Presentation
Acute onset of abdominal pain, nausea and vomiting. History of tubal ligation.
Patient Data
Scout coronal image shows gas-filled dilated loops of small bowel.
There are dilated loops of small bowel with the transition point in the right lower quadrant. The uterus is scarred to the anterior abdominal wall. The hernia sac contains a loop of small bowel with associated mesenteric edema and engorgement of the vasa recta indicative of closed loop obstruction. The hernia sac originates in the inferior portion of the supravesical fossa and passes down into the prevesical space of Retzius compressing the anterior bladder wall. The uterus is scarred to the anterior abdominal wall.
Case Discussion
Supravesical hernia is an unusual type of hernia. It is of two types: internal or external. The supravesical fossa is a triangular area bounded laterally and superiorly by the median (remnant of urachus) and medial (remnant of left or right umbilical artery) umbilical ligaments and inferiorly by the peritoneal reflection passing from the anterior abdominal wall to the dome of the bladder.
Internal hernias are protrusions of the gut through the peritoneum, mesentery, or omentum into a compartment in the abdominal or pelvic cavity. The hernia orifice is usually a pre-existing foramen, recess, or fossa, but can be a sequelae of surgery, ischemia, or trauma.
Patient was taken to surgery. There was dense scar with adhesions between the small bowel and anterior abdominal wall just below the umbilicus. The uterus was found to be scarred to the anterior abdominal wall below this point. The point of obstruction was a flap created by the scarring of the left tube and uterus to the anterior abdominal wall. Some small intestines had herniated around this and were completely trapped. This was the point of obstruction based on intestinal dilation.
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