Editor
to Letter
Spontaneous rupture of incisional hernia hernia
Sir, We present the case of a spontaneous rupture of the incisional hernia, an exceptionally rarely reported in English literature, in the developed world country. We strongly recommend early surgical management in large, long-standing incisional hernias. An 84-year-old white English female was pre sented to us with watery discharge from low er part of incisional hernia. She developed the incisional hernia about 18–24 months follow ing laparotomy in 1992. She did not have any symptoms due to the lump. She did not have any pain, nausea or vomiting. On general ex amination she was apyrexia with normal haemodynamic status. Abdominal examina tion revealed a large nontender reducible in fraumbilical incisional hernia with omental prolapse with discharge of the peritoneal flu id [Figure 1]. During emergency operation, re duction of hernia with repair of burst hernial sac with prolene mesh was performed. Follow ing operation, she recovered well though slow ly. At the time of discharge, her wound was nicely healed. At 4 weeks, she was doing very well without any complications. Complications such as adhesions, incarcera tion of bowel and intestinal obstruction, are well documented in association with incision al hernia but spontaneous rupture is very rare ly reported in literature.[1,2] Although theoreti cally, spontaneous rupture can occur with any type of hernia, it is more commonly seen in incisional and recurrent groin hernias.[1,3] Af ter Hartley’s report of two such cases in 1961, there have been very few case reports docu mented.[4] Although the incidence of this com plication is higher in developing countries compared to developed countries, this case focuses on such avoidable complication in developed country. The large incisional hernia is contained only by its sac and thin atrophic and avascular skin. Larger the hernia, more atrophic and avascu lar is the overlying skin and, this, along with thin sac leads to higher chances of rupture of
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Figure 1: Prolapsing omentum from ruptured incisional hernia
the incisional hernia.[1] Neglect for early operative in tervention or delay in seeking treatment increases the risk of rupture.[2,5] The use of the corset for the inci sional hernia is also considered as one of the contrib utory factors for facilitating the rupture of hernia.[2] Rupture/dehiscence occurs either spontaneously as in this case or may follow event of raised intra abdomi nal pressure, e.g. coughing, straining at defecation, leading to prolapse of intra abdominal contents, most common content being omentum (as in this case) and small bowel.[3] Rarely this may lead to obstruction and strangulation of small bowel and generalized perito nitis, a potential cause of fatality. The rupture of incisional hernia demands emergency operation to prevent further obstruction and strangu lation of bowel and to cover its contents. The hernial contents can either be covered primarily by mesh re pair of hernia if the general condition of the patient and local condition of operative site allows as in this case or can be covered by skin followed by delayed mesh repair. The purpose of this case is to draw attention to this exceptional, but avoidable, complication of incisional hernia. We strongly emphasize early operative inter-
Indian J Surg | October 2005 | Volume 67 | Issue 5
Letter to Editor
REFERENCES
vention in such cases, not only in developed coun tries, but also in developing countries. 1.
J. Sagar, B. Sagar, D. K. Shah
2.
Department of Surgery, Royal Free Hospital, London. UK 3. For correspondence: Jayesh Sagar,
1, Ivy Walk Rickmansworth Road,
Northwood Middlesex, HA6 2QQ, UK.
E-mail:
[email protected]
4. 5.
Hamilton RW. Spontaneous rupture of an incisional hernia. Br J Surg 1966;53:477-9. Singla SL, Kalra U, Singh B, Narula S, Dahiya P. Ruptured incisional hernia. Trop Doct 1997;27:112-3. Agarwal PK. Spontaneous rupture of incisional hernia. Br J Clin Pract 1986;40:443-4. Hartley RC. Spontaneous rupture of incisional herniae. Br J Surg 1962;49:617-8. Mudge M, Hughes LE. Incisional hernia: A 10 year prospective study of incidence and attitudes. Br J Surg 1985;72:70-1.
Complications of percutaneous endoscopic gastrostomy Sir, I read with interest the case report highlighting two complications of percutaneous endoscopic gastrostomy (PEG). The colonic injury is avoidable if attempts to insert PEG are only made when the parietes at the selected site is transilluminable after gastric insufflation, finger indentation of the selected site is seen on endoscopy and air aspiration through the trocar corresponds to its entry into stomach and not earlier. The complication of PEG site metastasis is extremely rare and unpredictable – akin to the port-site metastases in laparoscopic surgery for intra-abdominal malignancy, where the ‘chimney effect’- leakage of pneumoperitoneum through and around the ports allow seeding of shed but viable tumour cells.[1] This effect is much less with an insufflated stomach. A more plausible explanation is contamination of the retaining flange of the PEG tube during its passage through the tumour-bearing area of the upper aero-digestive tract during the ‘pull’ technique of insertion. Therefore, a logical approach would be to insert the PEG intraoperatively after excision of laryngeal or oral cancers whenever possible to minimise contamination of PEG tube. This has been practised in our institution to good effect. (Data presented at the Annual Conference of Association of Surgeons of India, Hyderabad, December 2005.) Alternatively, the more technically difficult ‘push’ technique of PEG can be used, which uses the Seldinger technique of PEG placement in an insufflated stomach, avoiding contact or friction of the tube with the tumour. Just as port-site metastases (incidence comparable to wound metastases after open surgery),[1] have not deterred laparoscopy in malignancy, the even rarer instances of PEG site metastasis (20 odd cases in the last two decades) should not prevent its use in ei-
Indian J Surg | October 2005 | Volume 67 | Issue 5
ther operable or in inoperable tumours. I would also like to contend the authors’ recommendation of laparoscopic enteral access as the simplicity and advantages of PEG in head and neck cancer patients far outweigh its disadvantages.[2] Laparoscopic placement requires general anaesthesia, which is more expensive and can also cause serious complications and occasionally requires conversion.[3] The expertise of interventional radiological placement is not widely available making PEG the preferred enteral access procedure for medium/long-term nutritional support in many head and neck/surgical gastroenterology units including ours.
REFERENCES 1.
2.
3.
Jain SK, Stoker DL. Abdominal wall metastases following percutaneous endoscopic gastrostomy in a case of carcinoma larynx. Indian J Surg 2005;67:145–6. Lloyd CJ, Penfold CN. Insertion of percutaneous endoscopic gastrostomy tubes by a maxillofacial surgical team in patients with oropharyngeal cancer. Br J Oral Maxillofac Surg 2002;40:122-4. Han-Geurts IJ, Lim A, Stijnen T, Bonjer HJ. Laparoscopic feeding jejunostomy: A systematic review. Surg Endosc 2005 (Epub ahead of print).
S. Saha Consultant Surgeon, North Bengal Clinic, Siliguri, Dist–Darjeeling, West Bengal 73403 For correspondence: Saumitra Saha Consultant Surgeon, North Bengal Clinic, Siliguri, Dist–Darjeeling, West Bengal 73403. E-mail:
[email protected] [email protected]
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