Nuño-Guzmán Carlos M, Arróniz-Jáuregui José, Espejo Ismael, Valle-González Jesús, Butus Hernán, Molina-Romo Alejandro, Orranti-Ortega Rodrigo I
Department of General Surgery, Calle Hospital 278, Guadalajara, Jalisco, México, CP 442801.
J Med Case Rep. 2012 Jan 10;6:4. doi: 10.1186/1752-1947-6-4.
Herniation of the liver through an anterior abdominal wall hernia defect is rare. To the best of our knowledge, only three cases have been described in the literature.
A 70-year-old Mexican woman presented with a one-week history of right upper quadrant abdominal pain, nausea, vomiting, and jaundice to our Department of General Surgery. Her medical history included an open cholecystectomy from 20 years earlier and excessive weight. She presented with jaundice, abdominal distension with a midline surgical scar, right upper quadrant tenderness, and a large midline abdominal wall defect with dullness upon percussion and protrusion of a large, tender, and firm mass. The results of laboratory tests were suggestive of cholestasis. Ultrasound revealed choledocholithiasis. A computed tomography scan showed a protrusion of the left hepatic lobe through the anterior abdominal wall defect and a well-defined, soft tissue density lesion in the right adrenal topography. An endoscopic common bile duct stone extraction was unsuccessful. During surgery, the right adrenal tumor was resected first. The hernia was approached through a median supraumbilical incision; the totality of the left lobe was protruding through the abdominal wall defect, and once the lobe was reduced to its normal position, a common bile duct surgical exploration with multiple stone extraction was performed. Finally, the abdominal wall was reconstructed. Histopathology revealed an adrenal myelolipoma. Six months after the operation, our patient remains in good health.
The case of liver herniation through an incisional anterior abdominal wall hernia in this report represents, to the best of our knowledge, the fourth such case reported in the literature. The rarity of this medical entity makes it almost impossible to specifically describe predisposing risk factors for liver herniation. Obesity, the right adrenal myelolipoma mass effect, and the previous abdominal surgery are likely to have contributed to incisional hernia formation.
肝脏通过腹壁前部疝缺损突出的情况罕见。据我们所知，文献中仅描述过三例。
一名70岁的墨西哥女性因右上腹腹痛、恶心、呕吐和黄疸一周前来我院普通外科就诊。她的病史包括20年前的开腹胆囊切除术和超重。她表现为黄疸、腹部膨隆伴有中线手术瘢痕、右上腹压痛，以及一个大的中线腹壁缺损，叩诊呈浊音，有一个大的、压痛明显且质地坚硬的肿块突出。实验室检查结果提示胆汁淤积。超声显示胆总管结石。计算机断层扫描显示左肝叶通过腹壁前部缺损突出，右肾上腺区域有一个边界清晰的软组织密度病变。内镜下胆总管结石取出术未成功。手术中，首先切除了右肾上腺肿瘤。通过脐上正中切口处理疝；整个左叶通过腹壁缺损突出，将该叶复位至正常位置后，进行了胆总管手术探查并取出多枚结石。最后，重建了腹壁。组织病理学显示为肾上腺髓脂肪瘤。术后六个月，患者健康状况良好。
据我们所知，本报告中肝脏通过腹壁前部切口疝突出的病例是文献中报道的第四例此类病例。这种医学实体的罕见性使得几乎不可能具体描述肝脏疝形成的易感危险因素。肥胖、右肾上腺髓脂肪瘤的占位效应以及既往腹部手术可能促成了切口疝的形成。
