Acta chir belg, 2003, 103, 329-331
Strangulated Umbilical Hernia Including a Mesenteric Cyst : a Rare Cause of Acute Abdomen C. Polat*, Ç. Tokyol**, O. N. Dilek* Departments of General Surgery* and of Pathology**, Faculty of Medicine, Afyon Kocatepe University, Afyon, Turkey.
Key words. Mesentery ; cyst ; diagnosis ; surgery. Abstract. Mesenteric cysts are rare intra-abdominal lesions. They are usually diagnosed as an incidental laparotomy finding in adults but in childhood, they may present with acute abdomen. In this report, a 72-year old female was referred to our hospital, suffering from acute abdominal pain, several episodes of nausea and vomiting. Clinical abdominal examination revealed an irreducible recurrent umbilical hernia. The patient had both muscular defense and abdominal tenderness. Plain abdominal radiography showed multiple air-fluid levels. With these findings, a diagnosis of acute abdominal pathology was accepted and an urgent laparotomy was performed. A 5-cm-diameter mesenteric cyst was excised from the mesentery of the proximal jejunum and a prosthetic mesh was placed for incisional hernia. This is the first report of a strangulated umbilical hernia complicated with a mesenteric cyst.
Introduction
Case report
Mesenteric cysts are rare intra-abdominal pathologies without typical clinical findings. It has been reported that the mesenteric cysts have an incidence of 1/100 000 hospital admissions in adults and 1/20 000 in children (1-2). They were first reported in an autopsy by an Italian anatomist, BENEVIENI in 1507. The first description of a chylous mesenteric cyst was recorded by ROKITANSKY in 1842. The first successful resection of a mesenteric cyst was performed by TILLAUX in 1880 and successful marsupialization of a mesenteric cyst was reported by PEAN in 1883 (2-3). Approximately 820 cases of mesenteric cyst were reported in the world literature up to now. They are usually incidentally found at laparotomy. The symptoms of this pathology vary from acute abdominal signs to non-spesific abdominal findings. Mesenteric cysts can be located anywhere in the mesentery from the duodenum to the rectum (1-2). The pathogenesis is not uniform and clinical and radiological diagnosis is difficult. The treatment of choice is resection. The complications which have been induced by a mesenteric cyst are rare. To our knowledge, only five cases, all of which have been located in an inguinal hernia, have been reported in the literature but a case of complicated mesenteric cyst located in an irreducible umbilical hernia sac has not been reported yet (4). We present a case of umbilical hernia including a mesenteric cyst which is an uncommon laparotomy finding.
A 72-year old woman presented with an abdominal pain persisting for the last 24 hours. The patient had had several episodes of nausea and vomiting. The patient had associated Type II diabetes mellitus, hypertension, chronic renal insufficiency, ischemic hearth disease, aortic stenosis, mitral insufficiency and cardiac arrhythmia. On physical examination, she had an irreducible umbilical recurrent hernia. She had muscular defense and abdominal tenderness. Bowel sounds were moderately hyperactive. Biochemical and haematological values were normal except the white blood cell count. Plain abdominal radiography showed multiple air-fluid levels. With the diagnosis of acute abdomen, an urgent laparotomy was performed. A 5 cm diameter mesenteric cyst originating from the mesentery of the proximal jejunum was found in the hernia sac. Exploration revealed minimal reactive intra-abdominal fluid and oedematous small intestines. The cyst was carefully removed. Macroscopic examination showed a 5 cm diameter, thin-walled and ovoid cyst. The inner surface of the cyst was smooth and unilocular. Microscopically, the cyst wall was lined by flattened epithelium. It contained fibrocollagenous, fibroadipose tissue infiltrated with chronic inflammatory cells (Fig. 1). The histopathological findings were consistent with a mesenteric cyst. The patient was discharged on the fifth postoperative day without complication. At one year follow-up, she had no evidence of recurrence.
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Fig. 1 Fibrocollagenous tissue with chronic inflammatory cells infiltrate beneath the epithelium (HEX200).
Discussion Mesenteric cysts are extremely rare intra-abdominal pathologies. They present as an abdominal mass in more than 50% of cases and are incidentally discovered in 40% of cases (1, 2). With the advances in the imaging techniques, they can be diagnosed even when they are asymptomatic. According to histopathological features, de PERROT classified mesenteric cysts into six groups (2) : i) ii) iii) iv) v) vi)
lymphatic (simple lymphatic cyst and lymphangioma), mesothelial (simple mesothelial cyst, benign cystic mesothelioma, and malignant cystic mesothelioma), enteric (enteric cyst and enteric duplication), urogenital, matura cystic teratoma (dermoid cyst), and pseudocysts (infectious and traumatic cysts).
Mesenteric cysts are most commonly localized in the mesentery of the small intestine, usually that of the
mesentery of the ileum but they can be seen anywhere from the duodenum to the rectal mesentery (1-2,5). Different aetiological mechanisms were suggested in the development of mesenteric cysts. While simple lymphatic and mesothelial cysts were reported to be congenital, a clear origin for lymphangiomas and benign cystic mesotheliomas have not been suggested yet. Trauma, previous pelvic surgery, pelvic inflammatory disease, endometriosis, and neoplasia were stated to be responsible in the development of these cysts (2). Most cases are usually asymptomatic unless complicated. They may be incidentally detected by a routine examination. They may cause nonspecific symptoms such as abdominal pain, nausea, vomiting, weakness, weight loss, diarrhoea, constipation, cramp and anorexia rarely (1-3, 7). Symptoms due to mesenteric cysts are related to size and localization of the lesion (5, 8). They usually become symptomatic when complications such as torsion, haemorrhage, infection, rupture, malignancy occur (5, 8). Also the compression on bowel and urethra may lead to various clinical obstructive findings (2). Mesenteric cysts with more than 5 cm in diameter are usually symptomatic. Malignant transformation is rather rare and only four cases with malign transformation have been reported in the literature (2, 5). Cysts situated peripherally tend to become symptomatic. They are usually mobile and may easily move in horizontal direction but have more limited motion in upward to downward (7). The diagnosis of mesenteric cyst is difficult at preoperative period because it presents no specific clinical findings and radiological signs. US, CT and MRI can be used in the diagnosis of the mesenteric cysts. It can be seen as well-outlined, non-enhancing near-water density abdominal mass on US. CT and MRI are helpful in the determination of the cystic content and their extension (9). Laparoscopy can also be used as a safe and reliable method for localization and further characterization of the cyst (1). The treatment of choice in large mesenteric cysts is surgery. The complete resection or enucleation can be performed in order to prevent complications (1-3, 5). Unroofing and opening techniques followed by a marsupialization can also be performed but with these techniques they usually recur (2). Partial small bowel resection or segmental colectomy is required in the treatment of the cases which transect the neighbouring bowel vessels and when it is impossible to separate the cyst from the intestine (2, 7). Resection can also be performed by laparoscopic techniques in patients who were diagnosed preoperatively. Open procedure must be preferred in cases with suspicion of malignancy and when resection seems impossible without opening the cyst (10). We believe that although mesenteric cysts are rare intra-abdominal lesions they should be kept in mind in
Strangulated Umbilical Hernia every unclear case that has been operated on as an acute abdominal pathology.
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331 (eds.). Principles of Surgery Vol 2, 7th edition. New York : McGraw-Hill, 1999 : 1551-84. 8. SARDI A., PARIKH K. J., SINGER J. A., MINKEN S. L. Mesenteric cysts. Am Surg, 1987, 53 : 58-60. 9. ROS P. R., OLMSTEAD W. W., MOSER R. P. Jr, DACHMAN A. H., HJERMSTAD B. H., SOBIN L. H. Mesenteric and omental cyst : histologic classification with imaging correlation. Radiology, 1987, 164 : 327-32. 10. SHAMIYEH A., RIEGER R., SCHRENK P., WAYAND W. Role of laparoscopic surgery in the treatment of mesenteric cysts. Surg Endosc, 1999, 13 : 937-9.
C. Polat Dumlupinar Mahallesi Kamil Miras Caddesi Lal Apt. No :7/24 TUR-03200 Afyon, Turkey Tel. : +90 0272 216 43 00 Fax : +90 0272 217 43 00 E-mail :
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