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Strangulated supravesical hernia: an unusual cause of mechanical small bowel obstruction

It is about a 62-year-old male patient that was operated on 2 years ago for a left inguinal hernia. He was initially admitted in our department with a bowel obstruction evolving for 4 days. On examination we found an apyretic patient with a tympanic distended abdomen, no incisional hernia on left inguinal scar, the rest of the hernial orifices were free and a rectal ampulla was empty at the RT. Computed tomography (CT) scan was performed, to assess the site of obstruction and look for signs of ischemia. It revealed small bowel obstruction upstream of two contiguous transitional zones delimiting a short intestinal segment, incarcerated on the right side into the lateral supravesical space compressing the urinary bladder. The initial diagnosis was acute bowel obstruction by bridle strangulation (Fig. S1). The patient underwent emergency surgery by median laparotomy. Exploration found distended small bowel in front of an incarcerated loop in a supravesical hernia. The hernia content was reduced (Fig. S2). The incarcerated loop was of good vitality. The neck was closed with separate stitches of 3–0 absorbable thread. The postoperative course was uneventful. The patient was discharged on day 5 post-operatively. Supravesical hernias develops in the supravesical fossae, localized between the umbilical arteries and the remnants of the urachus. It is about a triangular area which is delimited laterally and superiorly by the medial umbilical ligaments, medially and inferiorly by the peritoneal fold that passes from the anterior abdominal wall to the dome of the bladder. There are two types of supravesical hernia according to the development of the hernia sac: internal and external. In fact, the hernial sac most often insinuates through the anterior abdominal wall to form an external supravesical hernia which often presents as a direct inguinal hernia. More rarely, the sac develops in the spaces surrounding the bladder owing to the looseness of the preperitoneal bladder tissue to form an internal supravesical hernia. Skandalakis proposed a simpler nomenclature according to the position of the hernia in relation to the bladder: anterior if it is in front of the bladder, posterior if it is posterior and it can be right or left. The preoperative diagnosis of this pathology is very difficult. This type of hernia is often diagnosed intraoperatively and frequently presents as an acute intestinal obstruction of the small intestine. In fact, internal hernias represent only 0.5% to 1% of the etiologies of acute intestinal obstruction. The incidence of supravesical hernias remains difficult to assess as they are a rare form of internal hernia. It can be suspected on an abdominal scan. In fact, the CT scan can show a major sign which is an incarcerated intestine in front of the bladder. It can also show a hernial pseudosac which can contain several intestinal loops or a single small loop as was our case. Surgery remains the mainstay of treatment. Medline laparotomy is mostly preferred since this pathology is frequently revealed by an acute intestinal obstruction, but the laparoscopic approach is possible. In a recent review article published in 2020, the authors insist on that there are no Gold standard but the laparoscopic approach is not inferior since it seems that laparoscopy offers a clearer vision of the operating field and reduces hospital stay. The treatment consists in the reduction of the content of the hernial sac, verifying its vitality and closing the hernial orifice. Prognosis is good and depends mainly on the speed of management and the vitality of the contents of the hernia sac. In conclusion, internal supravesical hernia is rare With patients presenting with acute small bowel obstruction, it should be kept in mind that supravesical internal hernia may be an unusual cause.