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CASE REPORT
Year : 2015  |  Volume : 42  |  Issue : 3  |  Page : 198-200

Littré hernia: A surgical surprise


Department of Pediatric Surgery, KLE University, Belgaum, Karnataka, India

Date of Web Publication16-Sep-2015

Correspondence Address:
Dr. Vijay C Pujar
Department of Pediatric Surgery, KLE University, Belgaum, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.165580

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  Abstract 

Meckel diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract, occurring in 2-3% of the population. Littré hernia (LH) is the protrusion of MD through a potential abdominal opening in a sac. It results from improper closure and absorption of the omphalomesenteric duct. Protrusion of MD, along with coils of the intestine into the hernia sac may cause complications like obstruction, perforation, or fecal fistula. We report a very rare case of LH who presented with an irreducible mass in the left inguinal site, diagnosed preoperatively as incarcerated inguinal hernia in a 2-year-old boy.

Keywords: Inguinal, hernia, Meckel diverticulum (MD)


How to cite this article:
Pujar VC, Joshi SS. Littré hernia: A surgical surprise. J Sci Soc 2015;42:198-200

How to cite this URL:
Pujar VC, Joshi SS. Littré hernia: A surgical surprise. J Sci Soc [serial online] 2015 [cited 2022 Jan 18];42:198-200. Available from: https://www.jscisociety.com/text.asp?2015/42/3/198/165580


  Introduction Top


Littré hernia (LH) is the protrusion of Meckel diverticulum (MD) through a potential abdominal opening with a container sac. This clinical entity has been described after the autopsy findings of two patients by Alexis de Littré for the first time as "ileal diverticula in the inguinal hernia" in 1700. The concept of "LH" has only been improved after a century by Johann Friedrich Meckel. Meckel defined the true congenital diverticulum of the gut, which is now named after him. [1]

MD is the most common congenital anomaly of the gastrointestinal tract, occurring in 2-3% of the population. MD commonly complicates before the age of 2 years and due to this reason, it is accepted as a childhood disease. As the MD arises from the antimesenteric border of the small bowel, it is more prone to protrude through any abdominal opening. [1] Umbilical protrusion is more common than the other hernia sites. [1] But this presentation is quite rare in childhood and the true incidence of LH is unknown. There are limited data about the disease in the childhood period.


  Case Report Top


A 2-year-old male child was referred to our department with complaints of swelling over his left groin since 1 year. The swelling had increased in size and was associated with vomiting and pain in the abdomen and scrotum for 1 day prior to hospitalization.

On examination, the left inguinoscrotal swelling measuring up to 10 cm × 8 cm in size with an overlying skin that was stretched and shiny was observed. The swelling was tense and tender and was irreducible. A diagnosis of obstructed inguinal hernia was made and the child was scheduled for surgery. On opening the sac, MD was present and adherent to the neck of the sac, thereby preventing complete reduction [Figure 1]. Resection of MD with ileal segment was done and the continuity was restored by ileoileal anastomosis. The intestinal coils were repositioned and herniorrhaphy was done. Histopathology was suggestive of MD with intestinal mucosa; however, it did not reveal any heterotrophic mucosa. Oral feeds were started on the fourth day and the patient was discharged from the hospital on the fifth postoperative day [Figure 2].
Figure 1: Intraoperative view


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Figure 2: Postoperative view


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  Discussion Top


Presence of MD in the abdominal wall hernia is known as LH. It is a rare operative finding in adults, with an incidence of 4-10%, and much rarer in children. [1] The period of infancy seems to be the most risky one; the chance of LH is probably attributed to the tendency of incarceration in this age group. Umbilicus is the commonest site (64-85%), with the omphalomesenteric duct being a component of fetal umbilicus. [1] The inguinal region is the second commonest site, with a prevalence of 15-33.8% in all age groups. It is more common on the right side than the left but can occur on the left side as seen in our case, which was probably due to the large hernia.

MD is a true diverticulum found in the antimesenteric border and is the most common congenital abnormality of the gastrointestinal tract. It is the remnant of the persistent vitellointestinal or omphaloenteric duct comprising all the intestinal layers. [2],[4] It is found in 2% of the total population, 2 feet from the ileocecal junction and is 2 inches in length, with two types of common ectopic tissues (gastric and pancreatic tissues).

MD may manifest with hemorrhage due to ulceration, small bowel obstruction, diverticulitis, and perforation. [5] Bleeding (observed in 25% of the population) is the most common complication, especially occurring in children and it typically presents as hematochezia. [6] The hemorrhage is a result of heterotopic gastric mucosa, leading to ulceration. The most useful method of detection of a MD is technetium-99m scanning. This method depends on ulceration and bleeding due to the heterotopic gastric mucosa. [7]

LH is an unusual complication of MD. [8] LH seems to be a problem of infancy, generally among the male gender. Even though LH can be observed at any age, the period of infancy seems to be the most risky one.

This term is now used to describe the presence of MD in hernia in any location, with the commonest site being the umbilical. Another study has mentioned the inguinal site as being more common. [1] Any kind of persisting umbilical openings (including umbilical hernias, umbilical cord hernias, and exomphalos minor and exomphalos major) are the most common sites for LH. This common location is due to the fact that the fetal umbilicus is a component of the omphalomesenteric duct. Incomplete manual reduction of an incarcerated hernia, fecal fistulas in a hernia, and rectal bleeding or repetitive abdominal pain in such cases should increase the suspicion of a LH. [9] Intestinal obstruction may occur due to volvulus, intussusceptions, or very rarely as a complication of LH. [9],[10],[11]

The preoperative diagnosis of a LH is difficult to establish. Findings like incomplete manual reduction of an incarcerated hernia, fecal fistulas in a hernia sac, and previous history of rectal bleeding should alert the clinician about a LH. [12] Plain abdominal radiographs may demonstrate air-fluid level in case of obstruction. In the management of a LH, MD must be resected. The accepted treatment is wedge resection of the diverticulum and repair of the ileum from within the sac. [13] If there is an edema or inflammation at the base of the diverticulum, resection and anastomosis of a segment of the ileum may be necessary, as was done for our case. It may prevent postoperative stricture of the resected segment. [12],[13]


  Conclusion Top


In conclusion, MD can present as content of hernia in the inguinal region. Incarcerted hernia or history of rectal bleed in the past may give a clue about its presence. Resection and anastomosis do not increase morbidity and mortality.

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Nil.

Conflict of interest

There are no conflicts of interest.

 
  References Top

1.
Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P. Littre hernia: Surgical anatomy, embryology, and technique of repair. Am Surg 2006;72:238-43.  Back to cited text no. 1
    
2.
Evers BM. Small intestine. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, editors. Sabiston Textbook of Surgery. 17 th ed. Philadelphia: Elsevier Saunders; 2004. p. 1323-81.   Back to cited text no. 2
    
3.
Michael NM. Diverticular disease of the small bowel. In: Morris PJ, Malt RA, editors. Oxford Textbook of Surgery. Newyork: Oxford University Press 1994; 1:982-86.   Back to cited text no. 3
    
4.
Whang EE. Small intestine. In: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Pollock RE, editors. Schwartz′s Principles of Surgery. 8 th ed. New York, NY: McGraw Hill; 2005. p. 1043-5.   Back to cited text no. 4
    
5.
Brown CK, Olshaker JS. Meckel diverticulum. Am J Emerg Med 1988; 6:157-64.   Back to cited text no. 5
    
6.
Turgeon DK, Barnett JL. Meckel′s diverticulum. Am J Gastroenterol 1990;85:777-81.  Back to cited text no. 6
    
7.
Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ 3 rd . Surgical management of Meckel′s diverticulum. An epidemiologic, population-based study. Ann Surg 1994;220:564-9.   Back to cited text no. 7
    
8.
Fa-Si-Oen PR, Roumen RM, Croiset van Uchelen FA. Complications and management of Meckel′s diverticulum-a review. Eur J Surg 1999; 165:674-8.  Back to cited text no. 8
    
9.
Mishalany HG, Pereyra R, Longerbean JK. Littre′s hernia in infancy presenting as undescended testicle. J Pediatr Surg 1982;17:67-9.  Back to cited text no. 9
    
10.
Kang IS, Ahn SM, Han A, Oh JT, Han SJ, Choi SH, et al. Giant Meckel′s diverticulum associated with a congenital diaphragmatic hernia. Yonsei Med J 2004;45:177-9.  Back to cited text no. 10
    
11.
Margolies MN, Compton CC. A 23-year-old man with recurrent bouts of abdominal pain and vomiting. N Engl J Med 1989;320:171-8.   Back to cited text no. 11
    
12.
St-Vil D, Brandt ML, Panic S, Bensoussan AL, Blanchard H. Meckel′s diverticulum in children: A 20-year review. J Pediatr Surg 1991;26: 1289-92.   Back to cited text no. 12
    
13.
Ravikumar K, Khope S, Ganapathi BP. Littre′s hernia in a child-an operative surprise (a case report). J Postgrad Med 1989;35:112-3.  Back to cited text no. 13
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