incarcerated meckel’s diverticulum in a spigelian hernia

Incarcerated Meckel’s Diverticulum in a Spigelian Hernia Elijah Dixon, MD, John A. Heine, MD, Calgary, Alberta, Canada A 43-year-old woman had a 24-hour history of crampy right lower quadrant abdominal pain, ob- stipation, anorexia, nausea, and vomiting. She had a history of five other episodes of recurrent right lower quadrant abdominal pain with spontaneous resolution. On examination the patient was afebrile and vital signs were stable. Abdominal examination revealed a firm 8 3 8 cm tender mass in the right lower quadrant. The remainder of the abdominal and digital rectal examination was unre- markable. The white blood cell count was 12,000 with a normal differential. An abdominal series was consistent with an incomplete small bowel obstruction. Infused com- puted axial tomography of the abdomen and pelvis (Figure 1) shows a fluid- and air-filled mass in the soft tissues of the right sided abdominal wall at the level of the anterior superior iliac crest. At operation the patient was found to have an acutely inflamed 3 3 2 3 2 cm Meckel’s diverticulum incarcerated in a right sided Spigelian hernia sac in the subcutaneous tissues of the right lower quadrant with proximal small bowel obstruction secondary to the incarcerated hernia. Small bowel resection was undertaken to include the Meckel’s diverticulum with primary anastamosis. Pathol- ogy was consistent with a Meckel’s diverticulum with no heterotopic tissue. The patient made an uneventful recov- ery. Meckel’s diverticulum is the most commonly encoun- tered congenital small intestinal abnormality encoun- tered. 1 Autopsy studies have shown that it may be found in 1% to 2% of people and that men are more commonly affected. 2 Complications related to Meckel’s diverticulae include bleeding, obstruction, diverticulitis, perforation, and umbilical abnormalities. This case illustrates the in- carceration of a Meckel’s diverticulum causing small bowel obstruction in a Spigelian hernia. Management includes the prevention of further complications by repairing the abdominal wall defect and resecting the Meckel’s diverticulum. REFERENCES 1. Aubrey A. Meckel’s diverticulum. Arch Surg. 100;144:1970. 2. Matsagas M, Fatouros M, Koulouras B, et al. Incidence, complications, and management of Meckel’s diverticulum. Arch Surg. 130;143:1995. Figure 1. Am J Surg. 2000;180:126. Address correspondence to John A. Heine, MD, Department of Surgery, Peter Lougheed Hospital, University of Calgary, 3500 –26 Avenue N.E., Calgary, Alberta, Canada. T2N 1N4 Manuscript submitted January 31, 2000, and accepted May 30, 2000. CLINICAL IMAGE 126 © 2000 by Excerpta Medica, Inc. 0002-9610/00/$–see front matter All rights reserved. PII S0002-9610(00)00438-4

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Incarcerated Meckel’s Diverticulum in aSpigelian Hernia

Elijah Dixon, MD, John A. Heine, MD, Calgary, Alberta, Canada

A43-year-old woman had a 24-hour history ofcrampy right lower quadrant abdominal pain, ob-stipation, anorexia, nausea, and vomiting. She had

a history of five other episodes of recurrent right lowerquadrant abdominal pain with spontaneous resolution.

On examination the patient was afebrile and vital signswere stable. Abdominal examination revealed a firm 8 3 8cm tender mass in the right lower quadrant. The remainderof the abdominal and digital rectal examination was unre-markable. The white blood cell count was 12,000 with anormal differential. An abdominal series was consistentwith an incomplete small bowel obstruction. Infused com-puted axial tomography of the abdomen and pelvis (Figure1) shows a fluid- and air-filled mass in the soft tissues of theright sided abdominal wall at the level of the anteriorsuperior iliac crest.

At operation the patient was found to have an acutelyinflamed 3 3 2 3 2 cm Meckel’s diverticulum incarceratedin a right sided Spigelian hernia sac in the subcutaneoustissues of the right lower quadrant with proximal smallbowel obstruction secondary to the incarcerated hernia.Small bowel resection was undertaken to include theMeckel’s diverticulum with primary anastamosis. Pathol-ogy was consistent with a Meckel’s diverticulum with noheterotopic tissue. The patient made an uneventful recov-ery.

Meckel’s diverticulum is the most commonly encoun-tered congenital small intestinal abnormality encoun-tered.1 Autopsy studies have shown that it may be found in

1% to 2% of people and that men are more commonlyaffected.2 Complications related to Meckel’s diverticulaeinclude bleeding, obstruction, diverticulitis, perforation,and umbilical abnormalities. This case illustrates the in-carceration of a Meckel’s diverticulum causing small bowelobstruction in a Spigelian hernia. Management includesthe prevention of further complications by repairing theabdominal wall defect and resecting the Meckel’s divertic-ulum.

REFERENCES1. Aubrey A. Meckel’s diverticulum. Arch Surg. 100;144:1970.2. Matsagas M, Fatouros M, Koulouras B, et al. Incidence, compli-cations, and management of Meckel’s diverticulum. Arch Surg.130;143:1995.

Figure 1.

Am J Surg. 2000;180:126.Address correspondence to John A. Heine, MD, Department ofSurgery, Peter Lougheed Hospital, University of Calgary,3500–26 Avenue N.E., Calgary, Alberta, Canada. T2N 1N4

Manuscript submitted January 31, 2000, and accepted May 30,2000.

CLINICAL IMAGE

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