Strangulation of a Meckel's Diverticulum in aFemoral Hernia (Littre's) *

BENJAMIN A. PAYSON, M.D., F.A.C.S., KEmIT M. SCHNEIDER, M.D.,MimvuN B. VICrOR, M.D.

New York, N. Y.

From the Surgical Service, Beth Israel Hospital, New York, N. Y.

THE PRESENCE of an intestinal diverticu-lum as the sole occupant of a hernial sac isa rare entity. Littre 11 in 1700 was the firstto describe such a condition. Richter,19 re-porting a similar lesion in 1777, describeda partial herniation of the antimesentericportion of the intestine. A related herniawas subsequently recorded in which therewas a herniation of a loop or loops of in-testine containing a Meckel's diverticu-lum.25 Consequently, a confusion in termi-nology has arisen, which is not uncommonwhen pathologic conditions become asso-ciated with proper names. It has been ac-cepted by most investigators that the con-notation "Littre's hernia" be used onlywhen a Meckel's diverticulum is the soleoccupant of the sac.The most common route for a Littre's

hernia is through an inguinal orifice.20 24Herniation of a Meckel's diverticulumthrough the femoral ring is quite rare, andup to 1954 only 35 such cases have beenrecorded in the modern literature 2-4, 6, 9,1216-18, 20, 21, 24, 26 (see Table I). In additionto our case report, certain characteristicsof this type of hernia are emphasized andsome of the pitfalls in diagnosis are dis-cussed.

Meckel's diverticulum is found in 0.5 to2.0 per cent of individuals.1,8 At the NewYork Post-Graduate Hospital, Goodman7reported an incidence of 23 cases in 9,557laparotomies. The reported incidence atlaparotomy is much lower, probably be-cause a routine search is not made.10' 13

Submitted for publication January, 1956.

277

The anatomy of a Meckel's diverticulumis extremely variable. It may be repre-sented as a slight outpouching of the smallintestine or an appendiceal structure meas-uring 10 cm. long with or without amesentery. It usually projects from theanti-mesenteric border, but may be at-tached laterally or may be situated withinthe mesentery.8 It may also be repre-sented as a partially obliterated diverticu-lum with a fibrous band or fistula runningfrom its distal end to the umbilicus. How-ever, it is obvious that the diverticulumoriginating from the anti-mesenteric borderof the ileum, lying free in the peritonealcavity, would be the most frequently foundin the hernial opening. It is most commonlylocated within one to three feet from theileo-cecal valve.A Meckel's diverticulum usually contains

intestinal mucosa, but in 15 to 25 per centof the cases, gastric or duodenal mucosalelements with or without aberrant pan-creatic tissue may be present.13 In patho-logic diverticula, however, heterotropic tis-sue is present in 60 to 70 per cent.8

CASE REPORT

W. G., a 43-year-old white housewife, wasadmitted to Beth Israel Hospital (#291590-101)on June 6, 1955 with a chief complaint of epi-gastric and periumbilical pain of 3 days' duration.This was accompanied by frequent vomiting ofsmall amounts of bile colored fluid. She notedslight abdominal distention and was moderatelyconstipated during the preceding week. She hada bowel movement the day of admission and waspassing gas freely. At no time had she com-plained of pain in the inguinal regions nor wN

278 PAYSON, SCH'TABLE I. Collected Cases of Strangulated Meckel's

Diverticultm in a Femoral Hernia

[NEIDER AND VICTOR

No. ofAuthor Year Cases

Ekehorn 1901 8Pabst 1910 10Sweet 1930 2Weinstein 1938 4Quiri 1938 1Ringo 1940 1Marti 1942 1Bohn 1943 2Orlando 1945 1Patterson 1946 1Schena 1947 1DeFelice 1949 1Ingle 1952 1Cigarroa 1954 1Payson, et al 1955 1

Total 36

she aware of the presence of a hernia. For 3months prior to admission, the patient, a knownmild diabetic, had complained of epigastric painradiating posteriorly to the back. The pain was

occasionally relieved by food but was unaffectedby alkalies. For 3 weeks prior to admissionshe had been under treatment in the Gastroin-testinal Out-Patient Department where a provi-sional diagnosis of peptic ulcer had been madeand she was scheduled for a gastro-intestinalx-ray examination. However, while awaiting in-vestigation, the pain had become increasinglysevere and she was admitted with a diagnosis ofacute duodenal ulcer with penetration.

Physical Examination: Blood pressure 158/88.Pulse 82. Respiration 24. Temperature 100.4. Thepatient was a well-developed, somewhat de-hydrated woman in moderately acute distress.The salient findings were referable to the ab-domen. There was moderate distention with tym-any, on percussion, and active bowel sounds on

auscultation. There was only mild tenderness in themid-epigastrium without spasm or rebound tender-ness. A soft non-tender, walnut-sized mass was

present over the right femoral ring.Laboratory Examination: Erythrocyte count

4.5 million; leukocyte count 5,200. Differential:polymorphonucleated neutrophiles 64, bands 2,basophiles 1, monocytes 6, lymphocytes 25, eo-

sinophiles 2. Urinalysis: glucose two plus. Noacetone. Sodium 118.6 mEq/L, bicarbonate 26.8mEq/L, chlorides 82.4 mEq/L, potassium 4.5mEq/L.

X-Ray Examination: Chest x-ray revealed theheart and lungs to be normal. Scout films of the

FIG. 1 (above). 9 cm. segment of resectedileuim (serosal surface) revealing Meckel's di-verticulum with surrounding area of pressurenecrosis where the diverticulum was incarceratedin the femoral ring. (below). Mucosal surface re-vealing neck of Meckel's diverticulum with apenetrating ulcer in situ.

abdomen revealed a small amount of gas in thesigmoid and splenic flexures. A single loop ofslightly distended small intestine was seen in theright upper quadrant. These findings were consid-ered to be insufficient to warrant a diagnosis ofsmall intestine obstruction.

Hospital Course: The patient was placed onnothing by mouth and appropriate intravenoustherapy was administered to correct the existinghyponatremia and hypochloremia. The followingday she appeared much improved with a normaltemperature and pulse. There was no furthervomiting and the abdominal distention had dis-appeared. She had a bowel movement and passedflatus. A repeat scout abdominal film revealed nochange from those taken on admission. The massover the right femoral ring remained soft andnon-tender and appeared to be smaller than onadmission.

On the third hospital day the patient had arecrudescence of severe epigastric pain and vomit-ing. She had not had a bowel movement nor hadshe passed flatus for the preceding 18 hours. The

Annals of SurgeryAugust 1956

STRANGULATION IN A FEMORAL HERNIA

FIG. 2. Microscopic section revealing typical peptic glandson the right and ulceration on the left.

hernial mass was still non-tender, but appearedto be larger and more tense. In addition, herabdomen was distended and tympanitic. An ab-dominal film revealed dilatation of several loopsof small bowel. There was no gas present in thecolon. A white blood count at this time revealed aleukocytosis of 12,000 with a shift to the left. Anintestinal tube was passed and the patient wasbrought to the operating room with a diagnosis ofstrangulated right femoral hernia of the Richtertype.

Operative Procedure: Under spinal anesthesiaan incision was made overlying Poupart's liga-ment. The hernial sac was delineated below theligament and noted to be filled with bloody fluid.On opening the sac, a knuckle of the anti-mesenteric border of the small bowel was foundto be incarcerated in the femoral ring and ap-peared to be gangrenous.

An incision was then made in the externaloblique aponeurosis and transversalis fascia. Thesac and its contents were then delivered throughthe femoral ring. It was apparent at this timethat what was thought to be a Richter's hernia

was actually a Littre's hernia containing a com-

promised Meckel's diverticulum. Because of itswide base, it was considered unwise to resectonly the diverticulum. Consequently, a 9 cm. seg-ment of small intestine was excised. Continuity wasreestablished by side-to-side entero-enterostomy.A Cooper's ligament repair was used to close thefemoral ring and the defect in the posterior wallof the inguinal canal.

Convalescence was uneventful and the patientwas discharged 11 days postoperatively.

Pathologic Report: Three cm. from the proximalresected end there was a 4 X 1.5 cm. diverticu-lum which was hemorrhagic and necrotic (Fig.1). Microscopic examination revealed many pepticglands in the diverticulum (Fig. 2). In addition,a penetrating gastric ulcer was found in theneck of the diverticulum.

DISCUSSION

The diagnosis of a strangulating Littre'shernia is often not readily made. The in-flammation, fever and pain which accor-

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280 PAYSON, SCHNEIDER AND VICTOR Annals of Surgery

pany these types of herniae are less severeand occur late. The tumor over the hernialring is less marked, less tender, and not astense. Often the patient is first seen with afecal fistula over the hernial site.

It is claimed that complete intestinal ob-struction does not occur because the entirelumen is not compromised, creating nobarrier to the fecal stream. In addition,abdominal distention is not a significantclinical finding. However, in our case, com-plete obstruction did occur because thebase of the diverticulum was unusuallywide and the bowel became kinked as itwas caught inside the femoral ring.The interesting feature in our case was

the presence of a penetrating gastric ulcerin the neck of the diverticulum. The ulcera-tion usually occurs at the base or neck ofthe diverticulum, in the ileal lining at theedge of the gastric or duodenal mucosaand is due to the acid-pepsin secreted bythe heterotropic mucosa.22 Ileal mucosa isextremely susceptible to peptic digestion.Matthews and Dragstedt 14 produced a"Meckel's Diverticulum ulcer" by implant-ing a Pavlov pouch into an ileal diverticu-lum. The hormone, gastrin, secreted by thegastric mucosa in the stomach, is thoughtto be a factor in the etiology of the ulcera-tion.Our patient suffered from typical ulcer

pain, related to meals, but not relieved byalkaline medication. Dragstedt 5 has re-ported a similar occurrence in one of hispatients.We believe that in all cases the diver-

ticulum should be entirely excised becauseof the frequent occurrence of heterotropicgastric mucosa. Residual gastric mucosamay cause further ileal ulceration with thepossibility of perforation or bleeding. In-version may encroach upon the lumen andcause intestinal obstruction. If the diver-ticulum is small it may be excised locallyand the bowel closed transversely. How-ever, if the base is wide and the viabilityquestionable then resection of the involved

loop of ileum with anastomosis is the pre-ferred procedure.

SUMMARY

1. Strangulation of a Meckel's diverticu-lum (with a penetrating gastric ulcer insitu) in a femoral hernia is presented. It isto be emphasized that when examining anabdomen for a possible surgical condition,one must carefully inspect and palpate thesites of hernial orifices. A Littre or Richterhernia can be overlooked since early in itsincarceration there is minimal local reac-tion and no clinical evidence of obstructionto the fecal stream.

2. Heterotropic gastric or duodenal mu-cosa is not uncommonly found in a Meckel'sdiverticulum and may cause typical ulcersymptoms, not relieved by alkaline medica-tion.

3. In all cases the diverticulum shouldbe removed and in some instances resectionof the involved loop of intestine will benecessary depending upon the severity ofthe ischemia and the diameter of the di-verticulum.

BIBLIOGRAPHY

1. Bird, W. E.: Littre's Umbilical Hernia. Am.Jr. Surg., 60: 81, 1943.

2. Bohn, G. L. S.: Meckel's Diverticulum inCrural Hernias of Males, 2 Cases. Ugesk, f.Laeger, 105: 844, 1943.

3. Cigarroa, L. G. and Malakoff, M. E.: Strangu-lated Littre's Femoral Hernia. Texas Journalof Medicine, 50: 7, 481, 1954.

4. De Felice, L.: Strangulated Crural Hernia(Littre). Complicated by Stercoraceous Fis-tula and by Acute Osteoperiositis of FemoralEpiphyses. Arch. "De Vecchi" Anat. Pat.12: 283, 1949.

5. Dragstedt, L. R.: Ulcus Acidum of Meckel'sDiverticulum. J. A. M. A., 101: 20, 1933.

6. Ekehorn, G.: Die Bruch des Meckel'schenDivertickels. Arch. f. Klin. Chir., Berlin, 64:115, 1901.

7. Goodman, B. A.: Meckel's Diverticulum.Arch. Surg., 36: 144, 1938.

8. Gross, R. E.: The Surgery of Infancy andChildhood. W. B. Saunders Co., Phila., 1953.

Volume 144 STRANGULATION IN A FEMORAL HERNIA 281Number 2289. Ingle, N. G. and S. M. Hopkins: Lateral

Femoral Hernia and Strangulated Meckel'sDiverticulum. A.M.A. Arch. Surg., 64: 401,1952.

10. Kittle, C. F., Jenkins, H. P. and L. R. Drag-stedt: Patent Omphalomesenteric Duct andits Relation to the Diverticulum of Meckel.Arch. Surg., 54: 10, 1947.

11. Littre, A.: Observation sur une nouvelle Especede Hernie. Hist. Acad. Roy. d. Sc., 170:300, Paris, 1719. (Translated by F. A. Stahl.:Corpuscle 8, 212, 1899.)

12. Marti, T. and P. Cottet: Incarceration andPerforation of Meckel's Diverticulum in LeftFemoral Hernia, Case. Rev. Med. de laSuisse Rom., 62: 357, 1942.

13. Matt, J. G. and P. J. Tirnpone: Peptic Ulcerof Meckel's Diverticulum: Case Report andReview of Literature. Am. Jr. Surg., 47:612, 1940.

14. Matthews, W. B. and L. R. Dragstedt: TheEtiology of Gastric and Duodenal Ulcer,Experimental Studies. Surg., Gynec., & Obst.,55: 265, 1932.

15. Orlando, Vaz: Littre-Richter Hernia, with Re-port of Cases. Arch. brasil de Med., 35: 227,1945.

16. Pabst, F.: Ein Meckel'sches Divertikel ineiner Hernia Interparietalis Inguinalis In-carcerata Dextra. Beitrage. Klin. Chir., 69:646, 1910.

17. Patterson, F. M. S.: Incarceration of Meckel'sDiverticulum in Femoral Hernia, Case. NorthCaroline M. J., 7: 59, 1946.

18. Quiri, A.: Meckel's Diverticulum Strangulatedin Crural Hernia, Case. Arch. Ital. di Chir.,54: 16, 1938.

19. Richter, A. G.: Abhandlung von der Bruchen.J. C. Dieterich, Gottingen, 1777.

20. Ringo, R. E. and M. R. Charlton: Meckel'sDiverticulum and Littre's Hernia. NorthwestMed., 39: 60, 1940.

21. Schena, A. T., J. J. Maroni and D. I. Scopi-naro: Littre's Hernia, Case. Prensa Med.Argent., 34: 1096, 1947.

22. Smith, S. W., and E. R. Woodward: PepticUlcer in Meckel's Diverticulum, Bleedingand Perforation in Two Male Siblings. Ann.Surg., 142: 1021, 1955.

23. Stone, H. B.: Herniae. Practice of Surgery byDean Lewis. Hagerstown, Md., W. F. PriorCo., VII: 13, 1929.

24. Sweet, R. H.: Incarceration of Meckel's Diver-ticulum in Femoral Hernia. Case with Re-view of Literature. New England Jr. Med.,202: 997, 1930.

25. Watson, L. F.: Hernia. Second Edition. C.J. Mosby Co., 1938.

26. Weinstein, B. M.: Strangulated Littre'sFemoral Hernia with Spontaneous FecalFistula. Ann. Surg., 108: 1076, 1938.