
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Special in this case “W” like the configuration of four small gut loops within hernia sac with firm adhesions between central loops; adhesiolysis causing more damage to already edematous, congested and friable gut loops, leading to the decision to perform resection and anastamosis.
| Discussion|| |
Karel Maydl, a Bohemian surgeon in 1895, was first to describe this hernia in which the middle limb became strangulated., Incidence of 0.6%, 1.9%, and 1.92% reported by various authors. Both sexes and sides, predominantly males and right side, are involved. Features are also noted in large series of a strangulated hernia.,,
Based on contents of hernial sac, following types has been mentioned Type I – Only small bowel, Type II – Both small and large bowels, and Type III – Only large bowel. Small intestine or omentum or both may be involved in strangulation process but the large bowel to become strangulated is the utmost rarity. Frankau – 1931 – reported 4 cases requiring bowel resection. Paul – 1944 – one case – only small bowel as contents – requiring bowel resection. Cole – 1964 – 3 cases – only one case requiring bowel resection. Bayley – 1970 – 5 cases, 2 small bowel and 3 large bowel, one requiring bowel resection. Moss et al. – 1976 – one case, 72 years female with right strangulated inguinal-Maydl-hernia with caecum, ascending colon as first loop, a second loop of hepatic flexure of the colon as sliding hernia, compromised intra-abdominal remaining segment of ascending colon between herniated loops. Opened through the right paramedian incision with medial extension at the lower end over the hernia swelling, right hemicolectomy with Bassini repair done. Postoperatively - wound infection and cardiac failure; treated successfully. Ganesaratnam – 1985 – 7 cases with small bowel in one case, small, and large bowel in 5 cases and only large bowel in one case. He warned against postural and manual reduction with the risk of reduction of the nonviable loop which may be missed due to reduction. Narang et al. – 1987 – reported one case of Type II, needed a bowel resection. 2010 Zachariah et al. – reported two cases having caecum, appendix, and small bowel. One with perforation, an additional foot of gangrenous small gut, limited right hemicolectomy done, stoma created, and herniorraphy done. After 8 weeks, stoma closed and ileocolic anastomosis performed taken down and ileocolic anastamosis done. Second case – 45-year-old female, childhood hernia with refusal for operation many times, obstructive feature. Exploration - showed large sac with caecum as posterior and lateral wall with two loops of small intestine and odorless hemorrhagic fluid. On midline laparotomy, contents reduced after adhesionolysis.
The multiple factors that may lead to development of Maydl's hernia – Long standing, large hernias, adhesions developing over a long time and wide hernial orifice predispose more bowel being pushed due to the variations intra-abdominal pressure into hernial sac, specific “W” like configuration while allowing additional mobile gut loops to be herniated along with them and facilitate more gut loops to be herniated Maydl's hernia with large and small bowel as contents might begun as sliding hernia. A mobile caecum with long mesentery may also be the contributing factor. Anatomic predisposition may also be the contributing factor. Strangulation may involve one or all loops, typically closed loop type strangulation occurs first in the more vulnerable intra-abdominal segment.
Though rare Maydl's hernia be suspected in patients with long-standing, large hernia, the onset of irreducibility, pain, obstruction, or peritonitis. Manual or postural reduction not to be attempted, even if a hernia reduces spontaneously, probably returning of the nonviable segment, and presenting as delayed perforation. The dictum is to always explore these cases on urgent basis. All these patients be resuscitated with intravenous fluids, nasogastric aspiration, and broad spectrum antibiotics; the central line may be inserted. Before surgery possibility of additional laparotomy, gut resection, anastamosis or stoma creation, Intensive Care Unit (ICU) care and ventilatory support be discussed and informed consent taken. On exploration, it is recommended that additional contiguous two feet of bowel loops be inspected even if this requires laparotomy. The “W” should be converted to “U” for completion of operation; all these cases be explored on urgent basis according to Sir Asley Cooper, “the danger is in delay, not in the operation.”
| Conclusion|| |
The preoperative anticipation, informed consent of stoma creation, ICU care, and per-operative thorough examination of the gut loops in continuity and contiguity of the hernia sac contents, active perioperative management of the large, long-standing hernia with features of irreducibility is mandatory for diagnosis and proper treatment of the Maydl's hernia.
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| References|| |
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[Figure 1], [Figure 2]