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Abstract: This is a 90-year-old female patient who presented to the hospital with recurrent lower abdominal pain, abdominal distension and left lower limb pain for 4 days, and was not treated by several hospitals. The patient was discharged from the hospital 10 days later. The patient was discharged 10 days later. She came to our outpatient clinic for follow-up six months after the operation and did not develop intra-abdominal hernia again.
Basic information】Female, 90 years old
Disease Type】Intra-abdominal hernia with obstruction (closed hole hernia)
Hospital】Hefei Second People’s Hospital
Date of Consultation】July 2020
Treatment modality】Laparoscopic exploration + closed-hole hernia release + necrotic small bowel resection + pelvic drainage
Treatment Period】Hospitalization for 10 days, review in 6 months
Results】Stable condition after surgery, no recurrence
I. Initial consultation
Mrs. Zhang is a 90-year-old woman who came to our department in a night shift emergency three years ago. At that time, the patient’s complaints were abdominal pain and distension for four days, nausea and vomiting of stomach contents several times, pain in the left thigh, and anal cessation of defecation, and she went to the local hospital and had an abdominal CT examination suggesting small bowel obstruction and left intra-abdominal hernia (closed-hole hernia). There was no previous history of abdominal surgery, so the diagnosis of intra-abdominal hernia with obstruction (closed-hole hernia) was considered, and intestinal necrosis was tentatively considered. Although the patient usually had no underlying diseases such as hypertension and heart disease, he was 90 years old and the operation was extremely risky. After the family understood the seriousness of the disease, they once wanted to go home and give up the treatment because they were afraid of the risks of the operation. However, after detailed communication about the consequences of delayed treatment, the family decided to continue treatment.
II. Treatment process
The patient was 90 years old and had a long course of disease. After admission, hematological tests were completed to assess the internal environment, and in view of the need for surgery, we needed to further evaluate her cardiopulmonary function, so cardiac ultrasound, ambulatory electrocardiogram, and pulmonary function tests were completed. A dynamic review of abdominal CT after admission showed that the patient’s abdominal CT examination revealed extensive dilatation of the small intestine, a left-sided closed-hole internal hernia, and a significant increase in peritoneal effusion compared to the external CT. In view of the patient’s poor pulmonary function, the risk of general anesthesia, and the possibility of intestinal necrosis, surgery was the best treatment option, and the family was communicated with, and it was suggested that emergency surgical treatment be given, with laparoscopic exploration first, and depending on the intra-abdominal situation, the surgical approach would be decided, and the patient might be transferred to ICU for continued treatment after surgery, and the family eventually agreed to surgery.
The patient’s small intestine was found to be significantly dilated, with about 200 ml of dark bloody fluid in the abdominal cavity, and part of the small intestine was herniated into the left closed hole. Immediately, the small intestine was dragged out from the lower abdominal opening, necrotic intestinal canal was resected and anastomosis was made. The enlarged closed hole was intermittently sutured to reduce the size of the hole and prevent the recurrence of internal hernia, and a pelvic drain was placed after the operation.
III. Treatment results
The patient’s operation was smooth and took 90 minutes. After the operation, he was transferred to the ICU for further treatment because of the difficulty in extubation of the tracheal tube, and after 3 days, he was successfully taken off the machine and transferred back to the general ward. The patient’s condition was stable after the operation and was discharged home. The patient’s follow-up checkup after six months indicated that he did not have any more episodes of this symptom and was in good health, eating and sleeping well.
IV. Precautions
The patient is 90 years old and we are very happy that this surgery was successful. Although the surgery was successful, there is still a possibility of recurrent closed hernia, so the patient and her family are advised to eat regularly and to be admitted to the hospital promptly in case of abdominal pain.
The usual diet needs to ensure adequate nutrition and a balanced variety of foods, with more fruits, vegetables and other foods rich in dietary fiber.
Patients are also advised to get enough sleep, not to strain, and to maintain an optimistic state of mind. Maintaining a positive attitude toward the treatment of the disease will help the recovery of the disease.
V. Personal insight
First of all, for this case we should first summarize its characteristics. Intra-abdominal hernia is not a common disease in general surgery, mainly seen in elderly wasting women, and the attack is mostly accompanied by numbness or pain in the ipsilateral limb, which should be operated as soon as it is detected. Perioperative care is also very important for the success of surgery. Encouraging early bedtime activities helps the recovery of postoperative bowel function and also reduces the incidence of deep vein thrombosis, thus reducing pulmonary infections. Therefore, it is important to increase the awareness of intra-abdominal hernia among the elderly in daily life, and family members should pay full attention to regular physical examination and must seek early medical attention if abdominal pain and discomfort occur and are difficult to relieve.